Therapy goals
- Improvement of symptomatology. Low disease activity status.
- Ideally, remission (temporary or permanent abatement of disease symptoms) should be achieved.
Therapy recommendations
The therapeutic approach to psoriasis is classic dermatological: it consists of basic therapy, topical (local) therapy and systemic treatment:
- All severities of psoriasis receive basic therapy:
- Topical therapy:
- Oil or salt water baths, initially 2 times, then 1 time daily (15-20 min each), depending on age.
- Active substance-free ointment bases as well as topical urea preparations (5-10%) and salicylic acid preparations (for circumscribed plaques in the head area (from 6 years of age; 1%; in children < 8 years total treatment area max. palm size) (= keratolysis (“desquamation”)).
- Creams, emulsions or pastes with a low fat content are preferred.
- Topical therapy:
- Mild forms (less than ten percent of the body surface affected, PASI (Psoriasis Area and Severity Index), 10 points out of 72 at worst) receive local therapy:
- Initial therapy
- Therapy of 1st choice: fixed combination: (calcipotriol (Cal) + betamethasone (Bet)) 1 x daily [gold standard].
- Therapy of 2nd choice: topical calcineurin inhibitors (TCI) or vitamin D3 analogues as monotherapy.
- Therapy of the 3rd choice: dithranol (v. a. stationary).
Evaluation after 2-8 weeks: Therapy success no: modify therapy; Therapy success: yes → maintenance therapy.
- Maintenance therapy
- Therapy of 1st choice: (Cal + Bet) 1-2 x weekly.
- Therapy of the 2nd choice: TCI or vitamin D3 analogues 1-2 x weekly.
- Initial therapy
- Moderate and severe forms of psoriasis receive systemic therapy, phototherapy:
- Agents according to the guideline: ciclosporin (cyclosporin A), fumaric acid esters, methotrexate and retinoids; also biologicals (adalimumab, etanercept, infliximab and ustekinumab), if necessary.
- UV-B-311-nm phototherapy (narrow-spectrum UV-B phototherapy) or balneophototherapy [for adults; avoided as much as possible in children because of the unexplained risk of photocarcinogenesis (cancer development by light therapy); reserved for exceptional cases in adolescence].
- Special therapy situations
- Severe inflammatory psoriasis: class III-IV corticosteroid for 1-3 weeks, then as initial therapy.
- Hyperkeratotic infestation: salicylic acid 5-10% for 3 to 5 days, other keratolytics if necessary, then as initial therapy.
- Intertriginous affection / face: class II-III corticosteroid for 1-4 weeks, then as initial therapy.
- Scalp, hand and foot infestation: Class III-IV corticosteroid (occlusive if necessary), then as initial therapy.
- See also under “Further therapy”.
Further notes
- Acitretin: Due to lack of study data, the European psoriasis guideline gives an “open recommendation”.
- Ciclosporin (cyclosporin A): duration of therapy > 2 years → nephrologist to co-assess possible nephrotoxicity.
- Methotrexate: In the European psoriasis guideline, methotrexate is “strongly” recommended for both induction therapy and long-term therapy.
- Ustekinumab has the highest five-year efficacy compared with etanercept, (assessed using the PASI/Psoriasis Area Severity Index (PASI)): PASI-75 response by treatment with adalimumab or with ustekinumab is higher than with etanercept.
- Compared with fumaric acid ester, secukinumab showed very large positive effects in remissions.
- Ixekizumab compared with ustekinumab: significantly more remissions occurred under ixekizumab.
Phytotherapeutics
A systematic review is available on this topic. The following phytotherapeutics are supported with studies for adjuvant therapy of psoriasis:
- Cayenne pepper (Capsicum frutescens): capsaicin; note: do not use on the face! Contraindication: injured skin
- Chrysarobin (component of the bark of the araroba or goa tree (Andira araroba)): Cignolin (anthralin, dithranol); Effects: Inhibition of the release of proinflammatory cytokines and the growth of keratinocytes.
- Cartilage carrot (Ammi majus): from it psoralens; effects: Inhibition of keratinocyte proliferation; in combination with UV-A irradiation (PUVA) also anti-inflammatory effect.
- Mahonia (Mahonia aquifolium): 10% mahonia cream.
- Niembaums (Azadirachta indica): nimbidin
- Silver willow (Salix alba; salicylic acid from silver willow bark); Effects: Keratolysis
Supplements (dietary supplements; vital substances)
Other complementary and alternative medicine (CAM) therapies with evident effects:
- Indigo naturalis (derived from plants such as Baphicacanthus cusia); effect: the active ingredient indirubin is thought to reduce skin hyperproliferation (by influencing the cell cycle and epidermal growth factor receptor (EGFR)).
- Curcumin (from turmeric); effect: anti-inflammatory (anti-inflammatory); improvement of psoriasis plaques.
- Omega-3 fatty acids (in most RCT (randomized placebo-controlled trial) no significant improvement in skin lesions, while in uncontrolled studies showed benefit).
- Hypocaloric diet (low-energy diet), with the goal of achieving normal weight; participation in a weight-loss program, if necessary.
Suitable dietary supplements should contain the following vital substances:
- Vitamins (vitamin D (calciferols))
- Omega-3 fatty acid (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)).