MODERATE AND SEVERE PSORIASIS

Patients with psoriasis, non-responsive to other therapies, may be prescribed PUVA, Neotigason, Hydroxyurea, Methotrexate or Cyclosporin. All may help considerably but do have side effects. Some of these therapies may interact with other medicines. Please check with your doctor.

You must not become pregnant whilst on these therapies and for some time following treatment. With some of these therapies, it is important not to father a child. You must discuss all of these aspects in detail with your dermatologist.

PUVA
What is PUVA?

PUVA is a term used for a combined treatment with Psoralens (P) and ultraviolet A light (UVA).

What are Psoralens?

The psoralens are a group of naturally occurring chemicals found in more than 30 plants, including lemon, celery, parsley, fig and clove, but the amounts in these are too small to help in psoriasis. In PUVA therapy, a psoralen drug is taken by mouth, and the skin is then exposed to UVA. The psoralen acts by making the skin highly sensitive to sunlight and in particular to the longwave UVA.

How do you take Psoralen?

To get the best results, the psoralen drug (usually 8-methoxy psoralen, 8 MOP in capsule form) should be taken 1-2 hours before treatment. With some preparations, the time interval may be different. If the capsules make you feel sick; they should be taken with a light meal or a glass of milk. The level of psoralenint he blood reaches a maximum after about 2 hours, and to ensure that treatment is successful, you will have to be accurate about the times of taking the tablets, and of the UVA light exposure. Tell the nurse or hospital doctor when you need more capsules as these are only available from the hospital pharmacy.

What is UVA?

Ultraviolet light occurs naturally in the sun's rays. The longer wavelengths of the ultraviolet light are known as UVA. In most parts of the world, only small amounts reach the earth's surface. PUVA therapy needs large amounts of UVA, so this is provided by special machines.

How does PUVA work?

In the presence of UVA, the psoralen combines with the cells in the skin to slow down their rate of division. In psoriasis, these skin cells are multiplying too quickly. The treatment may cause your skin go red and more of the natural pigment melanin will be produced. This may give you a tan.

What is a PUVA machine?

The machines used contain many specially coated fluorescent tubes. These give out the UVA needed for PUVA and are built into boxes, rather like shower cabinets, into which you step for treatment. Some patients dislike the feeling of being inside these cabinets, but most quickly get used to it. Elderly patients may find it difficult or uncomfortable to stand for the time required. Fans are built into the cabinets for ventilation and temperature control.

How frequently will I have attend ?

Treatment times depend mainly on your skin type and how it reacts to sunlight. Fair-skinned people who burn easily will have shorter treatment times than dark-skinned ones who rarely burn in the sun.

Your treatment sessions will gradually increase from a few minutes usually to a maximum of 20 minutes if your skin tolerates the treatment and does not burn.

If you notice and burning or soreness, tell the nurse before you start further treatment. The treatment time may have to be cut, or the affected area may have to be covered up.

Frequency of treatment does vary but most doctors prescribe therapy 2 to 3 times a week. Psoriasis usually clears after 5-8 weeks of treatment and enjoy long periods free from the disease. Continuous PUVA therapy is to be avoided, if possible, to reduce the cumulative effects of the UVA.

For PUVA therapy, you will attend as an put-patient and therefore it should not interfere too much with your work or schooling. If you do have difficulty getting time off, your doctor may write to those concerned.

What is local PUVA?

Occasionally, the UVA needs to be given only to one or two small areas, such as the hands or feet. The psoralen may then be given orally or as lotion. Some centres also prescribe the psoralen as a bath therapy rather than as tablets.

Has PUVA any side effects?

It may have: they are divided into short-term and long-term ones.

Short-term effects

Some patients feel sick after they take their psoralen tablets.

Burning of the skin is sometimes a problem with PUVA, particularly at the start of the course. Unlike ordinary sunburn, the redness from PUVA can take 2 or 3 days to appear, and can last for more than a week.

A small area of skin may be tested at the start of the treatment to see how sensitive you are to PUVA.

Itching and dryness of the skin may occur, but usually respond to applications of emulsifying ointment.

Long-term side effects

It is known that PUVA treatment, if given for some years, may lead to premature ageing of he skin, and an increased risk of developing certain forms of skin cancer. The risks from a few courses of treatment (less than 5) are very small and should not cause undue concern. The risks are higher for those receiving continuous PUVA treatment over several years, or those who have had many courses of treatment. For this reason, we usually prefer not to recommend continuing PUVA treatment once the skin has cleared.

Precautions to take
Eye and genital protection

The eyes, as well as the skin, are made more sensitive to sunlight by the psoralen capsules. They have to be protected by wearing sunglasses when going outside, from the time you take the tablets until sunset on the days of PUVA treatment.

You need not wear your sunglasses indoors, except in rooms lit by natural sunlight. All polaroid-type sunglasses provide adequate eye protection. Your own glasses can be tested at the hospital to make sure that they are suitable. Some non-tinted glasses also provide adequate protection but they are likely to be expensive: the hospital can give you details about them of you wish.

The genital area in males should also be protected by wearing underpants.

Sunbathing and sunbeds

Avoid sun exposure on treatment days and wear suitable clothing to protect your skin from sunlight when you are out on a sunny day. Do not use a sunbed during the course of PUVA treatment.

Other skin treatments

Moisturisers can be used in the bath or applied to your skin if it becomes dry or uncomfortable during the treatment. Your scalp should continue to be treated with prescribed applications, as the UVA may not penetrate the hair sufficiently to help it. Other ointments and creams should only be sued if suggested by the doctors in the PUVA unit. Perfumes and aftershaves can sometimes cause a skin reaction with the UVA light and should not be used on treatment days.

Other prescribed medication

Some tablets (particularly antibiotics and water tablets) can make the skin more sensitive to the UVA light. Please tell the PUVA unit nurse or doctor if you have been prescribed any tablets during the course of PUVA treatment.

Conception

It is very important that women do not become pregnant while having PUVA: efficient contraception should, therefore, be used throughout.

Neotigason (acitretin)
What is Neotigason?

Neotigason belongs to a group of drugs known as retinoids , which are derivatives of Vitamin A.

How is Neotigason taken?

It is taken in capsule form on a daily basis, either on its own or combined with PUVA or topical therapy.

How does Neotigason work?

It slows down rapidly diving skin cells and allows shedding to produce normal skin.

What are the possible unwanted effects of Neotigason?

These are temporary , often wear off as treatment continues, and include:

• Dryness of the lips, eyes, face, and nose bleeds. These are often relieved by moisturisers - it is preferable to use a lip salve at the start of therapy.
• Hair loss · Muscle aches and pains: relieved by avoiding rigorous exercise and if necessary with paracetamol.
• Headaches: usually relieved with paracetamol - but therapy should be stopped if persistent.

Precautions to take while taking Neotigason

Pregnancy is totally contraindicated whilst on therapy and for 2 years post-therapy. Efficient contraception is therefore essential during this time period. Tetracyclines can exacerbate headaches. Sun lamps should be avoided.

What other tests may be needed?

A pregnancy test will be needed prior to starting therapy. At the start, you will be given a blood test; another after 1 month, and then every 3 months. An X-ray of certain joints may be taken every 1 or 2 years.

How long will the treatment last?

Until the skin has improved and usually for several months thereafter to keep you disease free.

Methotrexate
How does Methotrexate work?

Methotrexate has a number of actions which account for its helpful effects in psoriasis. The main one is an ability to slow down the skin cells which are dividing so rapidly in psoriasis. It is highly effective and most patients find their psoriasis clears completely, or nearly so, within 4-8 weeks.

How is Methotrexate taken?

Methotrexate is usually taken by mouth as a single weekly dose.

What may be the side effects of Methotrexate?

Although methotrexate has been used in the treatment of sever psoriasis for about 30 years, it can occasionally have some adverse side effects. It can occasionally make you anaemic, prone to infections and cause excessive bleeding. For these reasons, while taking methotrexate, you will need regular blood checks - frequently at first (i.e. weekly), and less often as time goes on - perhaps every 8-12 weeks once you are well under control.

Methotrexate can also damage the liver but usually only after a few years of continuous treatment. The way your liver is working can be checked from your blood, but it is possible to develop damage even if your blood tests seem normal. Therefore, it may be necessary to sample (biopsy) your liver at roughly 2-3 year intervals. If liver damage is detected early, it is not likely to get worse, and may well recover. In patients over the age of 70, a liver biopsy may not be needed.

Precautions to take while taking Methotrexate

Methotrexate does not mix with some medicines. Discuss this with your doctor. Avoid pregnancy Methotrexate affects male and female sexual/reproductive organs. You must not become pregnant or father a child whilst on methotrexate. Avoid alcohol The risk of damaging your liver can be greatly reduced by taking as little alcohol as possible while on methotrexate. The best policy is no alcohol at all except on high days and holidays (and there are not 365 of these in a year!)

Cyclosporin
What is Cyclosporin?

Cyclosporin has been extensively used in transplant patients for many years and recently has become available for severe psoriasis. It may take 3-4 weeks before you see much benefit.

How does Cyclosporin work?

Cyclosporin significantly reduces the inflammation seen in psoriasis and subsequently reduces the scaling.

How to take Cyclosporin

Cyclosporin is taken as capsules or as a solution by mouth. The doctor will tell you exactly how much and how often you should take the therapy each day. It is also important that you tell your doctor or any other doctor looking after you that you are on this medication, so that you are not prescribed any therapy that might interact with it.

What may be the side effects of Cyclosporin?

The most common side effects are nausea and indigestion. These can usually be treated very easily without stopping the Cyclosporin. Serious side effects can occur so blood test and urine test are carefully monitored. Long-term treatment may damage the kidneys and may cause high blood pressure. It is very important that you attend regularly for your hospital appointments so that relevant investigations to check your kidney and blood pressure can be arranged. Cyclosporin may cause growth retardation in a baby if you become pregnant. Thus you must not become pregnant on Cyclosporin. It is therefore important that you discuss any plans for pregnancy with your doctor before you actually conceive.

Hydroxyurea
How does the Hydroxyurea work?

Hydroxyurea slows down the rapidly dividing skin cells, a characteristic feature of psoriasis, towards their normal rate. Most patients notice an almost total clearing of the psoriasis in 8 weeks.

Has Hydroxyurea any side effects?

Although hydroxyurea has been used in the treatment of psoriasis for 30 years, it can occasionally have some adverse side effects.

It can occasionally make you anaemic, prone to infections and cause excessive bleeding. For this reason, while you are having hydroxyurea, you will require blood checks (initially weekly, then less often - perhaps every 8 weeks, once you are under control).

Adequate contraception is essential whilst on hydroxyurea and for 2 months post therapy. You must also not father a child for this time period.

How is treatment given?

It is prescribed as capsules and you will usually be asked to take 2 or 3 per day.

How long will the treatment last?

If you have not responded well in 6 weeks, alternative therapies will be discussed with you. If you respond well, treatment will continue for at least 6 months or even longer. From time to time, your doctor will probably decide to stop therapy to see if you still need it.

Rotational therapy

Most patients with severe psoriasis will be helped by at least one of these therapies. Your doctor may, from time to time, stop treatment or change the treatment to better control the disease and minimise the side effects.