Treatment of Psoriasis
As Published – June 2017

Local treatments, phototherapy, systemic treatments, and biological treatments – all you need to know about psoriasis treatment
By Dr. Felix Pavlotzky

Psoriasis is a chronic inflammatory skin disease characterized by the fact that the skin cell (keratinocytes), under impaired immune control, divide at an extremely rapid rate. The main characteristic of the disease is the formation of lesions on the surface of the skin, which may even itch or hurt.

Today there is no cure for the disease, but there are a variety of treatments that can alleviate symptoms, significantly improve the quality of life of patients, and lead to a temporary respite from the disease.

The treatment regime for the disease is not only based on the objective measures and severity of the disease as seen through the eyes of the physician but also based on how the disease affects the specific patient. Hippocrates said: “It is more important to know what kind of person has a disease than to know what kind of disease a person has.” This is especially true of psoriasis patients.

In psoriasis, it is common to use treatments in rotations – treatments that have been effective for the same patient many times stop working then are replaced with others. Sometimes, those are then replaced with the previous treatments.

The treatments are divided into local treatments – designed mainly for patients with mild or advanced psoriasis, advanced treatment for moderate to severe patients, treatments based on ultraviolet radiation – phototherapy and treatments at the Dead Sea (climatotherapy), systemic treatments for moderate to severe patients, and biological treatments focused on system processes. The immune system of the body characterizes the disease.

Local (Topical) Treatments for Psoriasis
Local, or topical, treatments are designed for people with mild disease, people whose area of skin is affected by the disease is not large, as a complement to other treatments and people who cannot get other treatments for health reasons. The topical treatments fall into two main categories: steroid cream treatment and other non-steroids.

Psoriasis Treatments Based on Ultraviolet Radiation
In most cases, psoriasis improves in the summer and worsens in the winter. Based on this finding, attempts were made to treat skin disease in various ways by exposure to the sun and ultraviolet radiation. These treatments are now known to be particularly effective against psoriasis.

All other treatments for psoriasis (ointments, systemic treatments, and biological treatments) are effective as long as they are given but when they are discontinued, the disease returns – in some cases the condition was as before the treatment and in some cases, it was worse. On the other hand, treatments based on ultraviolet radiation can provide long breaks from the disease. The big drawback of the treatments is that they can lead to trouble.
The Dead Sea

For patients who do not have a regular sun, there is a possibility to treat them by sending them to spend time at the Dead Sea – a low area where there is another type of sun rays that can provide a significant benefit. How long will the benefit last? This is a function of the time spent in the Dead Sea. It is recommended to reach the Dead Sea for a whole month – then the remission may last for a year.

In Israel, people receive four weeks at the Dead Sea as part of the health basket – when they participate in half of the cost. Most patients divide their stay twice, and after two weeks the improvement lasts about 3 months. According to the instructions of the Ministry of Health, stay at the Dead Sea in the basket will not be less than 10 consecutive days.

Artificial Phototherapy
Another option for treatment based on ultraviolet radiation is artificial phototherapy. Phototherapy is given with different devices with different types of radiation, given to the patient depending on the type of skin, age, location of the lesions on the body, and more.

This is an effective treatment and treatment for most people who have a mild case. The main problem with the treatment is the hassle – every treatment needs to be at a healthcare facility which can involve a wait and an investment of time. The treatment cycle is usually given three times a week for a period of two to three months. Most people need this cycle twice a year to three times in two years.

There are also home appliances for phototherapy, but they are expensive, lead to less positive results, and have no control – so they are less recommended.

Treatment of Psoriasis in Hospitalization (Goeckerman Protocol)
The Goeckerman protocol is the oldest and most effective treatment for psoriasis, with almost 100% success. The original protocol, developed at the prestigious Mayo Clinic, included a smear of tar and phototherapy. The patients were hospitalized for a month of treatment and this would have given very long periods of relief – over a year.

In modern life, it is not easy to disconnect and enter hospitalization for a month, insurance companies may not pay for such long and extensive hospitalization, so they make compromises. It is now customary to give shorter hospitalization – full hospitalization for a week and a half to two weeks – and there is also a possibility of hospitalization for daily outpatient treatment for about 15 days. The treatment is given along with other preparations that improve its effectiveness and provide successful results – intervals that last about eight months. This is a very safe and effective treatment but it requires people to take a break from life and especially to lose work days.

Systemic Treatments in Psoriasis
Systemic treatments for psoriasis are usually given in swallowing pills and are suitable for patients with moderate to severe psoriasis. There are three main types of systemic treatments: Vitamin A derivatives (retinoids), Methotrexate, and Cyclosporine.

Biological Treatments for Psoriasis
Biological treatments are relatively new treatments that work specifically on immune system processes that characterize the disease and are usually antibodies against biological substances secreted in the body. Biological treatment tries to get to the root of the problem – it does not deal with the dandruff that has been created, but with the defect in the immune system behind the disease.

The patients who receive the biological treatments are patients with a serious illness – either because it involves important strategic areas or in terms of the affected skin area – and those who have not been helped or otherwise unable to receive other treatments for medical reasons.

The biological treatments currently available in Israel for the treatment of psoriasis are divided into three groups:

Anti-TNFα treatments – one of the cytokines that cause T-cells to be excreted in the inflammatory processes leading to psoriasis, including drugs such as Anberal, Arlesi, Humira, Agitiba and Remykide.

Other anti-cytokine-protein treatments involved in the inflammatory process that characterizes psoriasis include Stellar against cytokines interleukin 12 and interleukin 23, and three drugs against cytokine interleukin-17, cosentics, taltas / talate and silic.

Treatments that inhibit the enzyme PDE4 – the drug Otazella.

*Dr. Felix Pavlotzky is Director of the Psoriasis and Phototherapy Unit, Department of Skin at Sheba Medical Center in Tel Hashomer, Israel.

As published on:
“Like Me” website by The Gertner Institute, Tel Hashomer Hospital, Ramat Gan.
The information and content on the “Meimni” website are intended to expand and serve as general information only. These contents do not constitute a professional opinion or advice, or substitute for direct consultation with an appropriate professional regarding the required treatment.

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