A young girl with scaly skin plaques
The patient had numerous thick red plaques on her back and the extensor surfaces of elbows, knees, and forearms.
New directions in treating psoriasis
A summary of future directions and current investigations in the management of psoriasis is given in TABLE 3.
Our patient’s treatment consisted of topical emollients, mid-potency topical corticosteroids, and tar shampoos/tar baths. She was responding well to the treatment. Introducing calcipotriene and reducing topical steroids is our next step. Regular follow-up visits are scheduled every 4 to 6 weeks.
TABLE 3
Future investigations
| Photodynamic therapy | The use of a photosensitizing drug in combination with a light source is showing promise, and clinical studies are under way for the treatment of psoriasis |
| Excimer lasers | Deliver high-dose narrowband UVB to a localized area sparing uninvolved skin. Clear psoriasis faster than conventional phototherapy, and may become predominant in the future |
| CNTO-1275 | Anti-interleukin-12 antibody that switches the immune response from a T-helper cell 1 cytokine reaction most commonly seen in psoriasis to a T-helper cell 2 cytokine response |
| T-cell receptor vaccines | Have been developed and are undergoing clinical trials in patients with psoriasis |
| Pimecrolimus | Used orally. It is a cytokine-release inhibitor with lesser immunosuppressive effects and side effects than tacrolimus and cyclosporin |
| Angiogenesis | Cutaneous blood vessels in psoriatic plaques are dilated, tortuous, and leaky |
| Vascular endothelial growth factor (VEGF) is overexpressed, and VEGF or its receptors are potential therapeutic targets for psoriasis | |
| Gene therapy | Chromosomes involved in psoriasis are being mapped |
| Gene therapy promises to be one of the most important areas of treatment of psoriasis for the new millennium |
Conclusion
Patients with mild localized psoriasis can easily and effectively be managed by family physicians using topical treatments or combinations modalities as outlined above. Patients with extensive disease or resistant to treatment should be referred to a dermatologist in conjunction with a rheumatologist if psoriatic arthritis is suspected.
With improved understanding of the immunopathogenesis and genetics of psoriasis, advent of the biologic agents, and future strategies under investigation, our approach to treating psoriasis may be very different in the years to come.
CORRESPONDING AUTHOR
Amor Khachemoune, MD, CWS, Wellman Center for Photomedicine (BAR 314), Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, 40 Blossom Street, Boston, MA 02114. E-mail: amorkh@pol.net
