Newer agents for psoriasis in adults

A 30 year old man presented with symmetrically distributed plaques of psoriasis on his extensor surfaces and scalp. His general practitioner initially assessed the disease as mild and prescribed calcipotriol ointment plus betamethasone valerate 0.025% ointment, each to be applied once daily, and calcipotriol scalp solution. Despite seeing an initial response, the psoriasis is now more extensive (covering more than 10% of the patient’s body, including face and flexures) and he feels depressed and self conscious about his appearance; his GP refers him to a dermatologist. He asks about the topical treatments he has been using and what new treatment options might be available in secondary care. This review aims to highlight, for the non-specialist, newer agents and treatment modalities for psoriasis in adults. We have included developments in topical vitamin D and its analogues, recent cost effectiveness analyses, advances in ultraviolet B (UVB) phototherapy, fumaric acid esters, and a brief overview of biological therapies. Other newer topical agents, including calcineurin inhibitors and retinoids, are not discussed in detail because they are not recommended as first line treatment and are used as second line drugs infrequently. Treatment of psoriasis is generally stepwise (fig 1⇓) and dependent on disease severity, clinical subtype, comorbidities, and patient preference, as described in UK, US, and European guidelines, and the British National Formulary. 1 2 3 4 5 Depending on these various factors, patients may be started on a combination of treatments. Treatments are not mutually exclusive and particular ones may not be suitable for all patients. Patients are not necessarily required to transition through each “step,” and combination treatments may be from multiple “rungs” of the ladder. Treatment goals that may depend on the site and type of psoriasis (including comorbidities) should be discussed at the outset; these could include symptom control, induction …