Despite the advances in biologics, classic therapies still have a large role to play in treating moderate to severe psoriasis, according to Dr. Jeffrey M. Sobell.
"Biologics have expanded our treatment options, not replaced them," said Dr. Sobell at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).
Dr. Jeffrey M. Sobell
Dr. Sobell of Tufts Medical Center in Boston discussed how he uses three classic psoriasis therapies.
Methotrexate
The efficacy of methotrexate is quite respectable, with a PASI 75 (that is, an improvement of 75% on the baseline Psoriasis Area and Severity Index) of 40% at 16 weeks, said Dr. Sobell. He said that he uses the drug for patients as a monotherapy for concomitant psoriatic arthritis and for life-impacting nail psoriasis. For some patients, he uses methotrexate in combination with anti–tumor necrosis factor therapy both for the synergistic effects on the skin and to reduce potential antibody formation.
The clinical dose of methotrexate is 7.5-25 mg/week (averaging 10-15 mg/week). Clinical effects should be seen by week 8, and doses greater than 20 mg/week are rarely necessary, he noted.
Clinicians who want to use methotrexate for psoriasis do need to be mindful of the possible side effects, which include hepatotoxicity, bone marrow suppression, gastrointestinal intolerance, pulmonary toxicity, and induction of malignancy. Also, methotrexate is teratogenic and is contraindicated during pregnancy, he said.
Cyclosporine
"Cyclosporine is an indispensable therapy in my clinic," said Dr. Sobell. He said that he uses it mostly for psoriasis in crisis situations, but also as a transitional therapy. "Clinicians have concerns about potential nephrotoxicity, but at low doses for short treatment periods, cyclosporine is extremely safe as long as serum creatinine levels are followed," he said.
A standard clinical dose of cyclosporine for psoriasis is 2.5-4.0 mg/kg per day. Other side effects to watch for include hypertension, paresthesias, and gastrointestinal intolerance.
Acitretin
Dr. Sobell said he uses acitretin in psoriasis patients as a monotherapy and in conjunction with phototherapy, biologics, and other oral medications.
His standard clinical dose is 10-25 mg/day. Follow-up lab tests should be done monthly for the first 3 months of acitretin use, and then every 3 months, he said. Acitretin is teratogenic, and other possible side effects include ocular or musculoskeletal problems, hyperlipidemia, and hepatotoxicity.
Dr. Sobell disclosed financial relationships with Abbott, Amgen, Celgene, Eli Lilly, and Janssen. SDEF and this news organization are owned by Elsevier.