Once the diagnosis of psoriasis has been established, the next step is to evaluate the choice of treatment options.
In developing a treatment plan, the following factors should generally be considered.
The degree of the patient’s disease, the patient’s attitude toward the disease and confidence in the treatment, the price of drugs and the patient’s financial ability and the medical conditions of the hospital where the patient is located.
I. Evaluation of the severity of psoriasis.
Before formulating a reasonable treatment plan for psoriasis patients, clinicians need to evaluate the severity of psoriasis. The Psoriasis Area and Severity Index (PASI score) is currently the most widely used and authoritative standard. Although the PASI score has its limitations and poor sensitivity for patients with relatively small lesion areas, clinicians still use the PASI score as the gold standard for psoriasis severity evaluation. The severity of psoriasis is now evaluated in terms of the patient’s quality of life with the following criteria: mild as disease does not alter the patient’s quality of life, the patient is able to minimize the impact of the disease, no treatment is required, there are no known serious adverse effects of treatment measures, and <5% body surface area. Moderate as the disease does not change the patient's quality of life, but the patient expects treatment to improve quality of life, minimal adverse effects of treatment, 2% to 20% body surface area involved; severe as the disease changes the patient's quality of life, the disease is unsatisfactory for treatment with minimal adverse effects, the patient is willing to accept remission or cure of the disease with adverse effects affecting life status, >10% body surface area involved; other factors. Patient’s attitude towards the disease, site of the disease (e.g. face, hands and feet, nails, genitals), symptoms (pain, tightness, bleeding, intense itching), arthrosis/arthritis. Evaluation of disease severity needs to be individualized. Psoriasis is considered severe if it causes embarrassment, anxiety, severe itching or pain that interferes with interactions as well as daily life, work and study, sports or joint involvement. From a dermatologist’s perspective, psoriasis is considered severe if it is extensive, erythematous, extensively pustular, or if specific manifestations such as scalp, fold, and extremity involvement are of great concern to the patient. In contrast, from the clinical investigator’s perspective, whether or not psoriasis is severe requires assessment of clinical signs, such as area of involvement (BSA), degree of erythema scales, and thickness. A simple way to define severe psoriasis is called the tenth rule: that is, BSA > 10% (area of 10 palms), or PASI > 10, or Dermatologic Disease Quality of Life Index (DLQI) > 10 is considered severe psoriasis.
Second, the purpose of treatment.
The aim of psoriasis treatment is to rapidly control the disease at the beginning, reduce the number of lesions, alleviate clinical symptoms, maintain long-term remission with minimal adverse effects, and improve the patient’s quality of life. Complete removal of lesions is unrealistic and communication with patients and assessment of their goals during treatment is an important part of treatment.
The goals of treatment for different types are as follows.
1. for patients with initial punctate type is to aim for a cure and to aim for long-term non-recurrence.
2.For some refractory patients, it is to eliminate or reduce the patient’s somatic discomfort as much as possible, to relieve the patient’s psychological pressure, to reduce the economic burden and to improve the patient’s quality of life.
3, for intermittent, recurrent patients is to extend the remission period.
4, for patients with erythrodermic type and other severe patients is to promote the transformation to the common type.
Three, treatment principles.
1.Treatment of mild psoriasis.
Generally speaking, mild and limited psoriasis is mainly treated with topical medication, but if patients are not satisfied with the effect of topical medication, they can undergo phototherapy or systemic treatment.
2.Treatment of moderate to severe psoriasis.
The treatment of moderate-to-severe psoriasis mainly includes phototherapy and systemic treatment. When individualized treatment, in addition to considering the different severity of the patient’s disease, the difference in the patient’s health status and lifestyle should also be considered. Single therapy is not effective in patients with moderate and severe psoriasis, and combined, alternating or sequential therapy should be given.
Since psoriasis may be triggered or aggravated by infection, mental tension and alcoholism, patients’ misunderstandings and worries should be eliminated, confidence should be enhanced, poor living habits should be changed and possible triggers should be eliminated, etc. Patients’ attitude and confidence towards the disease often affect the choice of treatment plan. Therefore, if the patient’s demand for treatment is not urgent and the condition is not very serious, simple psychotherapy and disease knowledge education can be the primary choice; some patients have less skin lesions but have a heavy burden of thought, so they should choose active therapy; in addition, the patient’s affordability should also be taken into consideration when choosing treatment measures. Therefore, the treatment of psoriasis should vary from person to person, advocate individualized treatment, and attach importance to the psychological treatment of patients.
IV. Combined, alternating and sequential treatment.
1.Combination therapy.
Synergize or add up each other with the smallest dose to achieve the best effect with the least adverse effects. Combined treatment with two different therapies at the same time has become an important means to deal with psoriasis. Once the psoriasis lesions are effectively cleared, the combination therapy drugs should be gradually reduced to one of the maintenance treatments.
2.Alternate therapy.
The main purpose of alternating therapy is to minimize cumulative toxicity by switching from one treatment to another before the initial treatment reaches a level of toxicity, or an increase in adverse effects due to a gradual decrease in the effect of the initial treatment. Alternating therapy is administered after a relatively long period of application (months or years) to reduce the cumulative toxic effects of the drug. The earliest applied alternating treatments were UVB plus tar, PUVA, methotrexate and avobenzone, alternating every 1 to 2 years. Topical drugs, systemic drugs, and phototherapy can be used alternatively. Biological agents can also play a role in the alternating treatment.
3.Sequential therapy.
In sequential therapy, the clinician sequences specific treatments to achieve the best results with the initial treatment and to reduce long-term adverse effects.
Sequential therapy consists of three phases.
1. clearance phase: utilizing fast-acting drugs, but often with greater adverse effects.
2. transition phase: the use of maintenance therapy with a gradual reduction of the initial therapeutic drug once the patient’s condition improves.
3, maintenance phase: using only maintenance therapy drugs. Some patients can combine fast-acting drugs and maintenance drugs in the clearance phase, especially when the combination of the two can improve the efficacy.