Psoriasis Vulgaris: The Primary Care Approach

Selected by Pietro Cazzola

PsoriasisPsoriasis vulgaris is a chronic, autoimmune-related dermatologic condition that is commonly seen in primary care. It can be quite distressing for patients, as the large, red, scaly plaques can present noticeably anywhere on the body, but mostly on the extensor surfaces of the elbows, knees, and on the scalp and lower back.
In primary care, the most utilized treatment options are topical corticosteroids and vitamin D3 analogs. Given in conjunction or in consultation with a dermatologist, other commonly used treatment options include phototherapy and systemic biologics. These biologics, such as tumor necrosis factor (TNF)-alpha blockers, work by blocking cytokine TNF-alpha, which triggers an inflammatory response in the body. This inflammatory response leads to the skin and joint damage that accompanies psoriasis and associated psoriatic arthritis. Biologics, delivered by injection or IV infusion, are quite costly and also can trigger adverse reactions, for example respiratory infections and tuberculosis infections. Use of biologics must also be maintained to achieve sustainable effects.
Cyclosporin has been considered a treatment option for moderate-to-severe psoriasis vulgaris. Ito and colleagues in a prospective 2-year study examined the use of cyclosporin for mild-to-moderate psoriasis vulgaris administered intermittently through a microemulsion gelatin capsule (2.5 mg/kg per day divided twice daily with breakfast and dinner) over 2-12 weeks until remission.1 If skin lesions relapsed significantly after this period, treatment was restarted and repeated if necessary. Patients still continued their topical treatments (corticosteroids and vitamin D3 analogs), but the dose and usage of these topicals decreased over time with adjunct use of cyclosporin. This approach proved to be a highly effective alternative therapy, with improved patient satisfaction and quality of life, and it may be an option that can be discussed with our patients. However, Ito and colleagues did not evaluate the effects on the development or treatment of psoriatic arthritis with the use of cyclosporin. Future assessments of such associated conditions would be useful as psoriatic arthritis can be a significant debilitating chronic condition associated with psoriasis vulgaris.
Adverse reactions to cyclosporin such as elevated blood pressure, elevated creatinine, liver dysfunction, and hyperlipidemia occurred in a few patients, but resolved after cessation of cyclosporin. Fewer kidney and liver abnormalities are likely to occur with intermittent therapy than with chronic cyclosporin therapy.
As primary care physicians, it is imperative to work in conjunction with our specialty colleagues and understand these treatment options and the potential risks and benefits. Periodic clinical and laboratory testing with blood pressure monitoring, liver function tests, blood urea nitrogen, creatinine, urinalysis, and lipid panels are crucial for minimizing long-term adverse outcomes.

Ito T, Furukawa F, Iwatsuki K, et al. Efficacious treatment of psoriasis with low-dose and intermittent cyclosporin microemulsion therapy. J Dermatol. 2014;41:377-381.

Tricia C Elliott