Psoriasis guidelines provide updates on pharmacotherapy, guidance on special populations

New consensus guidelines for the management of plaque psoriasis include updates on pharmacotherapy options and the treatment of special populations such as children, pregnant women and their partners, nursing mothers, the elderly, and patients diagnosed with cancer, HIV, or hepatitis B or C.

Key Point: Biologics and other immunosuppressive agents are becoming more commonplace in North America and other parts of the world to treat severe plaque psoriasis. Treatment in India has been limited by available agents, and in some cases, cost and issues with monitoring. If methotrexate is used to treat psoriasis, it’s important to monitor liver function and to avoid liver toxicity. Many topical therapies are available for less severe forms of the disease.

The consensus statement, which was reviewed by the members of Canada’s National Psoriasis Foundation Medical Board, also discusses the use of tumor necrosis factor (TNF)-antagonists, the use of vaccinations, and elective surgery for these patients.

The prevalence of psoriasis in India is estimated to range from 0.44% to 2.8% based on various studies and regional differences, according to a report by Dogra et al in 2010 in the Indian Journal of Dermatology, Venereology and Leprology. The authors reported that psoriasis is 2 times more common in[s2If !is_user_logged_in()]…

[/s2If][s2If is_user_logged_in()] men than women in India and that most patients are in their 30s or 40s at the time of presentation.

Many countries are moving to newer generation treatments for psoriasis because agents such as methotrexate, cyclosporine, and acitretin have many toxicities that limit their use. PUVA therapy (methoxsalen) also can be used. Methotrexate has moderate effects on psoriasis severity and can be used for many years, but prevention of liver toxicity needs to be monitored and a liver biopsy is recommended at different cumulative doses throughout therapy.


Dogra

“Systemic methotrexate is still the gold standard in the era of biologics for treatment of severe psoriasis in the Indian scenario. It has easy availability, affordability, and vast Indian experience of its safe and effective use.”
– Sunil Dogra, MD, DNB, MNAMS, associate professor, Department of Dermatology, Venereology & Leprology, Post Graduate Institute of Medical Education & Research, Chandigarh, India


Sunil Dogra, MD, DNB MNAMS, who wrote the 2010 paper about psoriasis in India, told mdCurrent-India that methotrexate can be useful if it is used conservatively and managed appropriately. “Systemic methotrexate is still the gold standard in the era of biologics for treatment of severe psoriasis in the Indian scenario,” said Dogra, associate professor, Department of Dermatology, Venereology & Leprology, Post Graduate Institute of Medical Education & Research, Chandigarh, India. “It has easy availability, affordability, and vast Indian experience of its safe and effective use of the 0.3 mg/kg to 0.5 mg/kg once weekly dose in psoriasis,” he explained.

TNF- antagonists have more long-term data for other conditions and lack common safety concerns such as end-organ damage that can occur with methotrexate or cyclosporine. However, serious infections, autoimmune conditions, and lymphoma are potential safety concerns associated with TNF-antagonists. Biologics used in India include infliximab and etanercept; others are available in other areas of the world.

Methotrexate should not be used in patients with hepatitis B (HBV). Before biologics are used, patients should be screened for HBV, because biologic treatment can cause HBV reactivation. Some patients with hepatitis C may be able to use biologics, but data are lacking.

Use of biologics, methotrexate, or other immunosuppressants in patients with HIV is not recommended. Inactivated vaccines or those made from specific protein subunits are generally safe in patients receiving methotrexate, cyclosporine, or a biologic.

Source: Hsu S, Papp KA, Lebwohl MG, et al. Consensus guidelines for the management of plaque psoriasis. Arch Dermatol. 2012;148:95-102. Dogra S, Yadav S. Psoriasis in India: Prevalence and pattern. Indian J Dermatol Venereol Leprol. 2010;76:595-601.

Access the original journal information here:
http://archderm.ama-assn.org/cgi/content/abstract/148/1/95
Journal publishers are independent from mdCurrent-India and may require a subscription or charge a fee to download the full article.

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