PSORIASIS

It typically appears as red circular and scaly lesions that can become very itchy. This disease has outbreaks. There are periods in which the disease aggravates and periods in which it is more controlled. There is no cure for this disease. The patient must focus on keeping the disease in check to prevent recurrences.

To prevent outbreaks early treatment of infections (especially tonsillitis) is recommended. Trauma due to scratching must be avoided, as these traumas can lead to the appearance of new lesions. It is also recommended to avoid stress and certain drugs such as lithium, beta-blockers, antimalarials, NSAIDs and systemic corticosteroids. Between outbreaks, as maintenance therapy, it is recommended to keep the skin hydrated by applying moisturizers on a daily basis. In some cases it is necessary to apply creams without corticosteroid, such as vitamin D derivatives to keep the disease under control.

• Vulgar
• Gutatta
• Facial
• Erythrodermic
• Facial
• Nail
• Scalp
• Arthropathic

Psoriasis is one of the conditions in which I have invested more effort and dedication.

Until recently dermatologists had the perception that we could not do much against a dermatosis that responded poorly to topical and systemic treatments, and had an unpredictable course. Patients felt hopeless, as if it were a biblical disease.

In my years of residence in Dermatology, during a vacation in London, I had the opportunity to learn about a treatment that offered satisfactory results known as Goekerman. It consists of applying a tar (mineral) and radiate with UVB (311 nm). Upon my return, I convinced the professor of the Clinical Hospital of Barcelona, Professor Piñol Aguadé, and my father, who had his office in Corachán Clinic, that we should introduce this treatment in our country. So the first lamps were imported to Spain.

At this time photobiology began in Dermatology; in fact, a few years after the photochemotherapy or PUVA was introduced, which consisted of associating the wall with oral psoralens and using long length (230 nm) radiation. This treatment achieved unprecedented results and extensive recalcitrant psoriasis.

As part of my training, I was also at the Mayo Clinic in U.S.A. Upon my return to Barcelona another promising treatment was introduced; oral retinoids derived from vitamin A.

I formed a Psoriasis unit at the Sagrat Cor Hospital in Barcelona, whose treatments were mostly outpatient and together with the Hospital of Sant Pau, we became the pioneers in Spain in puva therapy (therapeutic modality using long wave UV Rays).

The equipment required for this treatment is very costly such as the German Waldman Cabins. New models continue to be developed with different wavelengths, such as ultraviolet narrowband UV-B radiation. Unlike classical PUVA, the puva therapy (psoriasis) does not require administration of psoralens being a significant advantage. For instance, it does not require eye protection against ultraviolet rays during the day and does not produce digestive discomfort.

Topical treatments remain the first choice for localized psoriasis. Today they have been discovering new molecules, such as derivatives of vitamin D, potent corticosteroids or biological immunomodulators (tacrolimus), that are able to clear stubborn areas such as the scalp, nails, etc.

In these cases, our collaborators and we prescribe customized topical formulations in which we associate various active ingredients that enhance its effectiveness compared with commercial formulas. The difference is because commercial formulas use very rigid excipients and only one active principle, which reduce the efficiency on certain locations such as the scalp, nails, elbows, knees, etc.

Today we know that this is a chronic inflammatory disease of autoimmune etiology. Before we only knew part of the mechanism: the keratinocyte hyperproliferation and impaired epidermal differentiation. So we administered Methotrexate (antiproliferative cytostatic) and were getting effective results even though by then we were unaware that T lymphocytes, macrophages and different cytokines (ILK) are the main actors of the pathophysiology of the disease. Psoriasis and other autoimmune diseases benefit from biological treatments that inhibit cytokines (TNF-alpha) or monoclonal antibodies that act in other interleukin cells.

Currently the available drugs for systemic treatments are methotrexate, cyclosporine A, retinoids, photochemotherapy (PUVA) and new biological agents. Each has its indications and contraindications.

Topical corticosteroids are one of the most effective treatments, if used correctly. They have different strengths and are often used in combination with other active ingredients, to multiply their effectiveness and reduce side effects.

“Patients should not be afraid to use topical corticosteroids. They are essential in treating the early stages of multiple dermatosis and if administered correctly by a specialist it should not produce side effects.”

Topical corticosteroids may be associated with derivatives of vitamin D3. The skin is an organ metabolically active and can synthesize this vitamin along with ultraviolet radiation. There are vitamin D receptors in the skin.

Derivatives of vitamin D significantly improve psoriatic lesions since they inhibit keratinocyte proliferation. The most effective ones are analogs such as tacalcitol and calcitriol.

Psoriasis patients have dry skin and suffer from water loss. Therefore it is important to moisturize the skin.

I recommend emollient oils or moisturizers without synthetic ingredients made for sensitive skin, followed by an emollient cream. I often use custom design formulations tailored to the patient’s specific needs. The formula may be an ointment, a cream, a gel, a lotion or an aerosol. May contain 2-10% urea, kola extract, aloe vera, salicylic acid, propylene glycol, corticosteroids, and derivatives of vitamin D.

By administering oral retinoids or acid-acitretino 13 retinoico- cis along with a topical treatment we can expect to get a better response than administering them separately.