“There are a lot of treatments out there and they are quite effective, but often they stop being effective,” says Mark Lebwohl, MD, chair of the department of dermatology at Mount Sinai Medical Center in New York City. “There isnt one treatment over a lifetime, necessarily.”
Taming the beast
“I describe psoriasis to my patients as a wild animal in a roomand the room is their life,” says dermatologist Andrew Blauvelt, MD, who sees a variety of complex cases as the research director of the Center of Excellence for Psoriasis and Psoriatic Arthritis at Oregon Health & Science University in Portland. “The goal of therapy is to build a good cage for the animal. The animals always going to be there, but an effective treatment will allow the patient to move around the room and live his life.”
For physicians, a series of factors are weighed to determine how aggressively and with what tools they treat a particular case of psoriasis, including:
- How widespread the disease is on the body
- Whether lesions appear in sensitive areas, such as the face, palms, soles, or genitals
- The patients experience with previous treatments
- The cost of medications and what insurance will cover
- The patients other medical conditions (especially psoriatic arthritis)
- The patients preference for one type of treatment over another
The group of drugs known as biologics have in recent years expanded the number of people who can be treated, says Dr. Lebwohl. They have also pulled some patients away from older systemic (as opposed to topical) drugs often used for moderate-to-severe cases, such as methotrexate and cyclosporine, which patients sometimes need to take in rotation to minimize the risk of cumulative damage to their organs.
“Biologics are costly and have potential side effects, some of which are serious. But psoriasis is a bad disease, too,” says Steven Feldman, MD, PhD, professor of dermatology at the Wake Forest University School of Medicine in Winston-Salem, NC. “The potential benefits of biologics outweigh the risks for many patients.”
According to some doctors, the newer drugs appear safer for use over the long-termso long as they continue working. Instead of acting like “shotgun blasts,” as the older systemic drugs do, the biologics are “much more like a rifle shot, where theres a whole lot less collateral damage and fewer side effects,” says David M. Pariser, MD, president-elect of the American Academy of Dermatology.
It often takes trial and error
On the day he was diagnosed in 1991, Ed Dewke, now 57, of Midway, Ky., remembers his dermatologist saying: “I hope you have good insurance that will pay for a lot for drugs, because youre going to be making a number of pharmacists wealthy throughout the rest of your life.”
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At its worst, his psoriasis affected as much as 45% of his body, including his hands and feet, and made his nails “look like something out of the special effects cabinet of a science-fiction movie.”
For the first several years he was treated with a cycle of topical corticosteroids of varying strengths, which reduced his lesions but never cleared them entirely. He tried phototherapy, but his skin couldnt tolerate it. Dewke did get positive results from systemics when he decided to switch to them in the late '90s, but found that he had to shift back and forth between methotrexate and cyclosporine to avoid side effects.
He later found a biologic treatment that worked wonders for his skin but did nothing for the psoriatic arthritis in his knees, which at times became crippling. On the suggestion of his dermatologist and rheumatologist he started taking the biologic Humira (adalimumab) in early 2006, and now, he says, “Im living more comfortably and more normally than I have for a long time.”
Other biologics include Amevive (alefacept), Enbrel (etanercept), Remicade (infliximab), Simponi (golimumab), and Stelara (ustekinumab). These drugs have been approved for use in treating some or all types of psoriasis or in some cases, just psoriatic arthritis, a type of arthritis that occurs in 6% to 40% of people with psoriasis.
“Now, I know thats not a cure,” says Dewke. “I know if I stopped my Humira today, in two months Id be walking around limping again. But thats the name of the game.”
New drugs are on the horizon
Even the effectiveness of the newer drugs will fizzle after a while for some patients with severe enough psoriasis to warrant them, says Dr. Lebwohl. And after those patients move down the short line of latest-and-greatest treatments, they reach a dead end. “[But] there is literally a steady stream of new drugs coming out,” he says.
Dermatologist Michael Zanolli, MD, an associate clinical professor of medicine at the Vanderbilt University School of Medicine in Nashville, Tenn., says that when patients find something that works, they ask how long theyll stay on the regimen. “My standard answer now is, ‘Until something better comes along,” he says. “And there are some new advances in the treatment of psoriasis that are just around the corner.”
Last updated: Nov 15, 2010