What can a doctor do for psoriasis?

Psoriasis is treated topically with a strong steroid cream to reduce inflammation and a vitamin D–derived ointment or cream (calcipotriol) that works to slow cell turnover. Believe it or not, another effective prescription is 6% salicylic acid (compounded with petrolatum into an ointment), which should be applied to the affected area every day. It gently exfoliates the scaly surface so that the topical steroid can penetrate into the diseased skin.

A patient does see rapid improvement but must use these medications regularly to keep the condition under control. Phototherapy, using UVB light to treat psoriasis inflammation, is still used, although it does have side effects of photodamage and an increased risk of skin cancer. Basically, the patient stands inside a walk-in light box for thirty seconds to nine minutes three times per week.

The UV radiation, administered in metered doses, acts as an anti-inflammatory and immunosuppressant. A handheld UVB laser such as Excimer has also been used with great success for plaque psoriasis and doesn't expose the whole body to radiation. This is the golden age of psoriasis treatment.

The development of new medications for psoriasis is one of the most advanced and exciting in the entire field of dermatology. In the past five years, a revolutionary immunotherapy has been successful for treating more severe cases of psoriasis. This entails twice-a-week infusions of antibodies (proteins that lock onto a cell and suppress it) to block lymphocytes from attacking the skin.

This can now be prescribed as an at-home injection too. It has put many patients into remission for a long time. An FDA panel just voted to recommend approval of a new psoriasis drug called ustekinumab, which targets the immune system to reduce inflammation.

Another systemic medication that works well for psoriasis is acitretin (Soriatane), a vitamin A derivative similar to Accutane. It helps regulate the cell turnover cycle. Because the side effects of these medications can be intense, a doctor will choose one rather than using combination therapy for psoriasis.

Doctors usually prescribe a topical, not an oral, medication. A prescription topical steroid or a topical nonsteroidal anti-inflammatory - such as tacrolimus (Protopic) or pimecrolimus (Elidel) - reduce inflammation, relieve itching, and moisturize the skin. Steroids may be safer options for treating babies and children because they are time-tested.

A patient with moderate to severe eczema must calm the rashy inflammation down and should not worry too much about using a topical steroid. Patients use it temporarily, twice daily for one to two weeks. With mild eczema - normal skin that may have an itchy, dry patch or two - a nonsteroidal anti-inflammatory should work fine and would not have steroid side effects such as thinning or atrophied skin.

(These effects happen only with long-term use of topical steroids.).

A doctor can prescribe a topical antibiotic such as metronidazole (MetroGel), which works as a powerful anti-inflammatory, or Finacea, made from azelaic acid, which has anti-inflammatory properties, to control symptoms. Finacea is used for the papular, bumpy kind of rosacea, but it can be too strong for some people. Sulfa medications (lotion or cleansing pads) also work as anti-inflammatory antidotes.

New low-dose oral antibiotics such as Oracea provide another way to reduce inflammation but don't have the antimicrobial properties or side effects of stronger antibiotics. I often combine low-dose systemic medication with the topicals (MetroGel or a sulfa-based lotion) for moderate or severe conditions. Another magic bullet is a low dose of a beta-blocker such as propranolol, a systemic medication designed for high blood pressure that helps prevent vasodilation and its ensuing redness.

(I've used this for many blushing brides with great success.) Doctors don't prescribe topical steroids for rosacea. Though they can calm it initially, steroids cause a rebound rosacea flare-up soon after you stop applying the medication. Intense pulsed light (IPL) treatments augment topical or systemic medications by eliminating the superficial blood vessels that contribute to flushing.

As with acne, if someone is seeing me for rosacea I start with medications first and then move on to procedures that target inflammation. I've found IPL to be absolutely the most effective light or laser therapy for rosacea because it eradicates extra vessels (by inducing apoptosis, or programmed cell death) without causing bruising and with relatively no downtime or discomfort. IPL can disintegrate thousands of blood vessels at once with its larger, broad surface, whereas a vascular beam laser, which is shaped like a pen, gets fewer at a time.

I use Vbeam for cases of severe rosacea, when I need a more powerful machine to tackle stronger and bigger vessels. Most patients need about five treatments spaced out by three to six weeks. It takes at least three sessions for the IPL to kill off enough blood vessels to see a difference.

Eventually rosacea is bound to return, but if you're diligent with sun protection and avoid your triggers, positive results will last a lot longer.

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