Systemic Agents

Retinoids

Acitretin (Soriatane) is used for severe psoriasis.

• How retinoids work: Retinoids are used to control psoriasis and reduce the redness of the skin. They can be used in combination with medically controlled ultraviolet phototherapy to minimize the dose of each.



• Who should not use these medications: Individuals who are allergic to retinoids, are pregnant, or are breastfeeding should not take retinoids.



• Use: Acitretin is in a capsule. It is usually taken once a day by mouth with food. Therapy is continued until plaques have decreased.



• Drug or food interactions: Acitretin increases methotrexate toxicity when both are used together. This medicine can interfere with oral contraceptives ("minipill"). Do not use alcohol while taking acitretin and for 2 months after stopping the medicine. Alcohol causes the drug to convert to a long-acting form, and could prolong the risk of birth defects.



• Adverse effects: Women of childbearing age must use effective birth control measures. Birth control must be continued for at least 3 years after the woman stops taking acitretin because the drug stays in the body for a very long time and will hurt unborn babies. Caution must be used if the individual has kidney or liver problems. Contact the doctor immediately if you develop a rash or skin or vision changes.

Methoxsalen (Oxsoralen-Ultra) and trioxsalen (Trisoralen) are commonly prescribed psoralens. Psoralens are a class of drugs that make the skin more sensitive to light and the sun. Psoralens are used with ultraviolet light therapy. This therapy, called PUVA, uses a psoralen drug with ultraviolet A (UV-A) light to treat psoriasis when it covers a large area of the skin or is severe. More than 85% of patients report relief of disease symptoms with 20-30 treatments.

• How psoralens work: Psoralens have no effect unless combined with ultraviolet light therapy. They are used with the light therapy to slow skin-cell overproduction.



• Who should not use psoralens: Individuals with the following conditions should not take psoralens:
  
  
  • Psoralen allergy
  
  
  
  • History of skin cancer
  
  
  
  • Photosensitivity diseases such as porphyria, lupus erythematosus, xeroderma pigmentosum, or albinism
  
  
  
  • Inability to tolerate prolonged standing or heat, for example, in those with heart disease
  
  
  
  • Pregnancy
  
  
  
  • Children younger than age 12
     
• Use: Psoralens are taken by mouth several hours before PUVA therapy or sunlight exposure. These medicines can also be applied to the skin in creams, lotions, or bath soaks.



• Drug or food interactions: Other photosensitizing drugs, such as phenothiazines, bacteriostatic soaps, sulfonamides, tetracyclines, thiazides, or even perfumes may increase the skin’s sensitivity to the sun or may cause other problems. Before taking psoralens, let the doctor know if any other medicine are being taken.



• Adverse effects: A doctor experienced with PUVA therapy should supervise the use of these medicines. Severe burns can occur from sunlight or the ultraviolet light while taking psoralens. These drugs cause sensitivity to sunlight and increase the risk of sunburn, skin cancer, and cataracts. After each treatment, avoid going out in the sun for at least 24 hours. Cover up with clothing and use sun block if the skin will be exposed to the sun. A certain type of sunglasses are recommended to protect the eyes after treatments. Treatment usually causes reddening of the skin for 24-48 hours. However, contact the doctor if severe redness, blisters, fever, or peeling occurs.

These agents are potent drugs given by mouth or injection. They block inflammation and can slow the growth of skin cells in psoriasis.

Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), methotrexate (Rheumatrex), cyclosporine (Sandimmune, Neoral), and alefacept (Amevive) are in this group of drugs. They may be prescribed for moderate-to-severe psoriasis and psoriatic arthritis.

How these drugs work: These medications can block inflammation. They are used to treat people with severe disabling psoriasis who have not responded to or tolerated other treatments.

• Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade): These are man-made proteins that work with the immune system to reduce inflammation. Tumor necrosis factor (TNF) is involved in inflammation and is blocked by these medications.
  
  
  

  • Who should not use adalimumab, etanercept, or infliximab: Individuals with an allergy to these medications and those with a serious infection should not use these drugs.

  • Use:

    • Adalimumab is self-administered as an injection every 2 weeks.
    
    
    
    • Etanercept is given as an injection 2 times per week. The drug can be injected at home. Rotate the site of injection (thigh, upper arm, abdomen). Do not inject into bruised, hard, or tender skin.
    
    
    
    • Infliximab must be administered in the doctor's office. It is an intravenous (IV, given into the vein) infusion that is administered slowly over 2 hours. Initially, 3 doses are administered within a 6 week period, and then the drug is administered every 8 weeks for maintenance.
       
  • Drug or food interactions: The safety and efficacy of these medications in patients receiving other immunosuppressive drugs have not been evaluated. Patients receiving these medications may receive concurrent vaccinations, except for live vaccines, such as MMR.
  
  
  • Adverse effects: Serious infections may develop and the therapy should be discontinued if they occur. Possible adverse effects include injection site pain, redness and swelling at injection site, and headaches. Rare cases of lupus-like symptoms, lymphoma, reactivation of tuberculosis, and heart failure have been reported (discontinue treatment if symptoms develop).
     
• Methotrexate (Rheumatrex): This drug is used to treat plaque psoriasis or psoriatic arthritis.
  
  
  • Who should not use methotrexate: Women who are planning to get pregnant or who are pregnant should not take this drug. Men must not take this drug if there is a possibility of getting their partners pregnant because it can go into the sperm. Additionally, people with the following conditions should not use methotrexate:
    
    
    • Methotrexate allergy
    
    
    
    • Alcoholism
    
    
    
    • Liver or kidney problems
    
    
    
    • Immune deficiency syndromes
    
    
    
    • Low blood cell levels
       
  • Use: Methotrexate is taken by mouth (tablet) or as an injection once per week.
  
  
  
  • Drug or food interactions: Tell the doctor if any nonsteroidal anti-inflammatory drugs (Motrin, Advil, Aleve, aspirin) are being taken because these may act with methotrexate and cause adverse symptoms.
  
  
  
  • Adverse effects: The doctor will order blood tests to check blood cell count and liver and kidney function on a regular basis. Methotrexate may cause toxic effects on the blood, kidneys, liver, gastrointestinal tract, lungs, and nervous system. A liver biopsy may be needed to check the health of the liver, especially after prolonged use.
     
• Cyclosporine (Sandimmune, Neoral)
  
  
  • Who should not use cyclosporine: Individuals with the following conditions or treatments should not take cyclosporine:
    
    
    • Cyclosporine allergy
    
    
    
    • Uncontrolled hypertension
    
    
    
    • Kidney problems
    
    
    
    • Cancer
    
    
    
    • PUVA (UV-A light therapy combined with medications that make the skin sensitive to light) or UV-B light therapy (may increase cancer risk)
       
  • Use: Cyclosporine is taken by mouth once a day.
  
  
  
  • Drug or food interactions: Many drug interactions exist. Carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine blood concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase toxicity; acute kidney failure, muscle breakdown and muscle pain may worsen when cyclosporine is taken concurrently with lovastatin.
  
  
  
  • Adverse effects: The doctor will order tests to check kidney function, may monitor levels of cyclosporine in the blood, or may order other blood tests while an individual is on this medicine. Cyclosporine may increase the risk of infection or lymphoma, and it may cause high blood pressure.
     
• Alefacept (Amevive): In 2003, the FDA approved this drug for the treatment of psoriasis. It suppresses the immune system to slow the production of skin cells.
  
  
  • Who should not use alefacept: Individuals with allergy to alefacept should not take it.
  
  
  
  • Use: Alefacept is given as an injection once per week in the doctor's office.
  
  
  
  • Drug or food interactions: Administration with other immunosuppressive agents (for example, corticosteroids, cyclosporine) may cause excessive immunosuppression.
  
  
  
  • Adverse effects: Women who become pregnant while taking alefacept should be enrolled in the manufacturer’s pregnancy registry by calling (866) 263-8483. Alefacept may increase the risk of malignancy or infection, may cause allergy or swelling of the throat or tongue, and may cause a hard lump, inflammation, or bleeding at the injection site.