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Severe Psoriasis Treatment

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After discharge from hospital a patient with severe psoriasis may still be receiving treatment with methotrexate, etretinate (Tigason) or PUVA and it is important to mention some of the questions that the practitioner may have in relation to these.

Methotrexate

Methotrexate treatment is usually given by mouth once weekly, although in some patients it is given by injection. It must be taken regularly to maintain its effect. Alcoholic drinks should be drastically reduced or prohibited during methotrexate treatment as severe liver damage is a not infrequent result of the combination. It can cause indigestion, nausea and vague abdominal discomforts. More serious side-effects to look out for include agranulocytosis, liver damage and susceptibility to infection. If other drugs have to be given during methotrexate treatment, enquiry should be made as to their interaction with methotrexate. Particular care should be taken with salicylates and other antirheumatics as they may interfere with the excretion of methotrexate. This may be a particular problem in the elderly who may already have a compromised renal function. Pregnancy must be avoided while on this drug as it is teratogenic. A total cumulative dose of > 1.5 g of methotrexate has been associated with hepatocellular damage and fibrosis. Particular caution is needed in patients who have taken the drug for more than one year. Some advocate liver biopsy after six months of treatment.

Etretinate

Etretinate (Tigason) is given daily by mouth and usually takes some four to six weeks before it starts to work. It does not usually give rise to intestinal symptoms but nearly always causes dryness and cracking of the lips. Some slight and temporary increased rate of loss of scalp hair may occur while on the drug. Other problems that occasionally occur with etretinate include dryness and itchiness of the skin, stickiness of the skin and nose bleeds. The drug can also cause hyperlipidaemia in some 25 per cent of patients and this should be checked by blood tests. In some patients who are on etretinate for longer periods and on high dosage, ossification may occur in ligaments and interosseous membranes. The disseminated interstitial skeletal hyperostosis syndrome may be seen in patients on longterm treatment but does not seem to compromise mobility in the large majority of patients. Etretinate is teratogenic and effective contraception must be used both while on the drug and for two years afterwards as it persists in the body for very long periods.

Acitretin (Neotigason), which is very similar to etretinate, has been introduced recently. It is more water soluble than etretinate and has slightly different pharmacokinetics - only 70 per cent of the dose of etretinate is required. Its efficacy and side-effect profile are exactly the same as for etretinate. Unfortunately a small proportion is actually metabolized to etretinate and therefore the implications with regard to teratogenicity are the same. In the United Kingdom, acitretin has supplemented etretinate and is only available from hospital pharmacies.

PUVA

PUV A (photochemotherapy with A-type ultraviolet radiation) has been in use in some hospitals and special clinics since the mid-1970s. Patients take a psoralen (8-methoxypsoralen or 5-methoxypsoralen) and receive UV A irradiation from special lamps some two hours later. Treatment is usually given three or four times per week at first but may be needed only once or twice a week during maintenance therapy. Patients receiving PUV A become quite tanned. This fact plus the lack of messy ointments makes this treatment popular with many patients.

Some psoriatic feel claustrophobic in PUV A cabinets and some larger patients cannot actually fit into them. These drawbacks and the occasional sunburn from overenthusiastic treatment apart, the treatment is remarkably trouble-free in the short term. There is some concern about carcinogenic effects on the skin in the long term, and fair-skinned subjects who are susceptible to the effects of sunlight are generally not considered for treatment. At the time of writing it is acknowledged that there is a much higher incidence of squamous cell carcinoma in patients who have received many PUV A treatments.