Options for moderate to severe psoriasis

Options for moderate to severe psoriasis

What is moderate-to-severe psoriasis?

A specific scale – Psoriasis Area and Severity Index (PASI) – is used to assess the extent and severity of psoriasis.1-3 The score ranges from 0 to 72, according to the intensity of psoriasis – degree of redness, thickness and scaling of plaques – and the proportion of the body affected.1-3 If you have a PASI score ≥10 then you have moderate-to-severe psoriasis.1-3 Your quality of life - using a scale called the Dermatology Life Quality Index (DLQI) - also helps to predict the severity of psoriasis in association with the PASI score.5

 

Treatment options vary according to the severity of psoriasis5

Only a doctor can properly assess the severity of your psoriasis.

What do you want to learn about?

Topical treatments

Topical treatments can be creams, lotions, washes or gels. They are applied directly to the skin. They do not all work in the same way, some help slow down excessive skin cell production, some reduce inflammation, and some do both.

Type of treatment

Topical corticosteroids

How it works

Reduce inflammation or the swelling and redness of lesions

Vitamin D analogues, e.g. calcipotriol

How it works

Slow the production of skin cells. They also have an anti-inflammatory effect

Vitamin A analogues,e.g. tazarotene

How it works

Help to slow skin cell growth and may decrease inflammation

Coal tar

How it works

Can reduce scales, inflammation and itchiness through an unknown mechanism

Dithranol

How it works

Works in a similar way to vitamin D by slowing the production of new skin cells

Salicylic acid

How it works

Softens keratin – a protein that forms part of the skin structure – helping loosen dry scaly skin making it easier to remove

 

Phototherapy

Phototherapy (or light therapy) uses the same ultraviolet rays given off by the sun – UVA and UVB – to treat psoriasis. It has mainly localised effects, suppressing the activity of specific cells in the skin. Phototherapy is effective, but there are factors that need to be considered, including potential long-term skin damage, and the need for frequent treatments (up to three times a week). When you also include the amount of time taken to travel to the clinic, phototherapy can be time consuming.

Systemic treatments

These work to address psoriasis from the inside, by targeting the immune system. They are generally only prescribed for people whose condition is moderate to severe. They can be divided into two categories:

  • Standard systemic treatments, which are usually taken orally

  • ‘Biologic’ treatments, which target very specific components of the immune system and are given as an injection under the skin (subcutaneous) or infusion (into a vein).

Standard systemic treatments

Most standard systemic treatments work to reduce the activity of the immune system, although some also affect how the skin cells behave.

Types of treatment

Acitretin

How it works

Slows down the production of new skin cells

Administration/dosing

Oral capsule given daily

Cyclosporin

How it works

Helps to reduce the harmful activities of the immune system on the skin by increasing production of a strong anti-inflammatory substance

Administration/dosing

Oral capsule given twice daily

Methotrexate

How it works

Helps to reduce the harmful activities of the immune system on the skin

Administration/dosing

Oral tablet or injection (intramuscular or subcutaneous) given weekly

Biologic treatments

Type of treatment

Tumour necrosis factor (TNF) inhibitors

How it works

Decrease inflammation by blocking part of the communication system between cells (TNF) that calls for an immune system response

Maintenance therapy

Adalimumab: fortnightly injection under the skin
Etanercept: weekly injection under the skin
Infliximab: infusion (intravenous drip every 8 weeks)

Interleukin 12/23(IL12/23) inhibitors

How it works

Inhibit or slow down the development of very specific immune cells as well as inflammatory substances thought to be important in the development and progression of psoriasis

Maintenance therapy

Ustekinumab: injection under the skin every 12 weeks

Interleukin 17A (IL17A) inhibitor

How it works

Inhibit or slow down a very specific part of the immune system reducing the production of inflammatory substances

Maintenance therapy

Secukinumab: injection under the skin every 4 weeks
Ixekizumab: injection under the skin every 4 weeks

Interleukin 23 (IL-23) inhibitors

How it works

Inhibit or slow down a very specific part of the immune system reducing the production of inflammatory substances

Maintenance therapy

Guselkumab: injection under the skin every 8 weeks following initiation dosing
Tildrakizumab: injection under the skin every 12 weeks following initiation dosing

What to ask your doctor about biological treatments

If you qualify for a biological therapy it is likely your dermatologist will ask you to consider a treatment trial. Biologics can be very effective, but there are some things you should discuss with your dermatologist before you make a decision.

  • What benefits does biologic treatment offer me?

  • Why are you recommending this particular biological therapy?

  • Are there safety factors I should consider?

  • What are my options for administration?

  • How often will I have to be treated?

  • How long does the treatment process take?

  • What are my responsibilities if I take this treatment?

  • What happens if I do not respond to this treatment?

Travelling while receiving a biologic treatment

Taking an injectable or infused biologic does not have to stop you travelling, but there are things you need to consider.

  • Do you have sufficient supplies to last the duration of your travel?

  • If your treatment is administered in a hospital or clinic will you be able to access one at the necessary times?

  • Do you know how to correctly store your treatment?

  • If you are flying have you confirmed, in writing, that you will be allowed to take your treatment into the plane cabin?

  • If travelling internationally have you confirmed that you are legally able to enter the country with your treatment and device?

What if treatment doesn’t work?

Psoriasis is a very individual disease, in the symptoms different people experience, and how they respond to treatment. There are a number of different treatment options at every step of the way, so if one treatment does not work for you, don’t panic. Your doctor will continue to try different options and different combinations of treatments until the best possible outcome for you is achieved.

Potential cost of treatments  

Many psoriasis treatments, including topical creams, oral medications and biologic medicines, are listed on the Pharmaceutical Benefits Scheme (PBS). If you are prescribed one of these therapies, you will be eligible for treatment funded by the Australian Government – providing you are a Medicare cardholder and the severity of your condition meets the funding eligibility criteria. Medicare also provides a rebate for dermatologist consultations and phototherapy treatments.

To learn more about PBS eligibility and other government-funded health services, visit humanservices.gov.au or call 132 011. If you’d like more information about the PBS Safety Net, speak to your pharmacist.

Accessing biological therapy under the PBS

If you have psoriasis covering large areas of your body, or if it affects your face, palms or soles you may be able to access a PBS-subsidised biological therapy.

Strict criteria must be met before you are eligible, including:

  • Treatment by a dermatologist.

  • Psoriasis of a certain severity level.

  • Failure of ≥3 other psoriasis treatments (ie. phototherapy, methotrexate, cyclosporin, acitretin).

Your dermatologist is the best person to ask about whether a biologic therapy might be suitable for you and whether you’re eligible under the PBS.

Maintaining eligibility for PBS-reimbursed treatment

If you qualify for a PBS-reimbursed biologic therapy you must meet certain ongoing criteria in order to continue receiving treatment.

  • You must take each dose according to a strict schedule.

  • You must have regular assessments of your psoriasis.

  • You must achieve a certain PASI score – determined by your baseline score – throughout treatment.

Your dermatologist is responsible for ensuring that all necessary paperwork is submitted to the relevant government authorities at the appropriate times. You are responsible for ensuring that you attend all necessary appointments.

 

    REFERENCES

    1. DermNet NZ. PASI score. Available at http://www.dermnetnz.org/topics/pasi-score/
    2. Fredricksson T, Pettersson U. Dermatologica 1978; 157: 238–44.
    3. Feldman SR, Krueger GG. Ann Rheum Dis 2005; 64(Suppl II): ii65–ii68.
    4. Mrowietz U, et al. Arch Dermatol Res 2011; 303: 1–10.
    5. Baker C, et al. Aust J Derm 2013; 54: 148–54.

    This educational resource is not intended to replace discussions with your healthcare team. If you have any questions about your condition or treatment, please contact your doctor.