Treatment options for psoriasis are expanding, with new biologic agents available that can offer improved help for those coping with the condition. Approximately 2% of individuals have the chronic, inflammatory, multisystem disease that is characterized by scaly, erythematous patches, papules, and plaques that are often pruritic. Defining the severity of psoriasis involves ascertaining not only the total affected body surface area, but also which portions of the body are involved; disease that affects the hands, feet, face, or genitals can have significant interference in daily activities. Its manifestations span a clinical spectrum encompassing limited skin disease, moderate to severe skin disease, and concurrent psoriatic arthritis.

Psoriasis has also been associated with multiple other conditions, including lymphoma, inflammatory bowel disease, heart disease, obesity, type 2 diabetes, metabolic syndrome, Crohn's disease, and multiple sclerosis. The psychological impact on the personal well-being of patients is often an issue, even for those with limited disease. Increased reports of depression and suicide, smoking, and alcohol consumption are common in patients with psoriasis.

Traditionally, psoriasis therapy has involved the use of oral, systemic treatments, such as methotrexate, cyclosporine, and acitretin. Research has led to a better understanding of the immunopathogenesis of psoriasis, facilitating the development of biological therapies that have revolutionized psoriasis treatment. Biologic agents can affect the specific molecules necessary for the development of psoriatic plaques, targeting specific components of the immune system.

Biologic agents are now in routine use. Examples of currently approved biologic agents for the treatment of psoriasis include the following:

• Monoclonal antibodies that inhibit TNF-alfa: Remicade (infliximab), Humira (adalimumab), and Simponi (golimumab)
• Soluble receptor that inhibits TNF-alfa and TNF-beta: Enbrel (etanercept)
• Monoclonal antibody directed at the p40 subunit common to IL-12 and IL-23: Stelara (ustekinumab)
• Monoclonal antibody/IL-17A antagonist: Cosentyx (secukinumab)
• PDE-4 inhibitor: Otezla (apremilast)

A comprehensive list of psoriasis drugs currently in the pipeline is available from the National Psoriasis Foundation.

Although the current focus is on biologic agents, the historical treatment options for psoriasis continue to play a central role. Topical medications, phototherapy, photochemotherapy, and traditional systemic drugs are often used as monotherapy or in combination, depending on the patient, severity of the disease, and contraindications. Patients require tailored treatment options, as efficacy, side effects, availability, ease of administration, comorbidities, family history, and coexisting diseases must all be taken into account.

In order to optimize psoriasis treatment, patient education is necessary. Physicians must take every step possible to improve adherence to treatment, and communication and education are vital components in this. All patients with moderate to severe psoriasis should receive ongoing counsel from a primary care provider in conjunction with specialist(s) in order to address comorbidities that can be prevented or diagnosed and treated early to minimize end organ damage. Patients with moderate to severe psoriasis have increased incidence of obesity, cardiovascular disease, diabetes mellitus, hypertension, metabolic syndrome, and depression, all which can be identified and managed among specialty and primary care physicians in order to provide effective, integrated care.

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Salvatore Volpe, MD, FAAP, FACP, CHCQM
Chief Medical Officer
PDR