Consensus & controversies
12. THERAPEUTIC STRATEGIES
12. 1. The classic strategy
It consists of a clearing phase followed by a maintenance phase. The aim of the clearing phase is to get rid of the lesions and the aim of the maintenance phase is to avoid them to relapse. As a rule, maintenance phase must be very prolonged, since modifications in the dermal capillaries remain extremely sizable, even six months after clearance. Without any rigorous study to demonstrate it, it is still worth bearing in mind that one year of maintenance therapy gives the patient a greater chance of returning to his situation before the first psoriasis attack. This aim should be striven specially if the psoriasis is recent.
This “clearing phase/maintenance phase” strategy may be enacted with topical treatments, wherever usable (limited and stable psoriasis) and sufficiently effective. These topical treatments include fair skin moisturizing. Strength 4 topical steroids are efficient for the clearing phase. Vitamin D3 derivatives can be used indefinitely when efficient. For some patients, alternation between topical steroids and vitamin D3 derivatives is the most convenient maintenance treatment.
The strategy most often adopted as systemic treatment is to start off with PUVA therapy. If relapse is too fast after PUVA therapy, start on acitretine or etretinate, adopting a strategy of progressively increasing doses. Once the maximum well-tolerated dose has been reached for three months, a number of situations may be encountered:
- a) Progressive improvement and hence continuation of treatment until the maximum effect is obtained. If the result is good, acitretine can be used indefinitely, adding UVB TL01 in the case of flare.
- b) Insufficient improvement. In this case, the clearing phase must be resumed, for instance phototherapy and/or topical treatment. After this, retinoids are resumed in the hope to avoid relapses. It should be noted that retinoids are much more effective in maintenance therapy in patients who clear rapidly on PUVA therapy (in less than 18 sessions).
Given the milder aggressiveness of UVB in comparison to PUVA, this treatment is used by some people in the clearing phase and in the maintenance phase. We do not know the maximum cumulative UVB radiation doses not to be exceeded, and in some countries patients are treated with UVB TL01 once a week and small doses of retinoids as a maintenance long-term treatment.There is a new strategy being developed at the moment: the combination of UVB TL01 phototherapy or broad-spectrum UVB with acitretine.“ This is a well-written chapter. It is, I believe, slightly outdated, ie you state that there is a “new strategy being developed at the moment: the combination of UVB TL01 phototherapy or broad-spectrum UVB with…retinoids.” This is certainly not a new form of therapy!Alan Menter
- c) Failure of phototherapy and retinoids. Methotrexate and cyclosporine are discussed. Methotrexate can be used over the long-term or as intermittent treatment, whereas cyclosporine is being used more and more as a short-term of four to five months, to “turn a corner” or to keep an attack in check.
This classic therapeutic strategy is an interesting one to be aware of but remains unfortunately rather theoretical, since even though the clearing phase improves very frequently the quality of life it does rarely clear the lesions completely. Therapists find themselves confronted thus with a difficult situation to manage, an apparently never-ending clearing phase.
All topical treatments may be pursued indefinitely with the exception of topical corticotherapy. Among the systemic treatments, Soriatane/Neotigason may be continued for an extremely long time, if useful, properly monitored and well tolerated. The same goes for methotrexate, as long as hepatic fibrosis can be monitored non-invasively. Broad-spectrum UVB phototherapy or TL01 can probably be used in a very prolonged fashion, but we have no criteria for stipulating the reasonable maximum duration. PUVA therapy has a cumulative toxicity that limits its use. Over the long run, cyclosporine is well tolerated only by some 5% of patients. In order to avoid reaching the toxic cumulative dose for the kidneys, short, intermittent cures are preferred, though without slackening off the monitoring.
In fact, the main point of optimal psoriasis management is to adapt the treatment to the patient’s needs. Psoriasis treatment is the prototype of the “tailored medicine”. We must assess the quality of life of each patient taking into account the reactions to treatments, the biological and psychological tolerance and the co-morbidities Thus, such thing as an algorithm does not exist in psoriasis treatment.