Internal Medicine

0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:19

Psoriasis 1239

■PUVA (photochemotherapy)

➣Office based procedure given 2 or 3 times per week

➣Psoralen (Oxsoralen ultra) is given based on body weight 1 hour

prior to therapy

➣Contraindications

History of photosensitivity diseases

History or presence of skin cancer

Inability to come to an office with appropriate equipment

■PUVA should not be administered in an uncontrolled setting – e.g. a

tanning salon

■PUVA may be combined with systemic retinoids to enhance the effect

and to limit the development of squamous cell carcinoma

Systemic Therapies

■Methotrexate

➣Indication – disabling psoriasis, not responsive to less toxic ther-

apy, generally >20% surface involvement, or disease of the hands

➣Begin at low dose (5 mg/week) and escalate gradually to 20–30

mg/wk

■Acitretin

➣Indications for treatment

Pustular psoriasis, erythrodermic psoriasis, PUVA or UVB fail-

ure

■Cyclosporine

➣Indications for treatment – Patients with extensive psoriasis who

have failed less toxic therapies

■Biologic agents

➣Anti-TNF agents – etanercept, infliximab and adalimumab are

approved for psoriasis (E) and psoriatic arthritis (E, I, A).

Contraindicated in patients with active infection, history of

tuberculosis, neurologic disease (particularly multiple sclero-

sis), unstable cardiac disease. May predispose to a greater risk

of lymphoma.

➣Efalizumab – affects T cells and their ability to migrate into the

skin

➣Alefacept – causes T-cell apoptosis; 20% of patients might have

long-lasting remissions

follow-up

■Assess response to therapy monthly, monitor blood tests in patients

on methotrexate, acitretin or cyclosporine every 2–4 weeks initially,

then every 2–3 months once on stable dosage