Discover modern treatment options for psoriasis and psoriatic arthritis in the USA, offering effective relief and long-term management for this complex autoimmune condition.

Psoriasis and psoriatic arthritis (PsA) are chronic autoimmune conditions that fall under the umbrella of "psoriatic disease." Psoriasis primarily affects the skin, causing red, scaly patches, while psoriatic arthritis is a form of inflammatory arthritis that affects the joints, spine, and entheses (where tendons or ligaments attach to bone).

Both conditions can significantly impact a person's quality of life. In the USA, the treatment landscape for psoriatic disease has evolved dramatically, with a wide array of options available to manage symptoms, prevent disease progression, and improve overall well-being. The choice of treatment depends on the severity of the disease, the specific manifestations (skin, joints, nails, spine), the patient's overall health, and their response to previous therapies.

Goals of Psoriatic Disease Treatment:

The primary goals of treatment are to:

• Clear skin lesions and reduce itching.
• Reduce joint pain, swelling, and stiffness.
• Prevent joint damage and preserve physical function.
• Improve quality of life and reduce the impact of the disease.
• Achieve and maintain remission or low disease activity.

Treatment Approaches in the USA:

Treatment strategies often follow a step-up approach, starting with less potent therapies and progressing to more aggressive options if needed.

1. Topical Therapies (for mild to moderate psoriasis): These are applied directly to the skin and are often the first line of defense for localized skin psoriasis.

• Corticosteroids: The most common topical treatment, available in various strengths (e.g., hydrocortisone, clobetasol). They reduce inflammation and control cell turnover.
• Vitamin D Analogues: Synthetic forms of vitamin D (e.g., calcipotriene, calcitriol) that help slow skin cell growth.
• Retinoids: (e.g., tazarotene) Vitamin A derivatives that normalize skin cell growth.
• Calcineurin Inhibitors: (e.g., tacrolimus, pimecrolimus) Reduce inflammation and are often used in sensitive areas like the face or skin folds.
• Coal Tar and Salicylic Acid: Older, effective ingredients that reduce scaling, itching, and inflammation.
• PDE4 Inhibitors (topical): Newer options like roflumilast foam/cream (Zoryve) target an enzyme involved in inflammation.

2. Phototherapy (Light Therapy): Utilizes controlled exposure to ultraviolet (UV) light, typically administered in a clinic setting. UV light slows the growth of skin cells and reduces inflammation.

• Narrowband UVB (NB-UVB): The most common and effective type of phototherapy.
• Psoralen plus UVA (PUVA): Involves taking a light-sensitizing medication (psoralen) before exposure to UVA light.

3. Oral Systemic Medications (for moderate to severe psoriasis and psoriatic arthritis): These medications work throughout the body and are used when topical treatments and phototherapy are insufficient or impractical.

• Conventional Synthetic DMARDs (csDMARDs):
  • Methotrexate: An immunosuppressant that slows skin cell growth and reduces inflammation. A cornerstone for both severe psoriasis and psoriatic arthritis.
  • Leflunomide (Arava): Can be used for psoriatic arthritis to reduce joint inflammation and damage.
  • Sulfasalazine (Azulfidine): Sometimes used for psoriatic arthritis, particularly for peripheral joint involvement.
  • Cyclosporine: A potent immunosuppressant, typically used for severe psoriasis for short periods due to potential side effects (e.g., kidney damage, high blood pressure).
• Phosphodiesterase 4 (PDE4) Inhibitors:
  • Apremilast (Otezla): An oral medication that modulates inflammation and is effective for moderate plaque psoriasis and psoriatic arthritis.
• TYK2 Inhibitors:
  • Deucravacitinib (Sotyktu): A newer oral selective allosteric tyrosine kinase 2 (TYK2) inhibitor approved for moderate to severe plaque psoriasis. It offers a targeted approach to inflammation without broad JAK inhibition.

4. Biologic Medications (for moderate to severe psoriasis and psoriatic arthritis): These are advanced, injectable or infused therapies that target specific components of the immune system involved in psoriatic disease. They are highly effective and have revolutionized treatment.

• TNF Inhibitors (e.g., Adalimumab, Etanercept, Infliximab, Golimumab, Certolizumab pegol): Block Tumor Necrosis Factor, a key inflammatory protein. They are effective for both skin and joint symptoms.
• IL-12/23 Inhibitors (e.g., Ustekinumab, Guselkumab, Risankizumab): Target interleukins 12 and 23, cytokines involved in the inflammatory pathway of psoriatic disease.
• IL-17 Inhibitors (e.g., Secukinumab, Ixekizumab, Brodalumab, Bimekizumab): Specifically block interleukin 17, another crucial inflammatory cytokine in psoriasis and PsA. Bimekizumab is notable for targeting both IL-17A and IL-17F.
• T-Cell Modulators (e.g., Abatacept): Works by interfering with the activation of T-cells, which play a role in inflammation. Approved for psoriatic arthritis but not primarily for skin psoriasis.

5. Targeted Synthetic DMARDs (tsDMARDs) / JAK Inhibitors (for psoriatic arthritis): These are oral medications that block specific Janus kinase (JAK) enzymes, which are signaling pathways inside immune cells that drive inflammation.

• Tofacitinib (Xeljanz): The first JAK inhibitor approved for psoriatic arthritis.
• Upadacitinib (Rinvoq): A selective JAK1 inhibitor approved for psoriatic arthritis, and also for other inflammatory conditions like rheumatoid arthritis and ulcerative colitis. Like all JAK inhibitors, they carry boxed warnings regarding serious infections, cardiovascular events, and blood clots.

Integrated Care and Future Directions:

In the USA, effective management of psoriatic disease often involves a multidisciplinary team, including dermatologists, rheumatologists, and potentially physical therapists, occupational therapists, and mental health professionals. Regular monitoring for side effects and disease activity is crucial.

Research continues to advance, with new medications constantly being developed and refined. The trend is towards more precise, targeted therapies that offer higher efficacy with improved safety profiles. Beyond medications, lifestyle modifications, including maintaining a healthy weight, regular exercise, stress management, and avoiding smoking and excessive alcohol consumption, play a vital role in complementing medical treatments and improving overall outcomes for individuals living with psoriatic disease.