What medication?

[Guest Posts]

When I last went to my GP about a flare up of psoriasis they said to me – well what medication would you like and showed me a whole book of medicines. I have absolutely no idea what I would want – apart from an obvious comment – what would you suggest I offer to them in the way of advice?! Thank you.

[Dr Anton Alexandroff]

Thank you very much for your question. Yes we are now so fortunate to have so many available treatments for psoriasis that it can be very confusing!

So available treatments:

I) topical:

1) topical Vitamin D (often combined with topical steroids)
a) most popular: Enstilar foam (contains vitamin D and steroid), can be used on body and limbs daily continuously up to 1 month after this can be used intermittently long term.
b) Dovobet ointment (vitamin D only) - it is less effective and it is greasy, can be used twice daily indefinitely.

2) steroid
a) Daktacort (steroid cream or ointment, creams are less greasy but ointments are more effective) - very mild, can be used twice daily indefinitely, usually it is used on face and neck.
b) Eumovate (steroid cream or ointment, stronger than Daktacort) - is usually used on face or skin fold areas daily long term as needed.
c) Etrivex shampoo - is used for scalp. Has to be applied to the dry scalp and washed /rinsed off with water after 15 minutes. can be used daily continuously up to 1 month after this can be used intermittently long term.

3) coal tar e.g. Exorex lotion. Can be used twice daily indefinitely. Can work quite well but smell and may stain clothes.

4) elidel cream/ protopic ointment - can be used off licence, work better for face and skin folds.

II) light sources:
1) Bluecontrol can be bought from Philips. Blue light visible light, does not give UV therefore completely safe, can be used indefinitely. Can work well for a few stubborn areas of psoriasis. Can be combined with topical treatment.
2) UVB - can be used safely if used under supervision for a limited period of time (usual duration of treatment 2 months, 2-3 times a week)

III) oral medications:
1) acitretin. Slow actin drug. Rare serious side effects. Often makes skin dry. Requires monitoring blood tests. May upset liver and cholesterol blood tests. Because of birth defects women should not get pregnant for 2 years after stopping acitetin. If they fall pregnant during this period of time they would reuire a termination of pregnancy.
2) methotrexate - commonly used. Can upset blood count, liver tests. Requires base line screening for hepatitis, TB, HIV and CXR. Patients can not drink more than 5 units of alcohol a week (but best none). Women should not get pregnant and men should not father children for 6 months after stopping methotrexate.
3) ciclosporin - works very quickly but should not be used for longer than 6 month continuously. Can upset renal, tests, blood pressure, blood count and CXR. Requires base line screening for hepatitis, TB, HIV.
4) fumaderm. It is now licensed in the UK. It is an effective drug. can upset renal, liver tests and blood count.
5) Otezla - no screeing or monitoring tests are needed but is is very expensive.

IV injections.
1) secukinumab (Cosentyx) - effective and fast (Il-17 antagonist).
2) Ixekizumab (Taltz) -similar to secukinumab.
3) humira - has been used for long time.
4) Ustekinumab (Stelara)
5) Etanercept (Enbrel) not very effective but can be used for long times. Can be stopped and started.

I hope this is helpful.
With Best Wishes,

Dr Anton Alexandroff FRCP(UK) PhD CCT(Derm) FRSM FAAD
Consultant Dermatologist and Honorary Senior Lecturer
The British Skin Foundation Spokesperson
London, Cambridge, Leicester and Bedford

http://www.alexandroff.org.uk
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