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Internationally recognized researcher, Alan Menter, M.D., considers the future of psoriasis treatment.
In 1994, with funding from the National Psoriasis Foundation, Dr. Menter and Ann Bowcock, Ph.D., started the National Psoriasis Tissue Bank with the mission of providing tissue to psoriasis genetics researchers around the world. The tissue bank quickly evolved into a research facility in its own right, and with Dr. Menter's involvement, it was responsible for the landmark discovery of the first gene for familial psoriasis susceptibility, as published in "Science" in 1994.
Q What roles do topical corticosteroids, tar, PUVA, and emollients currently have in the treatment algorithm for psoriasis?
However, for patients with more extensive involvement, topical corticosteroids do not have a place as monotherapy but remain valuable as adjunctive therapy in moderate to severe disease.
Tar is being prescribed very minimally for the treatment of psoriasis, due in part to concerns about carcinogenicity risk. It is used occasionally in Goeckerman therapy, but there are only a few centers offering that modality. We continue to use it for scalp treatment in a compounded preparation that combines tar with salicylic acid.
PUVA remains a very interesting therapy. It has its detractors who oppose it because of its skin cancer and photoaging risks. Nevertheless, PUVA has stood the test of time and continues to have a place for treating resistant, moderate-to-severe psoriasis. Administered alone in short courses of 20 to 30 sessions, it can result in very significant improvement, and the number of treatments required can be reduced when PUVA is combined with some systemic therapy, especially low-dose retinoid. Furthermore, PUVA is about the only agent available that produces relatively durable remissions, which can last between three and six months. Narrowband UVB rivals PUVA in terms of the ability to achieve clearing, and we are now using it more than PUVA. However, narrowband UVB does not offer the same benefit of prolonged remission.
Emollients are an important adjunct for all patients with psoriasis. As the plaques improve, they tend to become dry and scaly, and so it is helpful to use an emollient.
Q Has media publicity about the biologics had an impact on the number of psoriasis patients seeking treatment and are they better informed than in the past?
So far, there has been a modest amount of direct-to-consumer advertising in the mass media from the manufacturers of the biologics.
Even so, there is no doubt that we are seeing more patients with psoriasis and that they are more knowledgeable than ever before about the range of treatment options. However, while there are many individuals clamoring to receive the biologics, this does not mean they are all appropriate candidates and are being treated with those new agents. Interestingly, with the heightened patient interest in treatment, there is also increased patient awareness about older therapies, such as methotrexate, PUVA, and cyclosporine, which were little asked about before.
Q Is there a place for using topical corticosteroids adjunctively with biologic treatment?
With the possible exception of infliximab (Remicade), none of the biologics is able to clear psoriasis completely.
Therefore, we use those two modalities in a sequential regimen, beginning with a course of biologic therapy and then we use the topical corticosteroid for local treatment of resistant sites.
There is no doubt that topical treatments for psoriasis are here to stay. In fact, I expect usage of existing agents may even grow as we see more new patients who are not candidates for systemic therapy, and I think there is likely to be a place for the development of new non-steroidal topicals for treatment of psoriasis.