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Psoriasis

Stelara for Psoriasis

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Ustekinumab (Brand name: Stelara) a human monoclonal antibody which blocks the p40 subunit of IL-12 and IL-23 is the new biologics approved for the treatment of moderate to severe psoriasis. Stelara is new biologics for psoriasis indicated for those who fail to respond to other systemic therapies including methotrexate, cyclosporine and PUVA.

Stelara is administered subcutaneously. The current recommended dose for patients weighing less then 100 kg is 45mg initially, 45 mg 4 weeks later then 45 mg every 12 weeks. For patients weighing more then 100 kg, the dose is 90 mg initially, 90 mg after 4 weeks then 90 mg every 12 weeks. Details study on drug interaction and safety during pregnancy or nursing mother have not been evaluated. Ustekinumab is not recommended for children below 18 years of age.

Stelara is a medicine that affects your immune system. Stelara can increase your chances of having serious side effects. It may lower the ability of your immune system to fight infection and may increase risk of serious infection including tuberculosis, Herpes zoster and other infections caused by bacteria, fungi or viruses. Before initiating the therapy talk to your doctor about previous infection. If there is any risk of infection, it should be treated prior to Stelara treatment. Anti Herpes Zoster vaccination may be consider before starting therapy.

Before starting Stelara talk to your doctor about your past or current medical condition like:

  • Fever or chills
  • Shortness of breath
  • Cough
  • Muscle ache
  • Weight Loss
  • Red or painful sore in your body
  • Stomach pain or diarrhea
  • Burning micturation
  • If you are prone to infection
  • Have history of TB
  • Restless or tiredness

Side effects of Stelara
Stelara may increase the risk of infection and may also reactivate latent infection. Call your doctor right away if you have any symptoms stated below after starting the therapy. Below are some of the short term and long term side effects of Stelara.

  • Headache
  • Seizures
  • Confusion
  • Vision problems
  • Allergic reactions
  • Cellulitis
  • Diverticulitis
  • Osteomyelitis
  • Erysipelas
  • Herpes zoster
  • Gastroenteritis
  • Pneumonia
  • Urinary tract infections
  • Cutaneous and non cutaneous malignancies

Stelara is not indicated in pregnancy or breast feeding mother. So if you are pregnant or planning to get pregnant or you are breast feeding mother, talk to your doctor about it. Your doctor will decide it. You should not receive any live vaccines if you are under treatment with Stelara, talk to your doctor about vaccination. If you are taking any medicine tell your doctor about the medications, especially if you are under any medications that affect your immune system.

These may not be all possible risk factors or side effects, so talk to your doctor in detail about current and new possible long term side effects.

If you have any question regarding Stelara (Ustekinumab), feel free to ask us at our psoriasis forum.

For more details about Stelara visit: http://www.stelarainfo.com/

Phototherapy for Psoriasis

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In recent years phototherapy continues to be one of the essential therapeutic treatment options for patients with mild to moderate psoriasis, either as a monotherapy or in combination with other standard treatment modalities, such as systemic and topical agents.

There are two types of phototherapy for psoriasis, UVA and UVB and both have shown good response in treating psoriasis.  UVB have shown to be more effective then UVB for treating psoriasis.

UVB Therapy

High dose UVB therapy is as effective as PUVA in treating patients with psoriasis and it can be used during pregnancy and lactation or in patients with hepatic or renal failure. There are two types of UVB therapy: Broadband UVB and Narrowband UVB. UVB treatment can be given on daily basis or 3-5 times a week until the lesion is cleared. Recently Narrowband UVB is being widely used as it has more advantage over Broadband UVB as it can be used in any patients including children and pregnant women.

UVA Therapy

UVA therapy penetrates deep into the skin than with UVB therapy. For UVA to be effective combination of UVA with photosensitizing medication like psoralen( PUVA) is used.  Treatment is usually given 2-4 times a week until lesion clears. As PUVA make the skin more sensitive to light, one should avoid sun as much a possible.

Side Effect of Phototherapy in psoriasis

Short-term side effects:
Erythema (sunburn)
Dry skin with pruritus
Swelling
Phototoxic blisters
The frequency of recurrent herpes simplex might increase.

Long-term side effects of UV therapy include

Photo aging
Increase risk of skin cancer
Pigmentary changes
Xerosis
Loss of elasticity
Wrinkle formation
Actinic keratoses.
Hypertrichosis
Dark lentigines (“PUVA lentiginosis”).

Acrodermatitis continua of Hallopeau

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Acrodermatitis continua of Hallopeau, which is also known as “pustular acrodermatitis”, “Acrodermatitis perstans”,or “Dermatitis repens” is a rare, chronic, recurrent pustular eruption involving the fingers and toes.

The cause of Acrodermatitis continua of Hallopeau is still unknown. As it resembles the similar histologic features as pustular psoriasis, many consider it as a variant of pustular palmoplantar psoriasis. It is most common in middle-aged women and usually starts after localized infection or trauma on finger or toe. Later it may extend into generalized form during the chronic course of disease.

Initially, it may involve a distal one or two digits. Further, when disease progress it may be generalized over hands, forearm and foot. The skin over the lesion may be red and scaly and multiple pustules may develop. The lesion can be very painful and disabling. Involvement of nail bed and nail matrix often leads to nail dystrophy.

Treatment of Acrodermatitis continua is often difficult and there is no established treatment regimen. Because of its histopathologic similarity to pustular psoriasis, several psoriasis treatment modalities (topical and systemic ) have been tried. Topical treatment options include topical corticosteroids, tar, 5-fluorouracil, calcipotriol, racrolimus and dithranol. Systemic treatment options include oral retinoids, corticosteroids and other immunomodulating and immunosupressing drugs like cyclosporine, methotrexate, colchine, infliximab, dapsone, sulphasalazine, and PUVA photochemotherapy.

If you have any questions regarding Acrodermatitis continua of Hallopeau, ask us at our Psoriasis forum

Effects of Cigarette Smoking on Your Skin

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We have already known the fact about cigarette smoking and its association between lung cancer, heart disease and many other systemic diseases. But people may not be aware of smoking and its association with several skin conditions like premature aging of skin, wrinkle, and delayed would healing. Besides, several other skin disorders like psoriasis, skin cancer, cutaneous lupus erythematosus, hidradenitis suppurativa and many other oral and vascular diseases are also linked to cigarette smoking. In this article we’ll review some of those skin conditions and disease which are either influenced or are associated with smoking.

Premature Skin Aging and Wrinkles:

Several studies have shown that cigarette smoking promotes premature skin aging and skin wrinkles. These conditions tends to occur more likely in smokers than non smokers, research suggest. The exact mechanism by which smoking can cause premature aging and wrinkling is not clear. But they believe the following may be the likely mechanism:

  • Reduction in the blood supply to the skin due to the vasoconstrictive effects of nicotine in cigarette.
  • Decreased collagen synthesis due to reduction in blood supply.
  • Changes in the elastic fibres of the skin.
  • Chronic exposure to heat from the cigarette smoking resulting in burning of the skin.
  • Reduction in Vitamin A and moisture of the skin.
  • Pro-oxidant effects of smoking.

Poor Wound Healing

It has been shown from different research and studies that smoking has a harmful effect on would healing. Smoking can delays wound healing in any skin injuries. It also increase the risk of wound infection. The exact mechanism may not be unclear but the reason are the same:

  • Lack of oxygen due to vasoconstriction property of nicotine.
  • Decreased collagen synthesis
  • Increased blood viscosity and platelet aggregation.

All of these above mentioned factors might contribute to poor would healing.

Smoking and Skin Cancer

Compared to non-smoker, smokers have twice the risk of developing skin cancers like squamous cell carcinoma (SCC). The association between smoking and the risk of squamous cell carcinoma have been well documented in several studies. The risk may increase with duration and number of cigarette per day. There is also a high risk is of oral cancer. It is said that 75% of Oral cancer occurs in smokers. The risk might even be higher with smokers who consume excess alcohol. Oral leukoplakia often described as a pre-cancer lesion also occurs much more commonly in smokers. In some few cases it may undergo malignant changes.

Smoking and Psoriasis

Several studies have found that risk of psoriasis increases with smokers. Psoriasis may be severe and extensive in patients those who smoke. It may be due to immunosuppressive effects of smoking. Palmoplantar pustulosis, a localized form of psoriasis tends to occur more in smokers than non smokers.

Hidradenitis Suppurativa

Hidradenitis suppurativa, also know as Acne inverse tends to occur more commonly in smokers. It is considered severe form of acne affecting the area of sweat glands and hair follicles, usually in breasts, underarms, groin, thighs and buttocks. Although exact mechanism poorly understood, it is thought that smoking alters sweat gland activity, causes overproduction of acetylcholine in the hair follicle causing blockage of hair follicle and thus promoting poor healing.

Discoid Lupus Erythematosus

Recent studies have linked cigarette smoking and the risk of developing Discoid lupus erythematosus . Cigarette smoking have also linked with decrease effectiveness of therapy in discoid lupus erythematosus.

Other Various Skin conditions that are linked to Cigarette Smoking:

Premature graying of hair.
Discoloration of distal hair of mustache often called as Smoker’s mustache.
Discoloration of fingers and nails of hands.
Oral lesions like oral candidiasis, oral lichen planus.
Black hairy tongue and hairy leukoplakia.
Chilblains.
Acute necrotizing uncreative gingivitis.
Antiphospolipid syndrome
Buerger disease.

Biologics For Psoriasis

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There have been many discoveries and research in the management of moderate and severe psoriasis for last 2-3 decades. Better understanding about the pathogenesis of psoriasis has led to advance in better treatment options for psoriasis. Traditional systemic treatment for psoriasis like methotrexate, cyclosporine and acitretin are often associated with related side effects especially end organ toxicity. In a search for better treatment options while minimizing the side effects and toxicity has led to the development of new treatment agents, the so-called Biologics.

The use of biologics in the management of moderate and severe psoriasis over past few years have increased with excellent results. These new generation drugs are proteins derived using recombinant DNA technology designed with the understanding of immunogenesis of psoriasis which specifically targets and interfere with the immune system that are responsible for causing psoriasis. Moreover they are thought to limit the potential systemic side effects because of their high specificity directed towards specific pathogenic cells without affecting sells of other organ.

Currently available Biologics For Psoriasis are injectable. They cannot be taken by oral. We’ll review some of the Biologics For Psoriasis currently in used in this article.

Etanercept ( Brand name:Enbrel )
Etanercept inhibits the activity of Tumor necrosis factor alpha( TNF-alpha) a key mediator that triggers inflammation. The current suggested treatment regimen of etanercept is 50 mg administered subcutaneously twice weekly for three months, and then followed by once weekly thereafter. It is approved for the treatment of chronic plaque psoriasis. Study suggests that Etanercept may be a safe for those with hepatitis C. Common side effects may be injection site reaction that may last for 3 to 5 days, cough and respiratory symptoms and infection.

Infliximab ( Brand name:Remicade )
Infliximab is a monoclonal antibody currently approved for treatment of psoriatic arthritis and rheumatoid arthritis. It works the same way as other biologics, blocking the activity of TNF-alpha. In psoriasis patients, infliximab is given intravenously at 3-5 mg/kg body weight over 2 hours at week 0,2 and 6, then after every 8 weeks. Common side effects may be infusion site reaction, nausea, fatigue, joint pain. Every Patients must have tuberculosis skin testing prior to initiation of the therapy to avoid reactivation of latent tuberculosis. Infliximab is not given for patients with severe congestive heart failure or any neurological disease. Details study on drug interaction and safety during pregnancy or nursing mother have not been evaluated.

Adalimumab ( Brand name:Humira )
Like other TNF-alpha blockers (Infliximab, Etanercept ), Adalimumab also works the same way by interrupting the activity of TNF-alpha. Adalimumab is administered subcutaneously with 40 mg over 3-5 minutes every 2 weeks or in some cases every weeks or as directed by your doctor. Common side effects may be injection site reaction, nausea and infection. Every Patients must have tuberculosis skin testing prior to initiation of the therapy to avoid reactivation of latent tuberculosis. This drug is not recommended for breast feeding mothers and may not be safe during pregnancy. Talk to your doctor if you are breastfeeding mother or planning to get pregnant.

Alefacept ( Brand name:Amevive )
Alefacept works by blocking the antigen from binding and activation of T-lymphocytes by attaching itself to the site on T-lymphocyte where antigen attaches. Thus, preventing T-lymphocyte to cause rapid growth of cells and reducing the inflammation of skin. Alefacept is currently being used in adults with moderate to severe plaque psoriasis. Alefacept is administered 15 mg intramuscular or 7.5 mg by intravenous injection per week for 12 weeks. If necessary it can be continued for another additional 12 weeks, but only if T-lymphocyte counts are within the normal range. Some common side effects are nausea, dizziness, muscle ache, sore throat, cough, chills and injection site reaction. Details study on drug interaction and safety during pregnancy or nursing mother have not been evaluated.

Efalizumab ( Brand name:Raptiva )
Efalizumab is a humanised monoclonal antibody that binds to the CD11a subunit of Lymphocyte function-associated antigen 1 ( LFA-1) and blocks adhesion mechanism, thus preventing the activation of lymphocyte which is responsible for inflammatory process in psoriasis. Efalizumab is subcutaneously administered initially as 0.7mg/kg followed by weekly 1 mg/kg injection. The common side effects usually after first 2 injection are chills, headache, nausea and vomiting. Efalizumab is not recommended for children under 18.

Efalizumab was previously approved for the treatment of moderate to severe psoriasis in Europe and USA but now it has been withdrawn from US market due to its increase risk of fetal side effects like progressive multifocal leukoencephalopathy (PML), a rapidly progressive viral infection of the brain that has no known treatment and results in severe disability or even death.

Ustekinumab ( Brand name:Stelara )
Ustekinumab is a human monoclonal antibody that binds to interleukin( IL)-12 and IL-23 and prevents them from binding to T-lymphocytes and activating it. Ustekinumab is new biologics recently approved by FDA for the treatment of moderate to severe psoriasis. Ustekinumab is administered subcutaneously. The current recommended dose for patients weighing less then 100 kg is 45mg initially, 45 mg 4 weeks later then 45 mg every 12 weeks. For patients weighing more then 100 kg, the dose is 90 mg initially, 90 mg after 4 weeks then 90 mg every 12 weeks. Details study on drug interaction and safety during pregnancy or nursing mother have not been evaluated. Ustekinumab (Stelara) is not recommended for children below 18 years of age.

It is important to know that the safety of these drugs for long term use is unknown and these drugs might need to be continued for long term even lifetime. These Biologics For Psoriasis are thought to be less likely fatal then traditional psoriasis treatment, but as these agents interfere with your immune system there may be risk of infection or any serious systemic disorders. These agents are not recommended for those with weak immune system.

If you have any questions regarding Biologics For Psoriasis feel free to ask us at our Psoriasis Forum

Side Effect Of Phototherapy In Psoriasis

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Two Photo-therapeutic regimens UVB and PUVA have been developed simultaneously for the treatment of psoriasis, and both have been shown to be highly efficient and have therefore remained in use.

The short-term side effects of UVB or PUVA are quite similar and consist of erythema (sunburn), dry skin with pruritus, swelling, and occasional phototoxic blisters; in addition, the frequency of recurrent herpes simplex increases. The major difference is in the time frame: Although UVB-induced erythema peaks before 24 hour, the maximal PUVA reaction is not reached before 72 hours. A generalized pruritus or tingling sensation may herald phototoxic side effects and should be taken as a warning sign. With large areas affected, systemic symptoms of phototoxicity such as fever and general malaise may occur. PUVA-induced skin pain unrelated to actual phototoxic burns occurs rarely but may necessitate temporary or definitive discontinuation of treatment.

In the initial phase of PUVA and UVB therapy, an asymptomatic and transient maculopapular eruption unrelated to phototoxicity has sometimes been seen. Psoralens can induce systemic side effects in the absence of light, mainly nausea and vomiting. In addition, they can rarely cause elevations of liver transaminases, central nervous system disturbance (headaches, dizziness), bronchoconstriction, drug fever, and exanthema. Because of higher permeability of the eye lens in children, PUVA should be avoided.

Long-term side effects of UV therapy include photoaging and carcinogenesis. A high cumulative dose of whole-body UVB or PUVA exposure results in pigmentary changes, xerosis, loss of elasticity, wrinkle formation, and actinic keratoses. In addition, PUVA may induce hypertrichosis and dark lentigines (“PUVA lentiginosis”).The major concern with prolonged and repeated phototherapeutic regimens is the induction or promotion of skin cancers. UVB is a known carcinogen, although its carcinogenic potential seems to be less than that of PUVA. In a 16-center study, no relationship between UVB phototherapy and nonmelanoma skin cancer was shown; however, the authors strongly cautioned that future studies may reveal an increased risk of nonmelanoma skin cancer with UVB phototherapy. The risk of squamous cell carcinoma, but not of basal cell carcinoma, is significantly increased in PUVA patients compared with matched controls, with the magnitude of the increase appearing to be dose-dependent.

There is uncertainty about the role of PUVA in these observations, however, because many of the reported patients had previous exposure to excessive sunlight and to other carcinogenic treatments such as arsenic, UVB, and methotrexate. Only a few anecdotal cases of malignant melanoma have been observed in psoriatic patients who received long-term PUVA treatment. The conclusion from different study was that the risk increases about 15 years after the first treatment, particularly after more than 250 treatments. This increased incidence is alarming, especially considering the long latency period for this tumor. This trend will likely become even more marked in the future.

It is unclear whether melanomas are associated with a certain cumulative UVA dose or with episodes of phototoxic burns. In addition, no increased risk of melanoma was found in other large-scale studies reported so far.Still, it is important to emphasize that a patient with long-term PUVA treatment must receive life-long monitoring. In any case, to possibly reduce melanoma risk, the cumulative UVA total dose should be kept to the minimum and maintenance therapy should be avoided.

Diet and Lifestyle Changes in the management of psoriasis

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Psoriasis is a common chronic inflammatory disease involving a variety of factors affecting millions of patients worldwide. This disease is highly influenced by diet, lifestyle and environmental factors like stress and infection . It can occur at any age and can develop into chronic which is really fraustrating with major impacts on our quality of life. Based on the literature Diet and Lifestyle Changes doesn’t cure your psoriasis but may improve the response to psoriasis treatment.

Here are few things you need to change or avoid:

  • Limit or avoid alcohol intake.
  • Quit smoking.
  • Improve body composition.
  • Sleep 8 uninterrupted hours nightly.
  • Learn and practice daily an activity that elicits the relaxation response.
  • Exercise five to seven times weekly at a moderate level for 20 minutes.
  • Eat a nutrient-dense diet at the three main meals, and two to three small-meal snacks daily

    • a. Five or more servings of vegetables daily
    b. Two servings of fruit daily
    c. 8 to 12 ounces of protein-rich food daily (fish, chicken, turkey, lean meat, eggs)
    d. Whole grains, squash, sweet potatoes, beans; minimal refined carbohydrates
    e. Olive oil, coconut oil for cooking
    f. Small amounts of butter, cheese, and other dairy products
    g. Nuts and seeds if allergy is not an issue
    h. Consider a 3-month trial of a gluten-free diet
    i. Consider working with a nutritionist

    Good sleep hygiene
    1. Devote the time to sleep. Arrange consistent bedtimes and waking times to allow 7 to 8 hours of uninterrupted sleep.
    2. Begin unwinding 30 to 45 minutes before sleep should begin. Do not use this time to finish tasks, tidy up the house, or make to do lists.
    3. If you have worries, write them down and leave them for tomorrow.
    4. Try relaxation techniques as your prepare for bed.
    5. Do not eat 1 to 2 hours before bed. Do not drink a lot of fluids.
    6. Avoid caffeine (coffee, tea, chocolate) after 4 pm.
    7. Avoid alcohol 4 to 6 hours before bedtime.
    8. Avoid daytime naps.
    9. Exercise regularly and moderately. Do not engage in vigorous exercise after 6 pm.
    10. Do not keep the television in your bedroom.
    11. Use the bedroom only for sleep (and sex).
    12. Keep the bedroom quiet.
    13. Pull the shades so the room is dark. Light disturbs melatonin release.
    14. Ensure that the temperature of the bedroom is optimal for you.
    15. Consider putting a few drops of a high-quality lavender essential oil on a handkerchief under your pillow.
    16. Consider a bedtime ritual, such as a warm bath or a few pages of reading.

    Precautions:

    Diabetic retinopathy or neuropathy patients: avoid vigorous exercise
    Diabetic patients must monitor blood sugar before and after exercise. Delayed hypoglycemia can occur up to 6 to 15 hours after exercise.
    If you have the conditions listed above or have any concerns or questions, be sure to consult your physician before embarking on an exercise program.

    Source:Integrative Dermatology

    Indigo Ointment May Help Treat Patients With Psoriasis

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    An ointment made from indigo naturalis, a dark blue plant-based powder used in traditional Chinese medicine, appears effective in treating plaque-type psoriasis, according to a report in the November issue of Archives of Dermatology, one of the JAMA/Archives journals.

    Psoriasis is a chronic skin disease for which no cure exists, only therapies that bring it into remission, according to background information in the article. “Traditional Chinese medicine is one of the most frequently chosen alternative therapies in China and Taiwan, and psoriasis has been treated for centuries with topical and oral herbal preparations,” the authors write. “Indigo naturalis is one of the Chinese herbal remedies that has been reported to exhibit potential antipsoriatic efficacy. However, long-term systemic use has been occasionally associated with irritation of the gastrointestinal tract and adverse hepatic [liver] effects.”

    Yin-Ku Lin, M.D., of Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan, and colleagues conducted a randomized trial of an ointment containing indigo naturalis in 42 patients with treatment-resistant psoriasis. Participants enrolled in the study between May 2004 and April 2005 and applied the indigo naturalis ointment to a psoriatic plaque on one side of their body (usually on the arm, elbow, leg or knee) and then a non-medicated ointment to a parallel plaque on the other side of their body. The researchers assessed and photographed patients’ skin plaques at the beginning of the study and again after two, four, six, eight, 10 and 12 weeks.

    After 12 weeks of treatment, the plaques treated with indigo naturalis ointment showed significant improvement in scaling, erythema (redness) and induration (hardening) when compared with the plaques treated with non-medicated ointment. “Weighting the sum of scaling, erythema and induration scores by the lesion area and comparing between the start and end of the study, the indigo naturalis ointment–treated lesions showed an 81 percent improvement, whereas the vehicle [non-medicated] ointment–treated lesions showed a 26 percent improvement,” the authors write.

    Of the 34 patients who completed the study, none experienced worsening psoriasis in the areas treated with indigo naturalis, while the treated plaques were completely or nearly completely cleared for 25 of them (74 percent). None experienced serious adverse effects. Four patients reported itching after applying the indigo naturalis ointment, but only for a couple of days at the start of treatment.

    “In conclusion, we present a randomized controlled trial showing the use of topical indigo naturalis ointment for the treatment of chronic plaque psoriasis to be both safe and effective,” the authors write. “Future research for a more potent extraction from this crude herb that can provide better absorption and convenience would help improve patient compliance with the treatment regimen. However, much more research will be necessary to clarify the pharmacology of indigo naturalis.”

    This study was supported by a grant from Chang Gung Memorial Hospital.

    Adapted from materials provided by JAMA and Archives Journals
    .