What is the role of systemic medications in the treatment of psoriasis?

Updated: Mar 17, 2021
  • Author: Jacquiline Habashy, DO, MSc; Chief Editor: William D James, MD  more...
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In severe cases, systemic medications such as retinoids (acitretin), methotrexate, cyclosporine, 6-thioguanine, azathioprine, a biologic, or hydroxyurea may be necessary for adequate control. Retinoids have been reported to cause dry eye, blepharitis, corneal opacities, cataracts, and decreased night vision. All of these may be associated with gastrointestinal intolerance, hepatic damage (acitretin, 6-thioguanine, azathioprine, methotrexate), marrow suppression (6-thioguanine, methotrexate, azathioprine, hydroxyurea) or renal damage (cyclosporine).

The use of biologic agents (proteins with pharmacologic activity) is discussed in Section 1 (2008) and reviewed, with updated safety information, in Section 6 of the AAD guidelines. The AAD recommends a set of baseline laboratory studies before starting treatment with a biologic agent to ensure any underlying conditions or risk factors are understood. [39, 42] Some patients with chronic hepatitis C may be safely treated with biologic agents, [50] while active hepatitis B is still considered a contraindication.

The use of these systemic medications, with appropriate safety considerations, is supported by Section 4 (2009) of the AAD guidelines. [6] Increased risk of infection applies to all systemic immune-suppressing medications, especially when used in combinations. Many of the therapies for psoriasis manipulate the function of the immune system and expose the patient to risk of severe infections while blunting the body’s response. In these patients, findings suggestive of minor infections must be taken seriously, and the risk versus the benefit of continuing the drug in the face of the infection must be weighed.

In addition, systemic retinoids and hydroxyurea may interfere with proper wound healing and elective procedures, including dental surgery, which are best performed before the start of the medications. Acitretin appears more effective than isotretinoin in psoriasis and does not require enrollment in the IPledge program. On the other hand, there is a 3-year pregnancy prohibition after its use, and many will not use this medication in any patient capable of ever becoming pregnant. Combination therapies, such as a biologic plus another immunosuppressive medication, have been used with good effect but data detailing the safest way to do this are scant. All of the systemic medications except acitretin may increase the risk of infection.

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