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Find synonyms Find exact match. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting Psoriasis-Therapie-Center a multi-level review process, and through requirements for references to be provided Psoriasis-Therapie-Center support the content.
Appropriately referenced content is required of all authors and must conform to Psoriasis-Therapie-Center standards of evidence. Conflict of interest policy. Most cases are not severe enough to Psoriasis-Therapie-Center general health and are treated in the outpatient setting. Rare life-threatening presentations can occur that require intensive inpatient management. This topic reviews the treatment of psoriatic skin disease.
The epidemiology, clinical manifestations, and diagnosis of psoriatic Psoriasis-Therapie-Center disease are discussed in detail separately, as are psoriatic arthritis and the management Psoriasis-Therapie-Center psoriasis in pregnant women and special populations.
See Psoriasis-Therapie-Center, clinical manifestations, and diagnosis of psoriasis" and "Treatment of psoriatic arthritis" Psoriasis-Therapie-Center "Pathogenesis of psoriatic arthritis" Psoriasis-Therapie-Center "Clinical manifestations Psoriasis-Therapie-Center diagnosis of psoriatic arthritis" and "Management of psoriasis Psoriasis-Therapie-Center pregnancy" and "Treatment selection for Psoriasis-Therapie-Center to severe plaque psoriasis in special populations".
Therefore, Psoriasis-Therapie-Center of psoriasis involves addressing both psychosocial and physical aspects of the disease. Numerous topical and systemic therapies are available for the treatment of the cutaneous manifestations of psoriasis.
Treatment modalities are chosen on the basis of please click for source severity, relevant comorbidities, patient preference including cost and convenienceefficacy, and evaluation of individual patient response [ 1 ]. Although Psoriasis-Therapie-Center safety plays an important role in treatment selection, this must be balanced by Psoriasis-Therapie-Center risk of undertreatment of psoriasis, leading to inadequate clinical improvement and patient dissatisfaction [ 2,3 ].
The clinician Psoriasis-Therapie-Center to be empathetic Psoriasis-Therapie-Center spend adequate time with the patient. It may Psoriasis-Therapie-Center helpful for the clinician to touch the Psoriasis-Therapie-Center when appropriate to Psoriasis-Therapie-Center physically that the skin disorder is neither repulsive nor contagious.
Clinicians should lay out reasonable aims of treatment, making it clear to the patient that the primary goal of treatment is control Psoriasis-Therapie-Center the disease. Although treatment can provide patients with high degrees of disease improvement, there is Psoriasis-Therapie-Center cure for psoriasis.
Educating the patient about psoriasis is important and referral to an organization such as the National Psoriasis Foundation www. Patients with limited skin disease may still have significant psychosocial disability [ 6 ]. However, even patients on systemic therapy will Psoriasis-Therapie-Center continue to Psoriasis-Therapie-Center some Psoriasis-Therapie-Center agents. Topical therapy may provide symptomatic relief, minimize required doses of systemic Psoriasis-Therapie-Center, and may even be psychologically cathartic for some patients.
For purposes of treatment planning, patients may be grouped into mild-to-moderate and moderate-to-severe disease categories. Limited, or mild-to-moderate, skin disease can often be managed with topical agents, while patients with moderate-to-severe disease may need phototherapy or systemic therapy. Psoriasis-Therapie-Center location of the disease and the presence of psoriatic arthritis also affect the choice of therapy.
Psoriasis of the hand, foot, or face can be debilitating functionally or socially and may deserve a more aggressive treatment approach. The treatment of psoriatic arthritis is discussed separately.
See "Treatment of psoriatic arthritis". Moderate-to-severe psoriasis is typically defined as involvement of more than 5 to 10 percent of the body surface area the entire palmar surface, including fingers, of Psoriasis-Therapie-Center hand is approximately 1 percent of the body surface area [ 7 Psoriasis-Therapie-Center or involvement of the face, palm or sole, or disease that Psoriasis-Therapie-Center otherwise disabling.
Patients with more than 5 to 10 percent body surface area affected are generally candidates for phototherapy or systemic therapy, since application of topical agents to Psoriasis-Therapie-Center large area is not usually practical or acceptable for most patients.
Attempts to treat extensive disease with topical agents are often met with failure, can Psoriasis-Therapie-Center cost, Psoriasis-Therapie-Center lead to frustration in the patient-clinician relationship. There is ample evidence of efficacy of the newer systemic therapies "biologics" ; however, cost is a major consideration with these agents.
Established therapies such as methotrexate and phototherapy continue to play a role in the management of moderate to severe plaque psoriasis. Psoriasis-Therapie-Center management of patients with extensive or recalcitrant Psoriasis-Therapie-Center is a challenge even for experienced dermatologists. However, the availability Psoriasis-Therapie-Center biologic medications has reduced the challenge considerably.
The concept that many patients with psoriasis in the United States do not receive sufficient treatment to Psoriasis-Therapie-Center the disease is suggested by an analysis of surveys performed by the National Psoriasis Foundation between and [ 2 ]. Among the survey respondents with psoriasis, 52 percent expressed dissatisfaction with their treatment.
Many patients received no treatment, including 37 to 49 percent of respondents with mild psoriasis, 24 to 36 percent of respondents with moderate psoriasis, and 9 to 30 percent of respondents with severe psoriasis. Further studies will be useful for clarifying the reasons for these observations and for determining the value of interventions to increase the accessibility of treatment. Widespread pustular disease requires aggressive treatment, which may include hospitalization. Therapeutic approaches to generalized pustular psoriasis Psoriasis-Therapie-Center psoriatic arthritis are discussed separately.
Management" and "Treatment of psoriatic arthritis". Alternatives include vitamin D analogs, such as calcipotriene and calcitriolPsoriasis-Therapie-Center, and topical retinoids Psoriasis-Therapie-Center. For facial or intertriginous Psoriasis-Therapie-Center, topical tacrolimus or pimecrolimus may be used as alternatives or as corticosteroid sparing agents, though Psoriasis-Therapie-Center may not be as rapid. Localized phototherapy is another option for recalcitrant disease.
Combinations of Psoriasis-Therapie-Center topical corticosteroids table 1 and either calcipotriene, calcitriolPsoriasis-Therapie-Centeror UVB Psoriasis-Therapie-Center are commonly prescribed by dermatologists. Calcipotriene in combination with Psoriasis-Therapie-Center I topical corticosteroids is highly effective for Psoriasis-Therapie-Center control.
Calcipotriene alone can then be used continuously and the combination with potent corticosteroids used intermittently on weekends for maintenance. A combination product containing calcipotriene and betamethasone dipropionate is available for this use.
With proper adherence, considerable improvement with topical therapies may be seen in as little as one week, though several weeks may be required to demonstrate full benefits. Because adherence to topical Psoriasis-Therapie-Center see more be a major hurdle, keeping the treatment regimen Psoriasis-Therapie-Center and using treatment vehicles that the patient Psoriasis und Behandlung zu Hause acceptable is often beneficial [ 8 ].
Improvement usually occurs within weeks. Patients with severe psoriasis generally require care by a dermatologist. Topical calcipotriene or calcitriol and the topical calcineurin inhibitors tacrolimus or pimecrolimus are additional first-line treatments [ 9,10 ].
These agents may be used alone or in combination with topical corticosteroids Psoriasis-Therapie-Center corticosteroid sparing agents Psoriasis-Therapie-Center long term maintenance therapy.
Calcipotriene, tacrolimus, and pimecrolimus are more expensive options than topical corticosteroids. For many patients, lotion, Psoriasis-Therapie-Center, gel, foam, or spray vehicles are preferable to thicker creams or ointments. Topical corticosteroids are the primary topical agents used for psoriasis on the scalp [ 11 ]. Support for the use of these agents is evident in a systematic review of randomized trials that found that very potent or potent topical Psoriasis-Therapie-Center are more effective treatments for scalp psoriasis than topical vitamin D analogs [ 12 ].
Combining a corticosteroid and vitamin D analog may offer additional benefit; in the systematic review, combination treatment with a potent topical Psoriasis-Therapie-Center and a vitamin D analog appeared slightly more effective than potent topical corticosteroid monotherapy.
However, in clinical practice, complicating the treatment regimen with more than one topical product may reduce the likelihood of consistent adherence to the treatment regimen. Psoriasis-Therapie-Center, we usually prescribe a topical corticosteroid alone as initial therapy. Commercial betamethasone dipropionate-calcipotriene combination products are available, but are more expensive than most topical corticosteroid preparations.
Other topical therapies used for psoriasis eg, tazarotenecoal tar shampoo, anthralin and intralesional corticosteroid injections also may be beneficial for scalp involvement, though data on Psoriasis-Therapie-Center specifically in scalp disease are limited [ 11 ].
Salicylic acid can be a helpful adjunctive Psoriasis-Therapie-Center because of its keratolytic effect. Phototherapy eg, excimer laser and systemic agents are additional treatment Psoriasis-Therapie-Center for patients who cannot achieve sufficient improvement with topical agents [ 11 ]. Approaches include potent topical corticosteroids and topical bath psoralen plus UVA phototherapy Psoriasis-Therapie-Center. See "Psoralen plus ultraviolet A PUVA photochemotherapy".
Data are limited on the use of Psoriasis-Therapie-Center retinoids for localized pustular psoriasis. However, these drugs appear to be particularly effective in the treatment of pustular psoriasis, and we consider Psoriasis-Therapie-Center first line therapy.
Acitretin is the retinoid that is used most Psoriasis-Therapie-Center for this indication. Acitretin is a potent teratogen and should not be used in women who might become pregnant. Pregnancy is contraindicated for three years following acitretin Psoriasis-Therapie-Center. The management of Psoriasis-Therapie-Center psoriasis is reviewed in detail separately.
Based upon data from open-label or retrospective Psoriasis-Therapie-Center and case reports, a panel of experts suggested that patients with severe, unstable disease should be treated with cyclosporine or infliximab due to the rapid onset and high efficacy of these agents [ 13 Psoriasis-Therapie-Center. Patients with less acute disease can be treated with acitretin or methotrexate as first-line agents.
The panel advised against the use of systemic glucocorticoids due to the perceived potential for these drugs to induce a flare of psoriasis upon withdrawal Psoriasis-Therapie-Center therapy. Data are limited on the efficacy of Psoriasis-Therapie-Center agents other than infliximab for the treatment of erythrodermic psoriasis.
Etanercept was effective in an open-label study of Psoriasis-Therapie-Center patients [ 14 ], and case reports have documented successful treatment with adalimumab and ustekinumab [ 15,16 ]. Topical therapies, such Psoriasis-Therapie-Center mid-potency topical corticosteroids, emollients, wet dressings, and oatmeal baths can be used in concordance with systemic treatment Psoriasis-Therapie-Center manage symptoms [ 13 ].
Long-term maintenance therapy for psoriasis is required. Many agents used in the treatment Psoriasis-Therapie-Center adult psoriasis have also been used for children Psoriasis-Therapie-Center 17 ].
However, high Psoriasis-Therapie-Center studies on the efficacy and safety of Psoriasis-Therapie-Center for psoriasis Psoriasis-Therapie-Center children are limited. Guidelines for the treatment of children based upon the available evidence have been published [ 18 Psoriasis-Therapie-Center. See Psoriasis-Therapie-Center selection for moderate to severe plaque psoriasis in special populations" and "Management of psoriasis in pregnancy".
Published guidelines for the treatment of psoriasis with Psoriasis-Therapie-Center therapies are available [ 19 ]. Keeping psoriatic skin soft and moist Psoriasis-Therapie-Center the symptoms of itching Psoriasis-Therapie-Center tenderness. Additionally, maintaining proper skin hydration can help prevent irritation and thus the potential for subsequent Koebnerization development of new psoriatic lesions at sites of trauma.
The most effective are ointments such as petroleum jelly or thick creams, especially when applied immediately after a hydrating bath or shower. The mechanism of action of corticosteroids in psoriasis is not fully Psoriasis-Therapie-Center. Corticosteroids exert antiinflammatory, antiproliferative, and immunosuppressive actions by Psoriasis-Therapie-Center gene transcription.
The inherent potency of Psoriasis-Therapie-Center topical corticosteroid is frequently reported using a I to Psoriasis-Therapie-Center scale based on vasoconstrictive assays table 1. Although ointments are sometimes thought to be inherently more effective because Psoriasis-Therapie-Center their occlusive properties, this is not uniformly correct.
To minimize adverse effects Psoriasis-Therapie-Center maximize compliance, the site of application needs to be considered in choosing the appropriately potent corticosteroid:. The typical regimen consists of twice daily application of topical corticosteroids.
Most patients will show a rapid decrease in inflammation Psoriasis-Therapie-Center such therapy, Psoriasis-Therapie-Center complete normalization of skin or lasting remission is unpredictable. Topical corticosteroids generally can be continued as long as the patient has thick active lesions.
Skin atrophy from topical corticosteroids usually is not a problem Psoriasis-Therapie-Center the medication is continuously applied after the skin has returned to normal thickness. Once clinical improvement occurs, the frequency of Psoriasis-Therapie-Center should be reduced [ 19 ]. For patients in whom lesions recur quickly, topical corticosteroids can be click at this page intermittently such as on weekends only to maintain improvement.
The addition Psoriasis-Therapie-Center non-corticosteroid topical treatments can also facilitate the avoidance of long-term Psoriasis-Therapie-Center topical corticosteroids. The risks of cutaneous and systemic side effects associated with Psoriasis-Therapie-Center topical corticosteroid use are increased with high potency formulations.
Data support limiting the continuous application of Class I topical corticosteroids to two to four weeks; thus, close clinician supervision should be employed if longer treatment durations are required table 1 Psoriasis-Therapie-Center 19 ]. Data are Psoriasis-Therapie-Center clear regarding treatment durations for Psoriasis-Therapie-Center potent topical corticosteroids. Side effects Psoriasis-Therapie-Center topical corticosteroids, including the potential for suppression of the hypothalamic axis, are discussed separately.
See "Pharmacologic use of glucocorticoids" and "General principles Psoriasis-Therapie-Center dermatologic therapy and topical corticosteroid use". The Psoriasis-Therapie-Center of topical corticosteroids varies widely. The price of a 60 gram tube of a potent corticosteroid brand name product can be hundreds of dollars. There are generic preparations in each potency class Psoriasis-Therapie-Center have reduced the Psoriasis-Therapie-Center somewhat, though generic prices in the United Psoriasis-Therapie-Center are rising [ 21 ].
Different formulations have been developed in an effort to enhance the delivery Psoriasis-Therapie-Center topical corticosteroids. Betamethasone valerate in a foam had superior efficacy for scalp psoriasis and was preferred by patients when compared with betamethasone valerate lotion [ 22 ].
The foam becomes a liquid on contact with skin and is also well tolerated by patients with trunk and extremity psoriasis [ 23 ]. A Psoriasis-Therapie-Center propionate Psoriasis-Therapie-Center is also available; like foams, Psoriasis-Therapie-Center are easy to apply to large areas [ 24 ]. The main advantage of Psoriasis-Therapie-Center newer preparations is likely greater patient acceptance, which may translate into greater adherence; the main disadvantage is cost.
Although topical vitamin D analogs are effective as monotherapy for some patients, a systematic review found that combination therapy with a topical corticosteroid is more effective than either treatment alone [ 25 ]. Untilcalcipotriene was the only topical vitamin D analog available in the United States. Calcipotriene is obtainable as a cream, solution, Psoriasis-Therapie-Center, or foam, or as a combination ointment, suspension, or foam with betamethasone dipropionate.
Topical calcitriol ointment has been prescribed in Europe for years, and is now available in the United States. When compared with Psoriasis-Therapie-Center, calcitriol appears Psoriasis-Therapie-Center induce less irritation in sensitive areas of the skin eg, skin folds [ 26 ].
The precise mechanism is not clear, but a major effect is the hypoproliferative effect on keratinocytes [ 27 ]. An immune modulating effect has been postulated for calcipotriene, but has not been shown to be significant in psoriasis to date [ 28 ]. Only potent topical Psoriasis-Therapie-Center appeared to have comparable efficacy at eight weeks. Skin irritation is the main adverse event associated with calcipotriene.
Combined use of calcipotriene Psoriasis-Therapie-Center superpotent corticosteroids has demonstrated increased clinical response and tolerance in clinical trials compared with either agent used alone [ ].
One regimen Psoriasis-Therapie-Center daily use of both calcipotriene ointment and halobetasol ointment for two weeks, followed by weekend use of the halobetasol ointment and weekday use Psoriasis-Therapie-Center calcipotriene [ 30 ].
Psoriasis-Therapie-Center regimen produced six-month remission maintenance in 76 percent compared with 40 percent with weekend halobetasol alone. A similar regimen with calcipotriene ointment and clobetasol propionate foam also appears Psoriasis-Therapie-Center be effective [ 33 ].
In addition, a randomized trial found that a preparation that combines calcipotriene with betamethasone dipropionate 0. Patients who use topical corticosteroids in combination with calcipotriene must be monitored for adverse effects as with corticosteroid monotherapy.
Thus, topical calcipotriene may be used as an alternative or adjunct to topical corticosteroid therapy. It is applied twice Psoriasis-Therapie-Center when used as monotherapy. No controlled trials guide how best to use topical corticosteroids in Psoriasis-Therapie-Center with calcipotriene.
Once Psoriasis-Therapie-Center use of each Psoriasis-Therapie-Center be adequate. Acidic products can inactivate topical calcipotriene, and some topical corticosteroids may be acidic.
A reasonable approach to combination therapy is to have patients apply topical calcipotriene and topical Psoriasis-Therapie-Center each once daily at different times of day. Other than skin irritation, side effects of topical calcipotriene are usually minimal; the risk of hypercalcemia is low when the drug is used appropriately [ 35 ].
However, topical calcipotriene is more expensive than many generic potent corticosteroids. In addition, calcitriol inhibits T-cell proliferation and other inflammatory mediators [ 36 ]. At the end of the study periods up Psoriasis-Therapie-Center eight weeks In a systematic review, calcipotriene and calcitriol were equally effective [ 25 ]. However, on sensitive areas of the skin, calcitriol appears to be less irritating than calcipotriene.
Perilesional erythema, perilesional edema, and stinging or burning sensations were significantly lower in Psoriasis-Therapie-Center areas treated with calcitriol. A week open-label study of the Psoriasis-Therapie-Center of calcitriol ointment did continue reading reveal an adverse effect on Psoriasis-Therapie-Center homeostasis [ 38 ].
Psoriasis-Therapie-Center to calcipotriene, calcitriol ointment is more expensive than many generic potent topical corticosteroids. Psoriasis-Therapie-Center drug is applied twice daily. The precise mechanism of action Psoriasis-Therapie-Center tar is not known; it has an apparent antiproliferative effect. Tar can be helpful as an adjunct to topical corticosteroids.
Tar products are available without a prescription in the form of shampoos, creams, lotions, ointments, and oils. Newer products include a solution and a foam. Some patients may prefer the less messy formulations. Tar can also be Psoriasis-Therapie-Center into Psoriasis-Therapie-Center and ointments.
Topical tar preparations, including shampoos, creams, Psoriasis-Therapie-Center other preparations, can be used once daily. Patients should Psoriasis-Therapie-Center warned that tar products have the potential to stain hair, skin, and clothing. It may help to use them at night and wear inexpensive night clothes eg, old pajamas as Psoriasis-Therapie-Center tend to be messy.
Patients may also find the odor of tar products unpleasant. For shampoos, the emphasis should be on making sure the product reaches the scalp. Tar shampoo should be left in place Psoriasis-Therapie-Center 5 to 10 minutes before rinsing it out. Another study found Psoriasis-Therapie-Center once daily administration of tazarotene gel, 0. Absorption Psoriasis-Therapie-Center tazarotene please click for source minimal over the Psoriasis-Therapie-Center course of the study, suggesting that systemic toxicity Psoriasis-Therapie-Center unlikely during Psoriasis-Therapie-Center therapy.
A small uncontrolled study of short contact tazarotene found that a 20 minute application followed by washing appeared to be less irritating Psoriasis-Therapie-Center traditional use, and seemed to have similar efficacy [ 43 ].
Irritation limits use of tazarotene by itself; the irritation is Psoriasis-Therapie-Center by concomitant treatment with a topical corticosteroid [ 44 ]. Facial and intertriginous areas Psoriasis-Therapie-Center be well suited to Psoriasis-Therapie-Center treatments, which can allow patients to avoid chronic topical go here use:.
Topical tacrolimus and pimecrolimus are generally well tolerated when used to treat facial and intertriginous psoriasis [ 49,50 ]. However, corticosteroid therapy may be more effective, at least compared with pimecrolimus.
This was suggested in a four-week randomized trial in 80 patients with intertriginous psoriasis that compared various therapies applied once daily [ 51 ]. Inthe US Food and Drug Administration FDA issued an alert about a possible link between topical tacrolimus and pimecrolimus and cases of lymphoma and skin cancer in children and adults [ Psoriasis-Therapie-Center ], and in placed a "black Psoriasis-Therapie-Center warning on Psoriasis-Therapie-Center prescribing information for these medications [ 53 ].
No definite causal relationship has been established; however, the FDA recommended that these agents only be used as second line agents for atopic dermatitis. Subsequent studies Psoriasis-Therapie-Center not, however, found evidence of an increased risk of lymphoma [ 54,55 ].
The mechanism of action of anthralin in psoriasis is not well Psoriasis-Therapie-Center, but may involve antiinflammatory effects and normalization of keratinocyte differentiation [ 19 ]. Skin irritation is an expected side effect of anthralin that Psoriasis-Therapie-Center limit the use of this therapy. This side effect and the ability of anthralin to cause permanent red-brown stains on clothing and temporary staining of skin have contributed to a decline in the use Psoriasis-Therapie-Center anthralin therapy.
In order to minimize irritation, anthralin treatment is Psoriasis-Therapie-Center prescribed as a short-contact regimen that is titrated according to patient tolerance.
For example, treatment may begin with concentrations as low as 0. Then, Psoriasis-Therapie-Center, serial increases in the concentration of anthralin can be performed eg, 0.
Subsequently, the application time is titrated up to 20 to 30 minutes as tolerated. Application to surrounding unaffected skin should be avoided to minimize irritation. For patients with well-defined plaques, petrolatum or zinc oxide may be applied to the surrounding skin as a Salbe für Psoriasis, Tag und Nacht prior to application.
After the Psoriasis-Therapie-Center contact period has elapsed, anthralin should be washed off the treated area [ 19 ]. Benefit from anthralin therapy is often evident within the first few weeks of therapy. When administered by patients in the outpatient setting, anthralin is less effective than topical vitamin D or potent topical corticosteroid therapy Psoriasis-Therapie-Center 25,60,61 ].
As an example, patients often notice improvement in skin lesions during the summer months. UV radiation may act via antiproliferative Psoriasis-Therapie-Center slowing keratinization and anti-inflammatory effects inducing apoptosis of pathogenic T-cells in psoriatic plaques. In choosing UV therapy, consideration must be given to the potential for UV radiation to accelerate photodamage and increase the risk of cutaneous malignancy.
Phototherapy and photochemotherapy require the supervision of a dermatologist trained in these treatment modalities. The American Academy of Dermatology has provided guidelines for the treatment of psoriasis with ultraviolet light Psoriasis-Therapie-Center 62 ].
Despite Psoriasis-Therapie-Center efficacy and safety, the use of office-based phototherapy has declined in Psoriasis-Therapie-Center United States because Psoriasis-Therapie-Center administrative issues and the development of new systemic medications [ 63 ].
The mechanism of action of UVB is Psoriasis-Therapie-Center through its immunomodulatory effects [ 64 ]. Patients receive near-erythema-inducing doses Psoriasis-Therapie-Center UVB at least three times weekly until remission is achieved, after which a maintenance regimen is usually recommended to prolong the remission.
Suberythemogenic doses Psoriasis-Therapie-Center narrow band UVB are more effective than broadband UVB in clearing Psoriasis-Therapie-Center psoriasis [ 65 ]. Apoptosis of T cells is also more common with nm than with broadband UVB.
With oral PUVA, patients ingest the Psoriasis-Therapie-Center drug, 8-methoxypsoralen, Psoriasis-Therapie-Center within two hours by Psoriasis-Therapie-Center to UVA; Psoriasis-Therapie-Center sequence is performed three times weekly in increasing doses until remission, then twice or once weekly as a maintenance dose.
With bath PUVA, the psoralen capsules are dissolved in water, and affected skin hands, feet, or total body is soaked for 15 to 30 minutes prior to UVA exposure. There are few data on the comparative efficacy of oral and bath PUVA for psoriasis. A small open randomized trial of 74 patients with moderate to severe psoriasis did not find a significant difference in efficacy between the two Psoriasis-Therapie-Center [ 67 ].
Additional studies are necessary to confirm this finding. Some patients take psoralen Psoriasis-Therapie-Center to coming into the office or clinic for PUVA. Increased photosensitivity is typically Psoriasis-Therapie-Center starting one hour after an oral dose and resolves after eight hours. Pre and Psoriasis-Therapie-Center treatment photoprotection eg, hat, sunscreen, sun protective goggles are critical more info preventing serious burn injury to the Psoriasis-Therapie-Center and eyes from being outside.
Pretreatment emollients have long been thought to improve results with UVB. Psoriasis-Therapie-Center, while thin oils do not impede UV penetration, emollient creams can actually inhibit the penetration of the Psoriasis-Therapie-Center and should not be applied before treatment [ 68 ]. Gentle removal of plaques by bathing does help prior to UV exposure. Uncertainty remains about the comparative efficacy of UVB phototherapy and PUVA photochemotherapy for plaque psoriasis. Psoriasis-Therapie-Center trials comparing the efficacy of narrowband UVB to PUVA have yielded inconsistent findings [ 69 ].
Psoriasis-Therapie-Center convenience of not needing to administer a Psoriasis-Therapie-Center prior Psoriasis-Therapie-Center treatment is a favorable feature of Psoriasis-Therapie-Center phototherapy. This option may be preferred by patients who are not in close proximity to an office-based phototherapy center, Psoriasis-Therapie-Center schedules do not permit frequent office visits, or for whom the costs of in-office treatment exceed those of a home phototherapy unit.
Insurance coverage of these units varies. For some dermatologists, uncertainty regarding the safety of Psoriasis-Therapie-Center units has led to a Psoriasis-Therapie-Center to prescribe them.
Some have expressed concern for the potential for improper or excessive usage of these devices [ 71 ]. In contrast, a randomized trial of Psoriasis-Therapie-Center found that narrowband UVB administered via home units was as safe and effective as office-based treatments [ 71 Psoriasis-Therapie-Center. Home phototherapy units that are equipped with electronic Psoriasis-Therapie-Center that allow only a prescribed number of treatments are available and may help to mitigate clinician concerns.
Commercial tanning beds can improve psoriasis and are occasionally used for patients without access to medical phototherapy [ 72,73 ]. However, data are limited on this mode of treatment, and clinicians and patients should be cognizant that there is significant variability in the UV output of tanning beds [ 74 ].
The Psoriasis-Therapie-Center allows treatment of only involved skin; thus, considerably higher doses of UVB Hanf Psoriasis be administered to psoriatic plaques at a given treatment compared with traditional phototherapy.
Uncontrolled trials suggest that laser therapy results in faster responses than conventional phototherapy [ 75,76 ]. As an example, one study of excimer laser therapy involved patients with stable mild to moderate plaque psoriasis, of whom 80 completed the entire protocol [ 75 ].
Treatments were scheduled twice weekly. After 10 or fewer Psoriasis-Therapie-Center, 84 and 50 percent of patients achieved the outcomes of 75 percent or better and 90 percent or better clearing of plaques, respectively. This number of treatments was far fewer than that typically required of phototherapy 25 or more. Side effects of laser therapy included erythema and blistering; these were generally well tolerated, and no patient discontinued therapy because of adverse effects. A common sequela of excimer laser therapy is the Psoriasis-Therapie-Center of UV-induced hyperpigmentation tanning in treated areas, which can be cosmetically distressing for some patients.
Hyperpigmentation resolves after the discontinuation of treatment. Like nm UVB, the excimer laser represents a therapeutic advance Psoriasis-Therapie-Center specific wavelength therapies for psoriasis.
While both the excimer laser and narrow band UVB are approved for use in psoriasis, inconsistencies in third party coverage for these treatments limit their utilization. Ongoing monitoring is indicated in patients who have received prolonged courses of PUVA. In general, phototherapy is contraindicated in patients with a history of melanoma or extensive nonmelanoma skin cancer. In an in vitro study, exposure of plasma to UVA led to Psoriasis-Therapie-Center 30 to 50 percent decrease in the serum folate level within 60 minutes Psoriasis-Therapie-Center 77 ].
However, folate deficiency secondary to UVA exposure has not been proven Psoriasis-Therapie-Center occur in vivo. In a small randomized trial of healthy subjects, no difference in serum folate levels was identified between subjects Psoriasis-Therapie-Center with Psoriasis-Therapie-Center for six sessions and untreated subjects [ 78 ]. In addition, an observational study of 35 psoriasis patients found that narrow band UVB had no effect on serum folate levels after 18 treatment sessions [ 79 ].
Bathing in sea water in combination with sun exposure climatotherapy has also been used Psoriasis-Therapie-Center a therapy for psoriasis, as has the use of salt water baths with artificial UV exposure balneophototherapy. A large, open, randomized trial Psoriasis-Therapie-Center that treatment with UVB after a saltwater bath had greater efficacy than UVB after a tap-water bath, and similar efficacy to Psoriasis-Therapie-Center PUVA [ 80 ].
Although the raters of disease severity were intended to be blinded, treatment assignment was Psoriasis-Therapie-Center to the raters in nearly 60 percent of cases. In per-protocol analyses, no difference was found between saltwater and tap-water baths, and bath PUVA was superior to UVB after a saltwater bath. Additional studies are required to demonstrate that combining saltwater baths with phototherapy is superior to tap-water baths plus phototherapy or to phototherapy alone.
In andthe American Academy of Dermatology published guidelines for the management of psoriasis with systemic therapies [ 81,82 ]. Inan update to Psoriasis-Therapie-Center European S3-Guidelines on the Psoriasis-Therapie-Center treatment of psoriasis was published [ 84 ]. Options for systemic therapy include immunosuppressive Psoriasis-Therapie-Center immunomodulatory drugs such as methotrexatecyclosporinePsoriasis-Therapie-Center and biologic agents.
Systemic retinoids, which improve psoriasis through effects Psoriasis-Therapie-Center epidermal proliferation and Psoriasis-Therapie-Center as well Psoriasis-Therapie-Center immunomodulation, are also used for the treatment of this condition [ 81 ]. Psoriasis-Therapie-Center efficacies of the various systemic treatments for psoriasis were compared in a systematic review of randomized trials.
Indirect comparisons of the proportion of Psoriasis-Therapie-Center in placebo-controlled trials who achieved at least 75 Psoriasis-Therapie-Center improvement in the Psoriasis Area and Severity Psoriasis-Therapie-Center PASI score Psoriasis-Therapie-Center 8 to 16 weeks of treatment showed that the efficacy of infliximab within this time period was Psoriasis-Therapie-Center to etanerceptadalimumabustekinumab 45 mg dosealefacept, cyclosporineand methotrexate [ 85 ].
In addition, head-to-head trials included in the systematic review supported the superiority of infliximab and adalimumab over Psoriasis-Therapie-Center therapy and the superiority of Psoriasis-Therapie-Center over etanercept therapy.
Although knowledge of the relative Psoriasis-Therapie-Center of systemic treatments for psoriasis is Psoriasis-Therapie-Center, consideration of factors Psoriasis-Therapie-Center as drug side Psoriasis-Therapie-Center, patient preference, drug availability, and treatment cost eg, the high cost of biologic agents compared with conventional therapies also play an important role in treatment selection.
It is also Psoriasis-Therapie-Center for the treatment of psoriatic arthritis and psoriatic nail disease. Initial thoughts Psoriasis-Therapie-Center the Psoriasis-Therapie-Center of action centered around Psoriasis-Therapie-Center antiproliferative effects of methotrexate on DNA synthesis in epidermal cells; subsequent evidence supports the concept that it is the immunosuppressive effects of methotrexate Psoriasis-Therapie-Center activated T-cells that controls psoriasis [ 87 ].
In one trial, patients with moderate to severe plaque psoriasis Psoriasis-Therapie-Center randomized to receive oral methotrexate 7. After 16 weeks, the proportion of patients achieving a 75 percent improvement in the PASI score with methotrexate Psoriasis-Therapie-Center more than Psoriasis-Therapie-Center with placebo but less than with adalimumab 36, 19, and 80 percent, respectively.
A placebo-controlled randomized trial evaluating subcutaneous methotrexate After 16 weeks, 37 of 91 patients 41 percent in the methotrexate group achieved 75 percent improvement in the PASI score compared with 3 of 29 patients 10 percent in the placebo group [ 86 ]. Methotrexate is usually administered in an intermittent low-dose regimen such as once weekly.
Similar regimens are in use in Psoriasis-Therapie-Center with rheumatoid arthritis. Administration can be oral, intravenous, intramuscular, or subcutaneous; the usual dose range is between 7. Unlike cyclosporinewhich is generally used for only limited courses of treatment, methotrexate can be used for long-term therapy. Folic acid1 mg daily, protects against some of the common side effects seen with low-dose methotrexate such as stomatitis [ 89 ].
Folate does not appear Psoriasis-Therapie-Center protect against pulmonary toxicity, and it is Psoriasis-Therapie-Center whether it protects against hepatic toxicity; monitoring for bone Psoriasis-Therapie-Center suppression and hepatotoxicity are Psoriasis-Therapie-Center during Psoriasis-Therapie-Center. Concurrent use of other medications that interfere with folic acid metabolism, such as Gute Hilfe Salbe antibiotics, can increase the toxicity of methotrexate.
See "Major side effects of low-dose methotrexate". For patients with one or more risk factors for hepatotoxicity from methotrexateuse of a different systemic drug continue reading be considered. Inthe AAD and the National Psoriasis Foundation updated this recommendation with monitoring guidelines that are dependent upon the presence or absence of risk factors for hepatotoxicity [ Psoriasis-Therapie-Center ].
Risk factors for hepatotoxicity from methotrexate include [ 91 ]:. Patients without risk factors for hepatotoxicity should have liver chemistries drawn every one to three months. If five out of nine serum AST levels are elevated over the course of 12 months, or if the serum albumin level is decreased in the context of normal nutritional status and well-controlled psoriasis, a liver biopsy should be performed. Liver biopsy should also be considered after a cumulative dose of 3.
Once patients have reached this dose, options include proceeding with a liver biopsy, continuing to monitor without a liver biopsy, or discontinuing methotrexate therapy. In Psoriasis-Therapie-Center with risk factors for hepatotoxicity for whom the decision is made to proceed with methotrexatePsoriasis-Therapie-Center biopsies are considered earlier in the course of therapy.
Since a Psoriasis-Therapie-Center number of patients Psoriasis-Therapie-Center discontinue therapy within the first two to six months, it is reasonable to perform the biopsy after this time period. For patients Psoriasis-Therapie-Center continue methotrexate, liver biopsies should be click here after every 1 to 1.
Once Psoriasis-Therapie-Center have reached this dose, options include proceeding with Psoriasis-Therapie-Center liver biopsy, discontinuing methotrexate, Psoriasis-Therapie-Center consulting with a hepatologist for further evaluation. Psoriasis-Therapie-Center retinoid of choice in psoriasis is acitretin. In a pilot study, 6 of 11 patients with psoriasis click HIV infection achieved Psoriasis-Therapie-Center to excellent results with Psoriasis-Therapie-Center therapy, with four achieving complete clearing of their skin disease [ 92 ].
The usual dose range of acitretin is 25 mg every other day to 50 mg daily. Acitretin can be used in combination with UVB or PUVA therapy. Used in this way, patients see more higher response rates with better tolerance and less UV exposure [ 93,94 ].
Monitoring for hypertriglyceridemia and hepatotoxicity are required with retinoid therapy. Common side effects include cheilitis and alopecia. Acitretin is teratogenic; it is only indicated in men and in women of non-reproductive potential. Pregnancy is contraindicated for three years after discontinuing the drug [ 95 ]. Improvement is generally observed within four weeks. The use of cyclosporine in psoriasis is based upon multiple Psoriasis-Therapie-Center supporting its status as a highly and rapidly effective treatment [ 81, ].
As an example, a Psoriasis-Therapie-Center randomized trial found that after eight weeks of treatment with 3, 5, or 7. All three regimens were superior to placebo, and patients who received the 5 mg dose were least Psoriasis-Therapie-Center to require dose alterations due to Psoriasis-Therapie-Center effects or lack of efficacy. A few randomized trials have compared the efficacy Psoriasis-Therapie-Center cyclosporine and methotrexateutilizing varying treatment regimens Psoriasis-Therapie-Center Menü in Psoriasis Tabelle different Psoriasis-Therapie-Center. Close monitoring is required since renal toxicity and hypertension are common and often limit the long-term Psoriasis-Therapie-Center of cyclosporine Psoriasis-Therapie-Center patients with psoriasis.
See "Cyclosporine and tacrolimus nephrotoxicity". An investigational oral Psoriasis-Therapie-Center inhibitor, ISA, was Psoriasis-Therapie-Center in randomized trials Psoriasis-Therapie-Center patients with moderate to severe plaque psoriasis, and may have less nephrotoxicity than cyclosporine [ ].
The available biologics for psoriasis have excellent short-term and Psoriasis-Therapie-Center efficacy and favorable tolerability. Biologic therapies available for the treatment of psoriasis in the United Psoriasis-Therapie-Center include etanerceptinfliximabadalimumabustekinumabsecukinumaband ixekizumab. Network meta-analyses evaluating etanerceptinfliximabadalimumaband ustekinumab Psoriasis-Therapie-Center the designation of infliximab as the most effective of these biologic agents for psoriasis [ ].
As an example, Psoriasis-Therapie-Center the first network meta-analysis of randomized trials for biologic therapy designed to adjust for Psoriasis-Therapie-Center variability in reference arm responses, infliximab was associated with the highest likelihood for achieving 75 percent improvement in Psoriasis Area and Severity Index PASI 75 scores [ ].
In addition, ustekinumab 45 or 90 mg dose and adalimumab yielded significantly higher Psoriasis-Therapie-Center 75 rates than etanercept 25 or 50 mg dose. Of note, the network meta-analysis was based upon PASI 75 rates achieved after 8 to 16 weeks of therapy. Therefore, these results may not be applicable to longer periods of drug use.
A subsequent systematic review and meta-analysis that included the newer biologic agent secukinumab and Psoriasis-Therapie-Center randomized trials with treatment durations of at least 24 Psoriasis-Therapie-Center found evidence to support infliximab, secukinumab, and ustekinumab as the most effective long-term therapies [ ]. In a head-to-head trial, a week course of secukinumab was Psoriasis-Therapie-Center effective than ustekinumab.
Alefacept, another biologic agent, is no longer marketed. Itolizumab, a biologic agent marketed in India, is not available in the United States. There is a concern that all tumor necrosis factor TNF -alpha Psoriasis-Therapie-Center have the potential to activate latent infections such as tuberculosis, and increased rates of infection have been seen in patients with rheumatoid arthritis treated with etanerceptinfliximaband adalimumab.
In addition, risk for herpes zoster may be increased Psoriasis-Therapie-Center patients receiving biologic Psoriasis-Therapie-Center in combination with methotrexate [ ]. An analysis of data from adults with psoriasis in a large registry of patients eligible to receive Psoriasis-Therapie-Center receiving conventional systemic or biologic therapy Psoriasis Longitudinal Assessment and Registry [PSOLAR] found a higher risk of serious infections with adalimumab and Psoriasis-Therapie-Center compared Psoriasis-Therapie-Center non- methotrexate and nonbiologic therapies [ ].
Serious Psoriasis-Therapie-Center rates among patients treated with infliximab, adalimumab, etanerceptand ustekinumab were 2. Among patients who had never received a biologic therapy or methotrexate and patients who had never received a biologic therapy but had received methotrexate, rates were 1. Data from another study of 12, patients in the PSOLAR registry provides some reassurance regarding the use of biologic therapy for psoriasis [ ]. Compared with treatment with non-biologic agents, biologic therapy did not appear to be a significant predictor of death, major adverse Psoriasis-Therapie-Center events Psoriasis-Therapie-Centeror malignancy.
Patients were not randomized to the different treatment arms in the PSOLAR registry, and therefore selection bias could account for differences or lack Psoriasis-Therapie-Center differences between groups.
Potential side-effects of TNF-alpha inhibitors are reviewed in greater detail separately. See "Tumor necrosis factor-alpha inhibitors: Bacterial, viral, and fungal infections" and "Tumor necrosis factor-alpha inhibitors and mycobacterial infections" and "Tumor necrosis factor-alpha inhibitors: Risk of malignancy" and "Tumor necrosis factor-alpha inhibitors: An overview of adverse effects".
It is approved by the US Food and Drug Administration FDA for adults with psoriatic arthritis and for patients age four years Psoriasis-Therapie-Center older with chronic moderate to severe plaque psoriasis.
Standard dosing for etanercept for adults is subcutaneous injection of 50 mg twice weekly for the Psoriasis-Therapie-Center three months of therapy, followed by a 50 Psoriasis-Therapie-Center injection once weekly for maintenance therapy. Standard pediatric Psoriasis-Therapie-Center is 0. A randomized trial of etanercept in adult patients with active but stable plaque psoriasis involving Psoriasis-Therapie-Center least Psoriasis-Therapie-Center percent of Psoriasis-Therapie-Center body Psoriasis-Therapie-Center area found three doses Psoriasis-Therapie-Center subcutaneous etanercept 25 mg weekly, 25 mg twice weekly, 50 mg twice weekly Psoriasis-Therapie-Center superior to placebo [ ].
After 12 weeks, there was at least a 75 percent improvement in a psoriasis area and severity index PASI score in 14, 34, 49, and 4 percent, respectively. After 24 weeks, Psoriasis-Therapie-Center an improvement was seen in 25, 44, and 59 percent, respectively no patients Psoriasis-Therapie-Center placebo for more Psoriasis-Therapie-Center 12 Psoriasis-Therapie-Center. Etanercept was well tolerated with adverse events and infections occurring at similar rates in all four groups.
A week randomized trial found similar benefits with subcutaneous etanercept 50 Psoriasis-Therapie-Center twice weekly, and that, compared with placebo, patients receiving etanercept had significant improvements Psoriasis-Therapie-Center measures of fatigue and depression [ ].
Another randomized trial demonstrated efficacy in children and adolescents with moderate to severe plaque psoriasis [ ]. The long-term safety of etanercept for psoriasis is supported by a week study of etanercept 50 mg twice Psoriasis-Therapie-Center [ ]. The formation of anti- etanercept antibodies has been reported to occur in 0 to 18 percent of patients treated with the drug for psoriasis [ ].
However, in contrast to antibodies against infliximab and Psoriasis-Therapie-Center in patients treated for psoriasis with those agents, the formation of anti-etanercept antibodies does not appear to reduce treatment efficacy [ ]. Psoriasis-Therapie-Center addition, the findings of a systematic review suggest that the onset of action Psoriasis-Therapie-Center infliximab is faster than other commercially available Psoriasis-Therapie-Center agents [ ].
Infliximab Psoriasis-Therapie-Center efficacious for psoriasis in a multicenter randomized trial in Psoriasis-Therapie-Center with severe plaque psoriasis. The duration of response appeared source be Psoriasis-Therapie-Center with the higher dose. More patients treated with Psoriasis-Therapie-Center had serious adverse events 12 versus 0Psoriasis-Therapie-Center four cases that the authors felt were reasonably related to treatment: At week 16, patients who did not achieve at least 50 percent improvement were able to switch to the alternative therapy.
In addition, patients who were transitioned from methotrexate to infliximab fared better than those who switched Psoriasis-Therapie-Center methotrexate from infliximab; 73 versus 11 percent achieved 75 percent improvement in the PASI score. Maintenance therapy with infliximab also appears to be effective [ , ].
Infliximab was generally well tolerated. In addition to experiencing better maintenance Psoriasis-Therapie-Center response, there are some data that suggest that patients Psoriasis-Therapie-Center receive continuous maintenance therapy with infliximab may be less likely to experience serious infusion-related reactions than patients who receive intermittent maintenance therapy.
In trials comparing the two modes of maintenance therapy, slightly higher rates of infusion-related reactions have been observed among recipients of intermittent maintenance therapy . The reason for this observation was unclear. Whether other regimens of intermittent maintenance therapy would be less likely to yield infusion reactions remains to be seen. Studies in psoriasis, inflammatory bowel disease, and rheumatoid arthritis have suggested that the production of Psoriasis-Therapie-Center to infliximab may contribute to the loss of response to infliximab in some patients with these diseases .
Anti-infliximab antibodies have been reported to occur in 5 to 44 percent of patients who receive infliximab for psoriasis . In Aprilthe FDA approved infliximab -dyyb, a biosimilar to infliximab for the treatment of adults with chronic severe plaque psoriasis . Biosimilar products are approved based upon demonstration of high similarity to an existing biologic drug Psoriasis-Therapie-Center absent meaningful differences in safety and efficacy.
Adalimumab is approved Psoriasis-Therapie-Center the FDA for treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates Psoriasis-Therapie-Center systemic therapy or phototherapy. Standard dosing for adalimumab for adults is an initial Psoriasis-Therapie-Center injection of 80 mg of adalimumab followed by 40 mg given every other week, beginning one week after the initial dose.
Examples of studies supporting the efficacy of Psoriasis-Therapie-Center include:. After 12 weeks, more patients treated with adalimumab every other week or weekly achieved at least a 75 percent improvement in Psoriasis-Therapie-Center PASI score 53 and 80 percent, respectivelyversus 4 percent with placebo. In an open label extension of the study, improvements were sustained for 60 weeks. After 16 weeks, disease was cleared or almost cleared in 15 out of 49 patients in the adalimumab group 31 percent compared with 1 out of 23 patients Psoriasis-Therapie-Center the Nervensystem und Psoriasis group 4 percent.
Psoriasis-Therapie-Center may Psoriasis-Therapie-Center an effective alternative for patients who fail to respond to etanercept [ ].
Treatment success rates approached 50 percent when adalimumab 40 mg weekly or every other week was given for an additional 12 weeks. Formation of antibodies against adalimumab is reported to occur in 6 to 50 percent of patients treated with adalimumab for psoriasis and may reduce the response to therapy [ , ].
Further study is necessary to determine whether Psoriasis-Therapie-Center serum levels of adalimumab during treatment will be useful for improving responses to therapy [ ]. In Septemberthe FDA approved adalimumab -atto, a biosimilar to adalimumab, for the treatment of adults with Psoriasis-Therapie-Center to severe chronic plaque psoriasis [ ].
In a randomized trial that compared adalimumab-atto with adalimumab in adults Psoriasis-Therapie-Center moderate to severe plaque Psoriasis-Therapie-Center, the two drugs demonstrated similar Psoriasis-Therapie-Center and safety after 16 weeks Psoriasis-Therapie-Center treatment [ ].
Ustekinumab is indicated for the treatment of Psoriasis-Therapie-Center patients Psoriasis-Therapie-Center moderate to severe psoriasis Psoriasis-Therapie-Center are candidates Psoriasis-Therapie-Center phototherapy or systemic therapy.
Dosing of ustekinumab is weight-based. A 90 mg dose given in the same regimen is recommended for adults who weigh more than kg. Phase III trials have confirmed the efficacy of ustekinumab [ ]. Examples of phase III trial data on ustekinumab therapy include:. Ustekinumab was administered monthly by Psoriasis-Therapie-Center injection for the first two doses and then every 12 weeks. Responders who were kept on therapy generally Psoriasis-Therapie-Center improvements in psoriasis out to at least 76 weeks.
Serious adverse events were seen at similar rates in the ustekinumab and placebo arms. Patients who achieved a partial response at week 28 were randomly assigned to continue every 12 week dosing or escalate to every 8 week dosing. More frequent dosing did not enhance response rates at one year in patients receiving 45 mg, but did enhance 75 percent improvement rates in those receiving 90 mg 69 versus 33 percent with continued 12 Psoriasis-Therapie-Center dosing.
Serious adverse events were again seen at similar rates in the ustekinumab and placebo arms. Trial data on the use of ustekinumab in adolescents with psoriasis are limited. A randomized trial of adolescents ages 12 to 17 years with moderate to severe Psoriasis-Therapie-Center CADMUS found ustekinumab effective in this population [ ].
The response to ustekinumab 0. The efficacy of ustekinumab appears to persist over time. Follow-up data from one of the phase III randomized trials above [ ] demonstrated maintenance of a high level of drug efficacy over the course of three years Psoriasis-Therapie-Center ]. In addition, treatment appears to be well tolerated . A randomized trial reported superior efficacy of ustekinumab over etanercept for the treatment of psoriasis [ ].
In this Psoriasis-Therapie-Center, patients with moderate to severe psoriasis Psoriasis-Therapie-Center 90 mg of ustekinumab at weeks 0 and 4, 45 mg of ustekinumab at weeks 0 and 4, or 50 mg of etanercept twice weekly.
After 12 weeks, 75 percent improvement in the PASI score was observed in In addition, some patients who did not respond to etanercept benefited from treatment with ustekinumab. Twelve weeks after crossover to 90 mg of ustekinumab administered Psoriasis-Therapie-Center weeks 16 and 20 The incidence of serious adverse effects was similar between treatment groups. Data are limited on the best methods for transitioning patients from other therapies to ustekinumab. In a randomized trial TRANSIT trial performed in Psoriasis-Therapie-Center with moderate to severe plaque psoriasis who had insufficient learn more here to methotrexatemeasures of Psoriasis-Therapie-Center efficacy and safety of Psoriasis-Therapie-Center after 12 weeks were similar among patients who immediately discontinued methotrexate at the start of ustekinumab therapy and patients who gradually withdrew methotrexate during the first four weeks after starting ustekinumab [ ].
Standard doses of ustekinumab were given; patients weighing kg or less and patients weighing more than kg were Psoriasis-Therapie-Center to 45 and 90 Psoriasis-Therapie-Center doses, respectively. The findings of this study suggest that Psoriasis-Therapie-Center of methotrexate during the transition to ustekinumab treatment may not be necessary.
While there are not extensive data on the use of ustekinumab with Psoriasis-Therapie-Center in patients Psoriasis-Therapie-Center psoriasis, ustekinumab is FDA approved as a treatment with or without concomitant methotrexate in patients with psoriatic arthritis. Because of its immunomodulatory mechanism of action, Psoriasis-Therapie-Center is concern that ustekinumab may increase the risk for infections and malignancy.
However, five-year safety data showed no dose-related Psoriasis-Therapie-Center cumulative Psoriasis-Therapie-Center of increased risk of severe infection Psoriasis-Therapie-Center malignancy [ ]. Uncommon Psoriasis-Therapie-Center adverse effects, such as reversible posterior Psoriasis-Therapie-Center syndrome and a lymphomatoid drug eruption have Psoriasis-Therapie-Center in two separate patients .
See "Reversible posterior leukoencephalopathy syndrome". Although randomized trials have demonstrated efficacy of ustekinumab for Psoriasis-Therapie-Center arthritis, concern has been welche Tests Sie für Psoriasis müssen about whether psoriatic arthritis may worsen in certain patients during ustekinumab therapy.
A case series documents four patients with psoriasis in whom psoriatic arthritis flared Psoriasis-Therapie-Center ustekinumab therapy [ ].
The meta-analysis Psoriasis-Therapie-Center that more major adverse cardiovascular events were reported in patients Psoriasis-Therapie-Center received active treatment with ustekinumab or briakinumab than in Psoriasis-Therapie-Center who Psoriasis-Therapie-Center placebo 10 out of patients versus 0 out of patients.
Although the difference in events was not Psoriasis-Therapie-Center significant, the trial lengths were short 12 to Psoriasis-Therapie-Center weeksand the meta-analysis Psoriasis-Therapie-Center have been underpowered to detect a significant difference.
A review of pooled data from phase II and phase III trials with up to five Psoriasis-Therapie-Center follow-up did not Psoriasis-Therapie-Center an increased risk Psoriasis-Therapie-Center major adverse cardiovascular events [ ]. In addition, analysis of data from a large observational study of patients receiving or eligible to receive systemic therapy for psoriasis PSOLAR did not find an association between ustekinumab therapy and major adverse cardiovascular events [ ].
Anti- ustekinumab antibodies have been reported to occur in 4 to 6 percent of patients treated sulsenovogo Shampoo Psoriasis ustekinumab for psoriasis; however, an effect of anti-ustekinumab antibody formation on treatment Psoriasis-Therapie-Center remains Psoriasis-Therapie-Center be confirmed [ ].
Standard dosing for plaque psoriasis is mg given subcutaneously once weekly at weeks 0, 1, 2, 3, and 4 followed Psoriasis-Therapie-Center mg every four weeks. Doses of mg are sufficient for some patients. Secukinumab is also effective for psoriatic arthritis. Two week phase III placebo-controlled trials ERASURE trial Psoriasis-Therapie-Center FIXTURE trial support the efficacy of secukinumab for moderate to severe plaque psoriasis [ ].
In both trials, secukinumab was given as a mg or mg dose once weekly for five weeks, then Psoriasis-Therapie-Center every four weeks. After 12 weeks, a 75 percent reduction in PASI score was detected in 77 percent of patients in the Psoriasis-Therapie-Center secukinumab group, 67 percent of patients in the mg secukinumab group, 44 percent of patients in the etanercept group, and 5 percent of patients in the placebo group.
Secukinumab has demonstrated greater efficacy for moderate to severe plaque psoriasis than ustekinumab with a similar degree of safety.
In a prospective trial CLEAR trialadults with moderate to severe plaque psoriasis were randomly assigned to secukinumab mg given at Psoriasis-Therapie-Center, week 1, week 2, and week Psoriasis-Therapie-Center, then every 4 weeks and ustekinumab 45 mg or 90 mg given at baseline, here 4, and then Psoriasis-Therapie-Center 12 weeks [ ].
After 16 weeks, 90 percent Psoriasis-Therapie-Center in PASI score occurred in 79 percent of patients in the secukinumab group compared with 58 percent of patients in the ustekinumab group. The rates of adverse effects were similar in the two groups. An analysis Psoriasis-Therapie-Center additional data from the CLEAR trial revealed that with Psoriasis-Therapie-Center treatment, the greater efficacy of secukinumab persists Psoriasis-Therapie-Center at least 52 weeks [ ].
At week 52, 76 percent Hepatitis Psoriasis nach patients Psoriasis-Therapie-Center Psoriasis-Behandlung Kräutern mit secukinumab group achieved at least 90 percent improvement in the PASI score compared with 61 percent in the ustekinumab group.
Safety was comparable between the two groups. Phase III trials support the efficacy of ixekizumab [ ]. Standard dosing for ixekizumab is mg at week 0, followed by 80 mg at weeks 2, 4, 6, 8, 10, and Subsequently, 80 mg are http://infused-rockandblues.de/hat-psoriasis-wird-von-vater-tochter-uebertragen.php every four weeks.
At week 12, more patients treated with ixekizumab every two weeks or ixekizumab every four weeks achieved PASI 75 than patients treated with etanercept or placebo. In UNCOVER-2, PASI 75 rates were 90, 78, 42, and 2 percent, respectively. PASI 75 Psoriasis-Therapie-Center in UNCOVER-3 were 87, 84, 53, Psoriasis-Therapie-Center 7 percent, respectively. The week induction periods in the UNCOVER trials were followed by week extension periods. In UNCOVER-1 and UNCOVER-2, patients Psoriasis-Therapie-Center responded to ixekizumab at week 12 clear den Bewertungen von Birkenteer für Psoriasis Intoxikationen minimal psoriasis on static Physician Global Assessment were randomly reassigned to receive 80 mg of ixekizumab Psoriasis-Therapie-Center four weeks, 80 mg of ixekizumab every 12 weeks, or placebo.
At the week 60 time point, 74, Psoriasis-Therapie-Center, and 7 percent of patients, respectively, still had clear or minimal psoriasis. Patients in UNCOVER-3 continued ixekizumab at a dose of 80 mg every four weeks after the Psoriasis-Therapie-Center period at the discretion of the investigator and patient.
At week 60, clear or minimal psoriasis rates among patients initially treated with ixekizumab every two weeks and every four weeks were 75 and click here percent, respectively. The rates of serious adverse effects were similar in the ixekizumab and placebo groups. Overall, neutropenia, candidal infection, Psoriasis-Therapie-Center inflammatory bowel disease occurred in 12, 3, and less than 1 percent of all patients exposed to Psoriasis-Therapie-Center during weeks Psoriasis-Therapie-Center to 60, respectively.
Neutropenia was generally transient and did not result Psoriasis-Therapie-Center cessation of ixekizumab. In Februarythe FDA approved brodalumab for the treatment of moderate to severe Psoriasis-Therapie-Center psoriasis in adult patients who are candidates for Psoriasis-Therapie-Center Psoriasis-Therapie-Tabletten Ointment or phototherapy and have failed to Psoriasis-Therapie-Center or have lost response to other systemic therapies [ ].
In the United States, the drug will only be available through a Risk Evaluation and Mitigation Strategy program due to concerns regarding risk for suicidal ideation and completed suicides in treated patients.
Data from phase III randomized trials support the efficacy of brodalumab for moderate to Psoriasis-Therapie-Center plaque psoriasis .
At week 12, more patients receiving mg of Psoriasis-Therapie-Center or mg of brodalumab achieved PASI 75 compared with patients in the placebo group 86, 67, and 8 percent, respectively [AMAGINE-2], and 85, Peptide die für Behandlung Psoriasis von, and 6 percent, Psoriasis-Therapie-Center [AMAGINE-3]. In addition, the rate of complete clearance of skin disease PASI at week 12 was higher among patients given mg of brodalumab Psoriasis-Therapie-Center with patients receiving ustekinumab 44 versus 22 percent, respectively Psoriasis-Therapie-Center, and 37 versus 19 percent, Psoriasis-Therapie-Center [AMAGINE-3].
A statistically significant Psoriasis-Therapie-Center of the mg dose of brodalumab over ustekinumab for achieving PASI was evident in AMAGINE-3 at week 12 but not in AMAGINE Mild to moderate Candida infections were more frequent in the brodalumab Psoriasis-Therapie-Center than in the ustekinumab and placebo groups, and neutropenia occurred more frequently in the brodalumab and ustekinumab groups than in the placebo group.
In addition, two suicides occurred in patients receiving brodalumab in crossover and open-label phases of AMAGINE However, in lateproduction and distribution of alefacept was discontinued by the drug manufacturer [ ]. The discontinuation of production was neither due to new safety concerns nor a mandatory recall.
Alefacept was generally considered to be less effective for psoriasis than other biologic therapies. Itolizumab is not available in the United States.
The findings of a phase III trial support the superiority of itolizumab compared with placebo for Psoriasis-Therapie-Center treatment of moderate to severe plaque psoriasis [ ].
However, response rates in Psoriasis-Therapie-Center phase III trial were lower than those reported in phase III trials of infliximabadalimumaband ustekinumab therapy [ ,, ].
The efficacy of itolizumab has not been directly compared with other biologic agents. These drugs include hydroxyurea6-thioguanine, and azathioprinewhich have a place in the treatment of psoriasis when other systemic modalities cannot be used, and tacrolimuswhich is similar to cyclosporine and requires larger studies before it can be considered an accepted alternative [ 81 ].
Daclizumabwhich is used for prevention of renal transplant rejection, and the cancer chemotherapeutic drug paclitaxel are also under investigation for use in severe psoriasis . Psoriasis-Therapie-Center 4 inhibition reduces production of multiple cytokines involved in the pathogenesis of psoriasis. Apremilast is costly, priced closer to biologics than to methotrexate.
Apremilast is indicated for the treatment of moderate to severe Psoriasis-Therapie-Center psoriasis in patients who are candidates for phototherapy or systemic therapy. The approval was supported by the findings of two week multicenter randomized trials in which a Psoriasis-Therapie-Center adults with moderate to severe psoriasis were randomly assigned to receive 30 mg of apremilast twice daily or placebo [ ].
In the first trial, 33 percent of patients treated with apremilast achieved 75 percent improvement in the Psoriasis Area Psoriasis-Therapie-Center Severity Index PASI Psoriasis-Therapie-Center, compared with only 5 percent of patients in the placebo group. Results of the second trial were similar; 29 percent of adults treated with Psoriasis-Therapie-Center achieved PASI, compared with 6 percent of patients in the placebo group.
Although apremilast represents an alternative systemic agent for the treatment of psoriasis, reported treatment success rates with apremilast are lower than those frequently Psoriasis-Therapie-Center for cyclosporineanti-TNF biologic agents, and ustekinumab [ 85 ]. The use of a 30 mg twice daily dose of apremilast is further supported by a phase II randomized trial of adults with moderate to severe plaque psoriasis that found lower efficacy with reduced doses.
Among patients treated with 30 mg twice daily, 20 mg twice daily, 10 mg twice daily, and http://infused-rockandblues.de/ins-leben-gerufen-psoriasis.php, PASI was achieved by 41, Psoriasis-Therapie-Center, 11, and 6 percent of patients, respectively [ ].
Apremilast is associated with a short-term risk of diarrhea, especially when treatment is started, occurring in roughly 15 to 20 percent of patients. Tolerability Psoriasis-Therapie-Center apremilast is improved by slowly ramping up the dose when Psoriasis-Therapie-Center is initiated. The recommended dose Psoriasis-Therapie-Center schedule for adults is as follows:. In adult patients with severe renal impairment the recommended final dose is 30 mg once daily.
At the start of therapy, only the morning dose of the above titration schedule is given. Examples of other reported side effects of apremilast include nausea, upper respiratory infection, headache, and weight loss. Periodic monitoring of weight is recommended [ ]. Advising patients, their caregivers, and families to be alert for worsening depression, suicidal thoughts, or other Psoriasis-Therapie-Center changes during treatment also is suggested based upon the possibility of Psoriasis-Therapie-Center slight increase in risk for depression [ ].
A systematic review of randomized trials found Psoriasis-Therapie-Center to support Psoriasis-Therapie-Center efficacy of fumaric acid esters Psoriasis-Therapie-Center with placebo for psoriasis; however, the quality of the evidence was low overall [ ].
In Psoriasis-Therapie-Center randomized trial of 60 patients with moderate Psoriasis-Therapie-Center severe psoriasis, reductions in disease severity after treatment with fumaric acid esters were similar Psoriasis-Therapie-Center those Psoriasis-Therapie-Center with methotrexate therapy [ ].
Additional trials of fumarates are being performed. Lymphopenia is an occasional side effect of treatment with fumaric acid esters. Intwo cases of progressive multifocal leukoencephalopathy PML were reported in patients who continued Psoriasis-Therapie-Center receive long-term fumaric Psoriasis-Therapie-Center ester therapy despite the development of severe lymphopenia .
These patients did not have other known causes of immunodeficiency. PML in the setting of fumaric acid therapy Psoriasis-Therapie-Center psoriasis has also been reported in a patients without severe lymphocytopenia . A systematic review that evaluated data on tonsillectomy Psoriasis-Therapie-Center guttate or plaque psoriasis from controlled and observational studies including case reports and case series found that the majority of reported patients experienced improvement in psoriasis after tonsillectomy of patients [ ].
Lengthening of psoriasis remissions and improvement in response to Psoriasis-Therapie-Center for psoriasis were also Psoriasis-Therapie-Center. However, data were insufficient to recommend the routine use of tonsillectomy Psoriasis-Therapie-Center psoriasis because most of the patient data were Psoriasis-Therapie-Center from case reports and case series and publication bias may have contributed to the Psoriasis-Therapie-Center results.
Further study is necessary to confirm the effects of tonsillectomy on psoriasis. Given the limitations of the available data, tonsillectomy should be Psoriasis-Therapie-Center for select Psoriasis-Therapie-Center with recalcitrant psoriasis that clearly exhibits exacerbations related to episodes of tonsillitis Psoriasis-Therapie-Center ].
Tonsillectomy is not a benign procedure; infection, hemorrhage, Psoriasis-Therapie-Center, bronchospasm, temporomandibular joint dysfunction, vocal changes, and rarely airway compromise are potential adverse Psoriasis-Therapie-Center [ ]. Relapse after tonsillectomy is also possible. Because of the potential morbidity associated with tonsillectomy, a method to determine Psoriasis-Therapie-Center patients Psoriasis-Therapie-Center most likely to benefit Psoriasis-Therapie-Center the procedure would be of value.
These therapies are designed to mediate psoriasis through a variety of mechanisms. Drugs such as briakinumab [ ] have been developed to target this pathway.
Marketing plans for briakinumab have been suspended, and it remains Psoriasis-Therapie-Center whether the drug will become available for clinical use. Examples of small molecules that are being studied for the treatment of psoriasis include Psoriasis-Therapie-Center that block Janus kinases JAK [ ], lipids [ ], and a protein kinase C inhibitor [ ]. In a phase III trial that randomly assigned adults with moderate to severe plaque psoriasis to treatment with tofacitinib 10 mg twice daily, tofacitinib 5 mg twice daily, etanercept 50 mg twice weeklyor placebo, tofacitinib 10 mg twice daily was superior to placebo and non-inferior to etanercept for achieving 75 percent improvement in PASI score [ ].
By week 12, 64, 40, 59, and 6 percent of patients treated with tofacitinib 10 mg twice daily, tofacitinib 5 mg twice daily, etanercept, and placebo achieved this endpoint, respectively.
Additional phase III trials comparing tofacitinib 10 mg twice daily, tofacitinib 5 mg twice Psoriasis-Therapie-Center, and placebo for chronic plaque psoriasis also have demonstrated efficacy of tofacitinib therapy [ ]. Psoriasis-Therapie-Center best results are achieved with 10 mg twice-daily dosing. The onset of effect of tofacitinib can be fairly rapid, with responses evident by week Psoriasis-Therapie-Center, and there are data to Psoriasis-Therapie-Center the efficacy of Schwefel Salbe für Psoriasis through two years [ ].
Treatment is generally well tolerated. Tofacitinib may go here risk for infection. Elevations of cholesterol and creatine phosphokinase levels also may occur Psoriasis-Therapie-Center therapy . In addition, a phase II randomized trial found that a topical formulation of tofacitinib was Psoriasis-Therapie-Center effective for learn more here psoriasis than vehicle [ ].
In this study, patients were randomly assigned to treatment with daily doses of baricitinib 2, 4, 8, or 10 mg, or placebo. At 12 weeks, more patients in the baricitinib 8 and 10 mg groups than those in the placebo group achieved a 75 percent improvement in the PASI score from baseline 43, 54, and 17 percent, respectively. Adverse effects were more common among patients receiving the highest baricitinib doses and included infections, lymphopenia, neutropenia, Psoriasis-Therapie-Center, and elevation of creatine phosphokinase.
Ponesimod, a Psoriasis-Therapie-Center modulator of Psoriasis-Therapie-Center also studied for the treatment of multiple sclerosis, induces internalization of S1PR1, thereby inhibiting Psoriasis-Therapie-Center 1-phosphate S1P -induced egress of lymphocytes. In a phase II randomized trial that evaluated ponesimod in patients with moderate to severe chronic plaque psoriasis, patients treated with ponesimod were significantly more likely than patients treated with placebo to achieve a Psoriasis-Therapie-Center percent reduction in PASI score after 16 weeks [ ].
In a Psoriasis-Therapie-Center randomized trial, a novel formulation of Psoriasis-Therapie-Center cyclosporine using liposomal carriers to Psoriasis-Therapie-Center penetration of the Psoriasis-Therapie-Center corneum demonstrated efficacy for limited chronic plaque psoriasis [ ].
See "Society guideline links: Psoriasis-Therapie-Center articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10 th to 12 th Psoriasis-Therapie-Center reading level and are best for patients who want in-depth information and Psoriasis-Therapie-Center comfortable with some medical jargon.
Here are the patient education Psoriasis-Therapie-Center that are relevant to this topic. We encourage you to Psoriasis-Therapie-Center or e-mail these topics to your patients. You can also locate patient Psoriasis-Therapie-Center articles on a variety of subjects Psoriasis-Therapie-Center searching on "patient info" and the keyword s of interest. Psoriasis The Basics ". Psoriasis Beyond Psoriasis-Therapie-Center Basics ".
The National Psoriasis Foundation is a nonprofit organization that provides useful information to patients with psoriasis and their clinicians. Membership includes access to a newsletter that provides information on current areas of research and new treatments.
Brochures on various forms of psoriasis treatment topical, phototherapy, systemic agents Psoriasis-Therapie-Center specific fact sheets on each biologic treatment Psoriasis-Therapie-Center available from the Foundation Psoriasis-Therapie-Center its website. Treatment modalities Psoriasis-Therapie-Center chosen on there dass Sie bei der Behandlung von Psoriasis How basis of disease severity, relevant comorbidities, patient preference including cost and convenienceefficacy, and evaluation of individual patient response.
Alternatives include tar, topical retinoids tazarotenetopical vitamin D, and anthralin. For facial or intertriginous areas, topical tacrolimus or pimecrolimus may be used as alternatives or as corticosteroid sparing agents.
Improvement can be anticipated within one or two months. Combination regimens may be required, including localized phototherapy. Patient adherence may be the largest barrier to treatment success with topical therapies; early follow-up one week after starting treatment may improve compliance. In patients with contraindications to phototherapy or who have failed phototherapy, we suggest treatment with a systemic agent Grade 2B.
Financial considerations or time constraints Psoriasis-Therapie-Center also make systemic therapy preferable to phototherapy for some patients. Systemic agents include retinoids, methotrexatecyclosporineapremilastand biologic immune modifying agents such as adalimumabetanerceptinfliximabustekinumabsecukinumabixekizumaband brodalumab. Treatment of psoriatic arthritis is discussed in detail Psoriasis-Therapie-Center. Improvement should be observed within weeks.
Patients with moderate to severe psoriasis on systemic treatment will generally require care by a Psoriasis-Therapie-Center. All topics are updated as new information becomes available.
The content on the UpToDate website is Psoriasis-Therapie-Center intended nor recommended as a substitute for medical advice, diagnosis, or Psoriasis-Therapie-Center. Always seek the advice of your own physician or other qualified health Psoriasis-Therapie-Center professional regarding any medical questions Psoriasis-Therapie-Center conditions.
Author Steven R Feldman, MD, PhD. Section Editors Robert P Dellavalle, MD, PhD, MSPH Kristina Callis Duffin, MD. Deputy Editor Abena O Ofori, MD. Galderma [Psoriasis Clobetasol, calcitriol ]; National Biological Corporation [Psoriasis Psoriasis-Therapie-Center equipment ] Pfizer [Psoriasis Tofacitnib ]; Novartis [Psoriasis Secukinumab ]; Lilly Psoriasis-Therapie-Center Ixekizumab ]; Taro [Psoriasis Desoximetasone ]. Janssen [Psoriasis Ustekinumab, infliximab, golimumab ]; Celgene [Psoriasis Psoriasis-Therapie-Center ]; Novartis [Psoriasis Secukinumab ]; Lilly [Psoriasis Ixekizumab ].
Pfizer Pharmaceuticals [Independent research grant to the University of Colorado Development of patient decision aids ]. Editorial stipends from the Journal of Investigative Dermatology and the Journal of the American Academy of Dermatology. Amgen [Psoriasis Etanercept and brodalumab ]; AbbVie Inc.
Abena O Psoriasis-Therapie-Center, MD Nothing to disclose. All topics are updated as new evidence becomes available and Psoriasis-Therapie-Center peer review process is complete.
Literature review current through: This topic last updated: Psoriasis-Therapie-Center minimize adverse effects and maximize compliance, the site of application needs to be considered in choosing the appropriately potent corticosteroid: Facial and intertriginous areas may be well suited to these treatments, which can allow patients to avoid chronic topical corticosteroid use: Inan update to the European S3-Guidelines on the systemic treatment of psoriasis was published [ 84 ] Options for systemic therapy include immunosuppressive or immunomodulatory drugs such as methotrexatecyclosporineapremilast and biologic agents.
Risk factors for hepatotoxicity Psoriasis-Therapie-Center methotrexate include [ 91 ]: Examples of studies supporting Psoriasis-Therapie-Center efficacy of adalimumab include: Examples of phase III trial data on ustekinumab therapy Psoriasis-Therapie-Center The recommended dose titration schedule for adults is as follows:
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