Novel approaches to psoriasis tx include managing disease's psychological aspect

Manchester, England - Treatments for psoriasis have evolved, with state-of-the-art biologicals leading the way for the more severe forms, but to maximize the effectiveness of any therapy it is crucial to assess the psychological aspects of psoriasis, as well as the physical, according to one expert.

"Most physicians are well aware of the huge negative impact that psoriasis has on the quality of life of patients with psoriasis. Treating them psychosocially can be almost as important as treating their physical manifestations, as the psychosocial implications can be devastating to these patients," says Christopher E. M. Griffiths, M.D., F.R.C.P., of the Dermatology Center at Hope Hospital, University of Manchester, Manchester, England.

Cognitive behavior therapy

Dr. Griffiths says that adjunctive PSMP can significantly enhance the physical response to therapy in patients with psoriasis.

"When looking at the psychological and physical responses to therapy in psoriasis patients, it is important to take a more holistic approach to treatment," Dr. Griffiths says.

"Psychological distress, in the form of excessive worrying, has a significant and detrimental effect on treatment outcome in patients with psoriasis. Adjunctive psychological intervention before and during treatment may benefit those psoriasis patients identified as high-level worriers."

Proper referral

Dr. Griffiths says that in more than 80 percent of cases, psoriasis is classified as mild and is managed in primary care facilities. He says that in the United Kingdom, psoriasis patients see a general practitioner (primary care) before referral to a dermatologist (secondary care). The value of written guidelines for referral was demonstrated in a recent randomized, controlled study conducted by Dr. Griffiths.

"Written algorithmic guidelines of referral can significantly improve the appropriateness of referral. Psoriasis patients can therefore be managed by the right person in the right place at the right time," he says.

Systemic treatment

Dr. Griffiths tells Dermatology Times that while treating patient stress and improving referral guidelines, it is also important not to discard traditional systemic therapies, as a better understanding of their pharmacogenetics can help physicians personalize treatments. Current systemic therapies for psoriasis have varying degrees of hepatic, renal, metabolic or hematologic toxicity, he says. Advances in pharmacogenetics can help physicians target therapies to patients individually with respect to safety and efficacy.

"The testing of genes for drug metabolism and/or action, as well as studying single nucleotide polymorphism profiles for drug metabolism and/or action, is key to optimizing response to systemic therapies while reducing the current and unwanted systemic organ toxicity," he says.

Dr. Griffiths explains that for now, the biologics show promise as the ideal therapy for more severe forms of psoriasis, insofar as they provide effective control of the disease, are not organ-toxic, offer a selected or targeted approach, and require minimal monitoring. He says that drugs such as efalizumab (Raptiva, Genentech), etanercept (Enbrel, Amgen/Wyeth) and infliximab (Remicade, Centocor) all offer good short-term efficacy.

"Maintaining the remission of psoriasis can be a bit more challenging in the long term. Psoriasis patients want maintenance of remission and not just the quick-fix induction of remission. Recent trials have shown a significant medium-to-long-term clinical benefit with the aforementioned biologics, particularly with efalizumab, which some patients have received continuously for more than three years," Dr. Griffiths says.

Similar, but not such long-term, results have been seen with extended regimens of etanercept and infliximab in recent clinical trials. He says the data indicate that biological therapies may allow long-term and safe control.