Although no permanent cure is available, correct management should result in long term control of the psoriasis. Results are determined by the type of psoriasis, severity, location on body, age and general health of patient. No single treatment is effective in all cases and a combination treatment may be necessary for a synergistic effect.

TOPICAL TREATMENT

• Emollients: Psoriatic skin tends to be dry and may lead to itching.
• Cetomagrocol wax: Unlike moisturisers Cetomagrocol acts as an anti- inflammatory in eczema and psoriasis. The patient should keep on using this cream to prevent further outbreaks. It can be applied 1-3x daily on the areas prone to psoriasis. Trade name: CRéME CLASSIQUE CREAM or CRéME CLASSIQUE OINTMENT.
• Tar therapy: This has been used for decades as shampoo and topical applications. Trade name: CRéME CLASSIQUE COAL TAR SHAMPOO and CRéME CLASSIQUE COAL TAR CREAM containing 7% crude coal tar.
  Tar in combination with ultra-violet treatment is even more effective, no report of increased incidence of skin cancer, due to coal tar treatments to date.
  Side effects: Folliculitis (especially under occlusion) skin irritation, coal tar aroma.
• Dithranol: Synthetic tar derivative for scalp and chronic plaque psoriasis, but not for pustular, guttate or erythrodermic psoriasis. Tar may irritate and discolour the skin and clothing. Salicylic acid to preserve, burning of skin and even blistering may appear. Not for face, genitalia or skin folds.
  Protect the normal skin with Vaseline or Creme Classique ointment. May be applied for minutes to hours. It should be freshly prepared and stored in a fridge.
• Topical Cortisone: The least cortisone to be prescribed as topical and as single agent the better! Psoriasis may become refractory with resulting tendency to more potent cortisones and a rebound after cessation may appear. Atrophy, telangiectasia, superinfection, systemic absorption if large areas are treated. Pustular psoriasis may be precipitated. Hydro-cortisone or low potency in facial or flexural areas.
• Vitamin D3 Calcipotriol: Dovonex. Affects Langerhans cells and reduces cyto- kine production by keratinocytes may burn and irritate, especially in skin folds and face. It may take a few weeks before improvement. (Combination with coal tar or preferable ultra violet treatment). Risk of hypercalcaemia if more than 100g applied weekly.
• Tazarotene: Zorak Gel 0,5 – 1% (acetylenic retinoid) This is the first topical retinoid for stable plaque psoriasis. Odour free and none staining, apply at night on lesions, avoiding surrounding normal skin. It may take a few weeks to notice improvement and adding a topical steroid in the mornings or Créme Classique cream or ointment may prevent redness, burning and irritation and psoriasis may clear quicker.
  Scalp 1% alt. evenings with Fluocinolone or topical cortisone.
  Combination phototherapy Zorak with UVB at approximately 25% MED and then to increase gradually to keep below erythrogenic levels. Apply Zorak after phototherapy. This preparation may be teratogenic and contraception may be necessary.

ULTRA-VIOLET TREATMENT (Phototherapy)

This is the treatment of choice for extensive and stubborn psoriasis. Ultra- violet can be given as a monotherapy, but combination therapy to achieve a synergistic effect is preferable. Sun exposure and Dead Sea treatment was noticed to improve psoriasis. UVB short wave (290 –320nm) treatment radiated for decades. Later UVA long wave with psoralen (PUVA treatment) 20 – 30 treatments 3x a week and then maintenance. The PUVA patient must avoid sun exposure on skin and eyes as cataracts and premature ageing or skin and skin cancer may develop. A mottled pigmentation was also noted. Psoralen is not indicated in pregnancy, it may cause nausea. Combination treatments with Neo-Tigason or Dithranol speeded the treatment.

NARROW BAND UVB 311nm. This is the newest UV treatment. It is safer and quicker than PUVA in most cases. A short duration of exposure and even better results if in combination with Classique ointment or cream, Dithranol, Zorak, Classique coal tar cream, Neo- Tigason or the new systemic treatments. It is available at the Creme Classique Clinic and the Psoriasis Clinic .

Medical Aid usually pays for the treatment (in South Africa). Trained physiotherapists are performing the treatments at the clinics. LONG TERM REMISSIONS FOR MONTHS OR EVEN YEARS MAY BE ANTICIPATED

SYSTEMIC TREATMENTS

They are all toxic and dangerous if not controlled and under supervision of a dermatologist.

• Methotrexate: Folic acid antogonist, prevents cell proliferation. Cytostatic, Neutropenia, liver and kidney damage. Teratogenic. Weekly doses up to 20mg orally or IM. May interact with Aspirin, Sulphonamides and Lasix.
• Retinoids: Acitretin a synthetic vitamin A derivative . Especially for erythrodermic and pustular psoriasis. Neo-Tigason 25-50mg/day with Classique coal tar cream, Dithranol, PUVA or “Narrow Band” UVB. Maintenance 10-25mg / day. It is strongly teratogenic and pregnancy should be avoided for 2 years after the last tablet.
• Cyclosporine A: “Neoral” the micro emulsion of Cyclosporin Treatment for 6 weeks to a month and repeat short courses 6-8 months later if necessary. The blood pressure and kidney function should be monitored. Typical dosis is 2.5-5mg/kg daily, usually Neoral 200mg per day, very expensive up to ZAR6000 per month.
• Amevive Biogen Alefacept: Best remission treatment at present. 15mg intravenously for 12 weeks + ZAR100 000 Extremely expensive. Targets memory T (CD4) cells. 12 Week or longer remission. Combination with UVB or PUVA. This is a relative safe medicine. Special investigations weekly: CD4 cell and if less than 250 CD4 cells skip one or more weeks or stop in total. Side effects: Pharingitis, Dizzy, coughing, myalgia, chills, Nausea, Pruritis and Painful injection
• Remicade: 2h IV infusion 5mg/kg blocks TNF2. Every 8 weeks.More effective than Amevive. Trade name: INFLIXIMAB.
• Enbrel: Especially for psoriasis arthritis 25-50mg 1x/week. Subcutaneous injection. Tuberculosis an absolute contra indication.
• Ontak: BlockIL2. Many side effects. 0.3mg/kg
• Co stim factor Supressor: Ascomycin (SD2-ASM 981 Novartis) A macrolactam antibiotic. Supr. of IL2 + TL 40-60mg/day. Very effective. Low side effects

NEW TREATMENTS

• Tacrolimus topical cream. Expensive. Not as effective as in eczema and usually only for facial psoriasis. Trade name: ‘PRETOPIC’. May burn skin.

• Tacalcitol ointment: A new vitamin D3 from Japan (Bonalfa). Also for icthyosis, pustular eruption of palms and soles, palmoplantar keratoderma, pityriasis rubra pilaris. 83% of pro-psoriasis patients cleared, Side effects: In 0.3 – 1% of patient only.

• Liarozole fumerate (Janssen) An Imidazole, inhibiting cytochrome P450 followed by accumulation of endogenic produced retinoic acid for psoriasis and icthyosis. 77% Of patients' improved in 12 weeks. Side effects as in retinoids with dry oral mucosa, itching and headaches. 75mg bd 1 month, then 50mg bd for 8 weeks. Topical application to be developed.

• Tagretin RX Receptor (Not RA Receptor) Retenoid. Sup of Thyroid and triglycerides. No dry eyes or lips.