If you’re one of the millions of people with psoriasis who aren’t satisfied with their current therapy, it’s time to take a look at treatment that has come down the pipeline recently.
Psoriasis treatment has evolved over the years. More than 40 years ago, a new era in therapy began when the systemic drug methotrexate was successfully used to manage the skin disorder. About a decade ago, researchers were hailing the introduction of biologic agents—genetically engineered therapies derived from living organisms— as an alternative. Today, a new generation of biologics that may be more effective has entered the spotlight—the Food and Drug Administration (FDA) approved the first drug of its kind in January 2015.
An immune dysfunction
Plaque psoriasis, the most common form of the disorder, is a chronic autoimmune disease that affects the skin, forming patches, or plaques, of thick red skin lesions covered with silvery scales that flake off easily. Psoriasis is marked by cycles of flaring and clearing. Symptoms vary from mild to extreme. Some people have a few scaly patches on their elbows, knees or scalp; others suffer from debilitating flare-ups that involve large areas of the body. Thirty percent of patients develop psoriatic arthritis.
Psoriasis has no cure but can be managed in most people, although moderate to severe psoriasis requires lifelong treatment. People with mild psoriasis may be able to reduce symptoms and improve appearance with topical treatments. Stronger therapies are typically reserved for people who have moderate to severe psoriasis, which covers more than 5 to 10 percent of the body’s surface, and for those whose psoriasis affects the face, palms, or soles.
The new drug in town
The newly approved drug, secukinumab (Cosentyx), continues the trend of targeted treatment of psoriasis with biologics. Etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade) and ustekinumab (Stelara) are examples of effective biologic agents. They often produce a rapid, dramatic improvement in people who have failed to respond to other therapies. All are given by injection, ranging from once or twice a week to once every three months, and improvement is typically seen within several weeks.
The older biologic treatments home in on either specific overactive immune cells that prompt the overproduction of skin cells or protein in cells that help cause inflammation. Secukinumab uses a different mechanism of action: It binds to a protein called interleukin-17A (IL-17A) that’s involved in inflammation and prevents it from triggering the response that contributes to psoriasis.
“While the first generation of biologic drugs continues to play a large role in managing psoriasis, secukinumab gives us another first-line option—one that has been shown in clinical trials to be just as safe and effective, if not more so, than the earlier drugs,” says Alan Menter, M.D., chief of the division of dermatology at Baylor University Medical Center at Dallas. After 12 weeks of drug use, more than 80 percent of patients in a clinical trial saw significant improvement, which lasted at least one year on continued therapy. Psoriatic symptoms completely disappeared in 25 percent of patients.
“A big difference among biologic agents is that we have more than 10 years of safety data in millions of patients on the current biologic drugs,” Menter says, “whereas we don’t have long-term safety data for secukinumab yet.”
Adverse effects included diarrhea and upper-respiratory infections. People prone to infections or who have Crohn’s disease shouldn’t use secukinumab. Generally, people with serious infections should avoid biologic drugs. Biologics may possibly increase the risk of lymphoma and tuberculosis. Their side effects include pain at the injection site, nausea, vomiting, headache and fever. A major downside to biologics is their high cost.
Biologic agents are one of a wide range of treatment options for psoriasis. A trial- and-error approach is sometimes needed to determine effectiveness. Between long-standing therapies and newer drugs, doctors can tailor treatment to what’s best for each individual—and experts emphasize the importance of closely involving patients in decision making.
The strategies a doctor chooses to treat psoriasis depend on several factors, such as the areas of the body affected, the thickness of lesions, degree of redness and scaling, potential side effects, cost, overall patient health, and patient preferences.
Because no single psoriasis treatment is effective for everyone, personal preference is key. “More than half of people with psoriasis aren’t satisfied with their treatment,” says Menter, who also chairs the American Academy of Dermatology’s psoriasis guidelines committee. “Understanding all the options available can help you find the one that’s best for you.”
To achieve better outcomes, doctors often combine drug, light, and topical therapies to treat moderate to severe psoriasis, which allows for lower doses of each agent and decreased risk of toxicity.
Psoriatic lesions may become resistant to a treatment over time, and patients may need to switch therapies periodically. Rotational therapy can also reduce adverse effects that result from long-term drug use.
Moderate to severe psoriasis is often treated with powerful systemic medications, so called because they work throughout the body. Below is a brief overview of the commonly used systemic drugs:
■ Methotrexate is effective in about 40 percent of patients. It suppresses the entire immune system—in contrast to biologics, which target specific cells. Many people do well for years on methotrexate. But because this generic drug can cause liver problems, patients must be carefully monitored with blood tests every one to three months. Patients typically take the drug once a week, by either mouth or injection, and it may take up to three months before they see improvement. Side effects include nausea, headache, and fatigue. Patients must be cautious when consuming alcohol because of the increased risk of liver toxicity. Also, sulfonamide-containing drugs can never be taken with methotrexate.
■ Cyclosporine can clear psoriasis more rapidly than methotrexate, but because of its potency it can only be used short term. It’s major side effect, especially in older adults, is high blood pressure. Patients should be switched to another therapy for continued psoriasis management after about 12 weeks. It shouldn’t be used by people with significantly compromised immune systems or prone to infections.
■ Systemic retinoids, synthetic forms of vitamin A, are used to treat moderate to severe psoriasis. Acitretin (Soriatane) is an oral retinoid that’s often combined with light therapy. Improvements may be seen within one month, but it can take three to six months to see full results. It works well on people with predominantly hand and foot psoriasis. Potential side effects include dry skin, cracked lips, nosebleeds, poor night vision, hair loss, joint pain, depression, elevated triglyceride levels, and liver damage. Because acitretin doesn’t affect the immune system, it can be used long term by people prone to infections.
■ Apremilast (Otezla), an oral systemic drug that reduces inflammation, was approved last September to treat plaque psoriasis. Apremilast can begin to clear psoriasis in a few weeks; side effects may include diarrhea, stomach upset, headache, and upper-respiratory tract infection.
Talk with your doctor if you’re not improving on a particular regimen or having side effects. “Chances are at least one of the treatments available will be effective for you,” Menter says.
“Keep in mind that you may need to try different treatments— or combinations of treatments—to determine what works for you.” Menter urges patients to become educated about psoriasis and familiar with treatment options. A good resource is the [National Psoriasis Foundation](www. psoriasis.org).