Scalp Psoriasis Treatments Reviewed by Psoriasis Expert Dr. Jerry Bagel

Jerry Bagel, M.D.

Jerry Bagel, M.D., Dermatologist

Psoriasis expert and dermatologist Dr. Jerry Bagel published his clinical perspective on the management of scalp psoriasis in the August 2010 issue of Practical Dermatology.

“Scalp psoriasis is one of the more difficult-to-treat manifestations of psoriasis” said Dr. Bagel. “It can have a profound impact on quality of life and can even be disabling for some patients.”

Scalp Psoriasis

Scalp Psoriasis

Dr. Bagel reviewed the psoriasis medications with which he has seen success when treating scalp psoriasis, including Clobex® (clobetasol) shampoo, T-Sal® (salycyclic acid) shampoo, Dermasmooth® under occlusion, and Taclonex® Scalp Suspension (calcipotriene and betamethasone dipropionate).

Dr Bagel stated that “biologics should be considered if previous therapies have failed. ” He added that treatment with excimer laser might also be considered. The excimer lasers delivers concentrated UV treatments often with “impressive results”.

Dr. Bagel concluded his article by emphasizing the importance that patients take the psoriasis medications that they are prescribed. If the medication is taken regularly, “we can decrease the frequency of treatment to the least amount necessary to keep the scalp clear.”

Jerry Bagel, M.D., FAAD is a board-certified dermatologist in private practice at Windsor Dermatology in Windsor, New Jersey and is nationally recognized expert in the treatment of psoriasis. He is a member of the medical advisory board of the National Psoriasis Foundation and is regularly invited to speak across the country about the treatment of psoriasis.

High Stress Worsens Psoriasis

Chronic stress can lead to a worsening of psoriasis. Peak levels of stress increase the risk of a psoriasis flare one month later.

The correlation of stress with psoriasis has been well known. Now, a study published in the October issue of the British Journal of Dermatology, “How Stress Gets Under the Skin“, shows how stress leads to changes in cortisol levels that influence psoriasis severity.

Cortisol is a hormone produced by the body that regulates a wide range of bodily functions, including inflammation. High levels of cortisol reduce inflammation. Acute stress acts via the HPA axis to increase cortisol levels in the body. However, chronic stress can lead to an overall reduction in cortisol levels

The researchers followed 62 patients with psoriasis for 6 months, measuring their self-reported measures of stress, psoriasis severity (as measured with the PASI score) and blood levels of serum cortisol.

The researchers found that peak levels of daily stress predicted an increase in psoriasis severity a month later. The peak levels of daily stress were also significantly associated with lower cortisol levels. Those who persistently experienced higher levels of daily stress had lower average cortisol levels than patients who experienced lower levels of daily stress.

The researchers concluded that the “results suggest that daily stressors influence disease outcome in patients with psoriasis by affecting cortisol levels at moments of high stress. Furthermore, patients with persistently high levels of stressors seem to have a specific psychophysiological profile of lowered cortisol levels and may be particularly vulnerable to the influence of stressors on their psoriasis.”

Here is concrete evidence of the mind-body connection and its role in psoriasis. Now, if only there were a cure for psoriasis.

New Psoriasis Medications Reviewed by Psoriasis Experts

Craig Leonard, M.D. Dermatologist

Craig Leonard, M.D. – Psoriasis Expert

Psoriasis treatment options have expanded greatly over the last few years due to the development of new biologic medications.

In a story covered in Skin & Allergy News, dermatologists and psoriasis experts Dr. Craig Leonardi, M.D. and Dr. Alice Gottlieb, M.D. reviewed the latest research in new psoriasis medications and an evaluation of current therapies.

Briakinumab

The dermatologists noted that one of the most notable psoriasis medication in 2010 was of an investigational monoclonal antibody, briakinumab, made by Abbott. Like the recently approved psoriatic drug ustekinumab (Stelara), briakinumab is an injectable biologic agent that targets the interleukin-12 and -23 (IL-12/23) proteins, which are believed to promote the inflammation associated with psoriasis.

One briakinumab trial (M06-890) compared the efficacy and safety of briakinumab to placebo. The results showed that 80.7% of the 981 patients randomized to receive briakinumab every 4 weeks following an induction phase experienced a 75% improvement in psoriasis symptoms (PASI 75) at week 12, compared with 4.5% of the 484 patients randomized to placebo.

Three other trials compared briakinumab to etanercept (Enbrel) or methotrexate and found that significantly more patients randomized to receive briakinumab achieved improved clearance over those assigned etanercept, methotrexate or placebo.

Briakinumab has been submitted by the manufacturer to the FDA for approval.

Ustekinumab (Stelara)

Results of studies that investigated the use of Stelara for psoriasis found that there was a “favorable risk/benefit profile for up to 3 years of treatment.”

According to Dr. Leonardi, one of the study investigators, the maintenance of the favorable safety profile in patients who have been treated for several years is “encouraging”. He noted that ongoing 5-year follow-up studies will enable continued monitoring of the drug’s safety.

Psoriasis Medications in the Pipeline

The dermatologists reviewed additional psoriasis medications with a different mechanism of action. These include:

  • IL-17 inhibitors. Recent studies have suggested that immune system cells (T cells) produce IL-17A that may have acrucial role in the development of psoriasis. This has made IL-17  a potential treatment target. Two antibodies against IL-17 are being researched by Novartis and Amgen.
  • Oral and topical janus kinase (JAK) inhibitors are in phase II and III trials and have had promising results so far
  • Oral phosphodiesterase inhibitors, such as apremilast. Results from a Phase III studies regarding apremilast for the treatment of plaque psoriais is expected by summer 2011. Apremilast is manufactured by Celgene.
  • Topical niacin/calcipotriene. Calcipotriene is a vitamin D derivative that is a well established treatment for psoriasis. New studies are looking at combining this medication with other psoriasis medications for improved results. A recent double-blind, randomized trial reported that 50% of patients randomized to combination therapy with 0.005% calcipotriene and 1.4% nicotinamide achieved symptom clearance or near clearance, compared to 18.8% of those receiving placebo, 25% of those using nicotinamide alone, and 31.5% of those using calcipotriene alone. The findings suggest that the combination therapy “may prove effective as an alternative therapeutic option to calcipotriene monotherapy” according to the study authors.( Pilot, multicenter, double-blind, randomized placebo-controlled bilateral comparative study of a combination of calcipotriene and nicotinamide for the treatment of psoriasis.)

During the presentation, Dr. Leonardi stressed that the existing category of biologic medications, including tumor necrosis factor (TNF) antagonists (Enbrel, Humira, Remicade) continue to perform well.

Dr. Leonardi pointed out that “Given that the class is now 12 years old and includes 2 million patients, we are unlikely to learn of major safety risks at this point”.

What this means in clinical practice is that ustekinumab or briakinumab may be reasonable options for patients with a history of failure of TNF antagonists or a history of central or peripheral demyelination, but until longer-term safety data are available, it should not be the first choice in the majority of treatment-naive patients, said Dr. Leonardi.

Read the full story “Briakinumab, Ustekinumab trials point to future of psoriasis treatment“.

Guttate Psoriasis Outcome Relatively Good

Guttate psoriasis appears to have a better prognosis than other forms of psoriasis. That is the conclusion of a recent study published in the June issue of the Journal of Dermatology.

Clinical course of guttate psoriasis: Long-term follow-up study“studied 26 patients with guttate psoriasis and found that 61.1% experienced complete involution of their psoriasis with long remission of at least one year.

Family history of psoriasis tended to be associated with a poor prognosis, although only four (11.1%) of the patients had a family history of psoriasis. Psoriasis in three of these patients developed into chronic psoriasis.

Similar to previous reports, the trunk and extremities were the sites most commonly involved and pruritus and itching were more common in patients with a good prognosis, although not significantly so.

Stelara (ustekinumab) improves depression and anxiety.

Steve Feldman, M.D.

Study Author, Dermatologist, Steve Feldman, M.D.

Stelara (ustekinumab), one of the newer biologic medications prescribed for the treatment of psoriasis was found to reduce mild-to-severe anxiety in psoriasis patients after 12 weeks of use.
The research study by, Richard G. Langley, M.D., Steve Feldman, M.D., Alexa Kimball, M.D. and others published in the May 2010 issue the Journal of the American Academy of Dermatology (JAAD), “Ustekinumab significantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-to-severe psoriasis” showed that treatment with Stelara provided relief of anxiety and depressive symptoms in patients with moderate-to-severe psoriasis.

The researchers analyzed the effect of Stelara on anxiety, depression, and impaired quality of life in 1230 patients with moderate-to-severe psoriasis who were randomly assigned to receive Stelara (ustekinumab) 45 or 90 mg/day or placebo. This was part of the PHOENIX 2 trial.

At baseline, the patients had an average Psoriasis Area and Severity Index score of 20, and 40.3% of patients reported symptoms of anxiety and 26.7% symptoms of depression.

After 12 weeks of treatment, patients receiving either 45 or 90 mg/day of Stelara had significantly greater improvements in depression and anxiety symptoms than patients taking placebo.

By 12 weeks, the proportion of patients with mild-to-severe anxiety and mild-to-severe depression had decreased by 34% and 55%, respectively, in patients receiving ustekinumab, compared with corresponding increases of 1.4% and 10.2% in placebo-treated patients.

One of the study authors, Dr. Kimball concluded that “these benefits in mood are important to quantify and should remind clinicians to ensure the patients at risk are appropriately identified and treated.”

Calcitriol Helps Heal Corticosteroid-Damaged Skin

Researchers have found that calcitriol, the active ingredient of Vectical, can help to heal skin damaged by the use of topical corticosteroids. Both Vectical and corticosteroids are commonly prescribed medications for the treatment of psoriasis, but corticosteroids are known to harm the skin, even after short term use.

In a study published in the June 2010 issue of the British Journal of Dermatology, “Topical calcitriol restores the impairment of epidermal permeability and antimicrobial barriers induced by corticosteroids,” researchers investigated the changes to the skin of mice that had been exposed to corticosteroids, and the response to treatment with calcitriol (Vectical).

The skin treated with corticosteroids and calcitriol showed an improvement in the integrity of the outer layer (stratum corneum) and a recovery of the epidermal barrier that is important for controlling water loss and preventing infections.

Biologics Cost-Effective for Select Cases of Psoriasis

The use of biologic medications for the treatment of psoriasis may offer cost-saving benefits when prescribed for patients who might otherwise require long hospitalizations for their psoriasis.

This was the conclusion of a June 2010 issue of the British Journal of Dermatology, “The economic impact of high-need psoriasis in daily clinical practice before and after the introduction of biologics.”

A treatment course with biologics can be very expensive, and there has been concern about whether the high price is sufficiently offset by the clinical benefits and potential cost-savings from reducing the number of flares and use of other medications, as well as reduced risk of hospitalization.

The study investigated the medical costs associated with the treatment of 67 patients with “high need” psoriasis. Direct costs were calculated for the period of time prior to the availability of biologics and compared to the cost after their introduction. Direct costs for a subset of hospitalized psoriasis patients were analyzed separately.

Average total direct costs were 10,146 pounds per patient per year ($14,575) in the pre-biologic treatment period, compared with 17, 772 pounds ($25,445) in the biologic treatment period. For six patients in the cohort, introduction of biologics led to a reduction of direct costs, as these patients did not need long hospitalizations.

Treatment with biologics led to a decrease in the PASI (psoriasis severity score) from 19.0 at the start of biologic therapy to 6.4 at analysis (a 66·4% reduction).