Psoriasis: Treatment combinations require blend of art, science

"(Treatment) is complicated with no specific paradigm, so to some extent there is a science to it but there is also an art to it," Dr. Menter says.

"We used to start with topicals, and if that didn't work, you'd go to light treatment; if that didn't work, you'd go to systemic; i.e., a traditional 'ladder' approach. Now we are trying to get away from that approach. If a patient has more than 10 percent of body surface involved, there's little point in starting topical monotherapy, and we normally consider jumping in with light treatment or systemic therapy from the beginning," he says.

"No drugs give extended remissions in psoriasis except for possibly one, alefacept (Amevive), which in a small percentage of patients can achieve remissions that can last up to six months at a time. I wish we could predict which patients will achieve this remission. Alefacept is used 12 weeks on 12 weeks off. In order to accelerate the initial response, I will use light therapy for the first six weeks," says Dr. Menter, who is also a clinical professor of dermatology, Southwestern Medical School, University of Texas, Dallas.

"It is important to decide if your patient has psoriatic arthritis, and, if so, I would put them into a category for either methotrexate or anti-TNF-alpha agents like Remicade or Enbrel, or even adalimumab (Humira, Abbott), once it's approved for psoriatic arthritis," he says. "With these choices the skin and joint disease frequently comes under control. If the anti-TNF-alpha agent doesn't completely clear the skin, you may add light treatment or a small dose of systemic retinoid, or even methotrexate."

Single tx reserved for mild cases "There are some patients with very mild psoriasis (less than 5 percent of body surface area) that will require just a single agent. If you get it under control quickly with daily use of a single topical steroid agent, you can then reduce the steroid usage to once or twice a week to keep it under control," he says.

"The problem with steroids is tachyphylaxis and frequently I reduce the use of the potent steroid to weekends only and add a non-steroid topical during the week," he says. However, most patients find it "difficult to continue to use topical therapy morning and night on a long-term basis."