Psoriasis is a chronic skin disorder with remissions and relapses and without permanent cure. The goal of treatment is therefore, to establish disease control and prolong periods of remission and the period in-between flares.
Proper patient and parents education is necessary, emphasizing the need to control versus cure, as setting realistic expectations often enhances compliance. Apart from improving the physical symptoms the management of psoriasis should also consider minimizing the impact of disease on psychosocial development leading to a better quality of life and limiting the adverse effects of drugs on growth and future health of the patient. The disease is chronic, visible and can have significant impact on patient’s psychosocial development.
The choice of therapeutic modality depends on the type severity, extent, and sites of psoriasis measured by Psoriasis Area severity Index (PASI) score, patient’s age, quality of life factors, as well as safety and accessibility of treatment. Fortunately majority of the psoriasis cases are mild and hence adequately manageable with topical treatment modalities. Systemic options are considered in patient with severe, widespread rapidly evolving, debilitating disease like pustular or erythrodermic forms, psoriatic arthropathy and frequently relapsing psoriasis, which present the true challenge.
Management is influenced by presence of co-morbid conditions like Psoriatic Arthritis, hematological, liver and renal function parameters as well as with the level of functional, emotional or social disability.
Topical treatment is sufficient to manage majority of patients presenting with mild forms of psoriasis. Topical corticosteroids, coal tar, anthralin, Vitamin D analogues, calcineurin inhibitors and a range of emollients and keratolytics are available. The choice of topical agent depends on the morphology, site involvement, patient’s intolerability and side effect profile.
Treatment with systemic agents in psoriasis is reserved for severe, refractory, widespread or incapacitating disease with psychological effect, pustular or erythrodermic forms and psoriatic arthropathy. The lower tolerability and cumulative toxicities of systemic agents limit their use in psoriasis patients and are preferably used in rotational or sequential therapy when indicated.
Phototherapy is defined as the therapeutic use of ultraviolet light (ultraviolet A or B) without any exogenously used photosensitizer for the treatment of various dermatoses while photochemotherapy refers to the use of a sensitizer (psoralens) in addition. Phototherapy is effective and safe therapeutic modality in carefully selected patients with refractory disease, diffuse (>15-20% BSA) involvement or focal debilitating palmoplantar psoriasis. Broadband UVB (BB-UVB, 290-320nm), narrowband (NBUVB 311 ± 2nm) and UVA (320 – 400 nm) are the three main types of therapeutic lights useful in psoriasis, due to their action of inhibiting DNA synthesis, keratinocyte proliferation and induce T-cell apoptosis, immunosuppressive and anti-inflammatory cytokines.