PracticalDermatology

Psoriasis is a debilitating skin condition characterized by silver, scaled, erythematous plaques on the skin. These plaques occur due to dysregulation of the immune system, leading to a chronic inflammatory state that ultimately stimulates keratinocyte hyper-proliferation in genetically susceptible individuals. These lesions tend to occur symmetrically on the scalp and extensor surfaces (elbows, knees, etc.) and are often pruritic, although they may be asymptomatic.

During the past few years, many topical and systemic therapies have been FDA approved for the treatment of psoriasis. The purpose of this short paper is to provide a reference for all of the FDA-approved medications separated into topical treatments and systemic treatments in alphabetical order as well as their mechanisms of action, administrative advantages, indications, and side effects.

The goal for the treatment of psoriasis is to eliminate symptoms of the disease by at least 75 percent, based on the PASI (Psoriasis Area and Severity Index) scoring system. This result is considered PASI 75, with the intent to greatly improve the patient’s quality of life. Numerous medications have been utilized for years to treat the skin manifestations of psoriasis; however, this article will focus solely on the medications that have been FDA-approved for use in psoriasis. Currently, FDA-approved medications for psoriasis include multiple agents, which are broadly summarized into topical or systemic therapies. The mainstay of topical therapy is corticosteroids. Corticosteroids can be formulated to have various potencies; as such, they can be individually personalized as first line treatments for patients suffering from mild or severe disease as well as personalized for location on the body. Steroids may be used as monotherapy or in combination with other classes of medications, such as the retinoids or vitamin D analogs. Combination therapy may be more efficacious, while simultaneously hindering many of the side effects associated with steroid therapy. In addition, any of these combination medications can also be utilized as monotherapy, though they are more commonly employed in multi-drug topical regimens.

Within the “systemics” category are various medications that have been pioneered in recent years that have shown great efficacy in treating psoriasis; as such, they have garnered FDA approval. Many of these approved medications are classified as “biologics,” which is a broad category used to describe drugs that are synthesized and/or derived from biological sources. As previously mentioned, these medications have shown great results for many patients, particularly those with moderate to severe disease that have proven refractory to the more traditional therapies. These drugs have found superior efficacy when using a more stringent treatment success guideline, the PASI 90, which is based on a 90 percent reduction of signs and symptoms of disease. When used in combination with topical agents, many of these agents may provide the most advantageous approach in quelling the signs and symptoms of plaque psoriasis.

The following chart contains a brief review of the mechanism and indications for the various medications approved for psoriasis (source is the National Psoriasis Foundation; www.psoriasis.org/phases/fda-approved), their respective year of approval, and potential side effects for each.

1. Afifi, T., de Gannes, G., Huang, C., & Zhou, Y. (2005). Topical therapies for psoriasis: evidence-based review. Canadian family physician Medecin de famille canadien, 51(4), 519–525.

2. Bissonnette, Robert (2010). “Efficacy and safety of adalimumab in patients with plaque psoriasis who have shown an unsatisfactory response to etanercept.”. Journal of the American Academy of Dermatology (0190-9622), 63 (2), p. 228.

3. Feldman, S. R. (2019). Treatment of psoriasis in adults. Retrieved from https://www.uptodate.com/contents/treatment-of-psoriasis-in-adults?search=treatment of psoriasis in adults&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3630490835

4. Goel, N., & Stephens, S. (2010). Certolizumab pegol. mAbs, 2(2), 137–147.

5. Hong, C. H., Papp, K. A., Lophaven, K. W., Skallerup, P., & Philipp, S. (2017). Patients with psoriasis have different preferences for topical therapy, highlighting the importance of individualized treatment approaches: randomized phase IIIb PSO-INSIGHTFUL study. Journal of the European Academy of Dermatology and Venereology : JEADV, 31(11), 1876–1883.

6. Kim, W. B., Jerome, D., & Yeung, J. (2017). Diagnosis and management of psoriasis. Canadian family physician Medecin de famille canadien, 63(4), 278–285.

7. Lebwohl, M. G., Blauvelt, A., Menter, A., Papp, K. A., Guenthner, S., Pillai, R., … Jacobson, A. (2019). Efficacy, Safety, and Patient-Reported Outcomes in Patients with Moderate-to-Severe Plaque Psoriasis Treated with Brodalumab for 5 Years in a Long-Term, Open-Label, Phase II Study. Retrieved from https://link.springer.com/article/10.1007/s40257-019-00466-2#citeas

8. Lin VW, Ringold S, Devine EB. (2012). Comparison of Ustekinumab With Other Biological Agents for the Treatment of Moderate to Severe Plaque Psoriasis: A Bayesian Network Meta-analysis. Arch Dermatol.2012;148(12):1403–1410.

9. R. S. Wallis, M. S. Broder, J. Y. Wong, M. E. Hanson, D. O. Beenhouwer. (2004). Granulomatous Infectious Diseases Associated with Tumor Necrosis Factor Antagonists, Clinical Infectious Diseases, Volume 38, Issue 9, 1 May 2004, Pages 1261–1265.

10. Sarbacker, G.B., Witte, A.P., & Maize, D.F. (2016). Overview of Plaque Psoriasis Treatment. Retrieved from https://journalce.powerpak.com/ce/overview-of-plaque-psoriasis-treatment?utm_source=uspharmacist&utm_medium=banner&utm_content=article_ce_banner&utm_campaign=moreCE

11. Sbidian, E., Chaimani, A., Garcia-Doval, I., Do, G., Hua, C., Mazaud, C., … Le Cleach, L. (2017). Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. The Cochrane database of systematic reviews, 12(12).

12. Xu, S., Zhang, X., Pan, M., Shuai, Z., Xu, S., & Pan, F. (2019). Treatment of plaque psoriasis with IL-23p19 blockers: A systematic review and meta-analysis. International Immunopharmacology, 75, 105841. doi: 10.1016/j.intimp.2019.105841