Australas J. Dermatol 1992; 33: 127-130
REVIEW OF FIFTH INTERNATIONAL PSORIASIS SYMPOSIUM San Francisco, July 1991 HENRY H . ROENIGK
Chicago, USA This review was presented as a paper at The Annual Meeting of the Australasian College of Dermatologists, Perth, May 1991. Introduction
There has been a large volume of basic and clinical research devoted to understanding and treating the common skin disease, psoriasis vulgaris. Many important symposia have been held worldwide during the past 20 years to bring dermatologist and other scientist informatio,n on this research. Dr Eugene Farber, former Chairman of Dermatology at Stanford University, initiated these symposia in the 1970s and they have been held every four to five years since then in California. These symposia have resulted in bringing together basic science workers with clinical investigators and dermatologists caring for patients with psoriasis. The 5th International Psoriasis Symposium was Co-Directed by Henry H. Roenigk Jr, MD, of Chicago, II, and Howard I. Maibach, MD, of San Francisco, Ca. There were more than 350 scientific papers presented at plenary sessions, workshops, special symposia and summary presentations, helping to define the current status of psoriasis research and therapy. Many new and old therapies both topical and systemic were reviewed. The 6th International Symposium on Psoriasis will be held in July, 1994, in Chicago, II. Each new symposium offers new ideas and the hope that better therapy or a possible cure can be found for psoriasis. Pathogenesis
The concept of pathogenesis of psoriasis is a broad one. The cause of psoriasis is multifactorial and we have not identified one factor that seems to be predominant, although genetic considerations are certainly important. It appears that the Henry H. Roenigk Jr, MD. Walter J. Hamlin, Professor and Chairman, Department of Dermatology Northwestern University Medical School.
initiating event of psoriasis is probably injury and then an inflammatory reaction, combined with an immune response that sets off the process. Turnover time in psoriasis has long been an important factor, as has neutrophil migration. Cytokines and interleukins are currently a focus of attention and study, as are inflammatory factors that influence the growth of keratinocytes. Growth factor has become an important area of research, not only in psoriasis, but in a number of other conditions such as malignancies of the skin. There is an increased expression of growth factor in psoriasis. The cyclic nucleotide system has long been a subject of interest. Recently there has been consideration of other aspects of this system that appears to regulate the growth of keratinocytes, differentiation, and the inflammatory response. Drugs that can modify keratinocyte growth are thought to have an effect on improving psoriasis. The arachidonic acid system is one that has received much attention. However, there have not been great therapeutic advances from studies. Leukotriene B is an important mediator in the inflammatory process concerned with development of microabscesses and neutrophilic infiltration of the skin. Many investigators are now looking more carefully at the immune response and the T lymphocytes in the skin. This is the result of the beneficial therapeutic effect shown by cyclosporine in the treatment of psoriasis. Corticosteroids
Topical steroids are important in the treatment of psoriasis, although they are overused. As the hallmark of therapy for psoriasis, they are firstline therapy because they are effective, especially fluorinated steroid under occlusion. Superpotent steroids are effective for small areas but they are also overused, not just by the dermatologists, but 127
HENRY H . ROENIGK
by patients. There can be rebound psoriasis and unstable psorieisis including pustular and erythrodermic flares from superpotent corticosteroids. Vitamin D Extensive clinical studies from Denmark and other European countries were presented on topical Vitamin D and there are ongoing trials in the USA. Vitamin D deficiency in psoriasis has been studied, and although there is conflicting data, at least one study showed that in patients with severe psoriasis there were low concentrations of Vitamin D. This suggests that there is a deficiency of Vitamin D when disease is severe. In patients with moderate psoriasis, however, there does not appear to be any difference in serum Vitamin D levels when compared with controls. Several Vitamin D compounds have been studied by investigators. Vitamin D can inhibit keratinocyte growth, which has a beneficial therapeutic effect in psoriasis. This inhibition has been demonstrated in cultured keratinocyte studies. Vitamin D does affect proliferation and differentiation of keratinocytes. It has an effect on T lymphocytes and neutrophils. Several years ago, small dose-range studies were done with various doses of oral Vitamin D preparations. Many of these studies were uncontrolled. Oral Vitamin D for psoriasis has shown adverse effects on calcium metabolism and there was improvement in psoriasis but hypercalcemia developed in 40% of patients treated. Therefore, it was deemed not to be very safe. The oral approach to therapy has lost interest mainly due to its potential toxicity. Instead, attention was focused on topical compounds. Calcipotriol is the agent that appears to have been most widely studied. Other topical Vitamin D compounds have been tried and have been well tolerated, but these have been studied only in small clinical trials. The topical agent on the market in Europe is calcipotriol. There have been controlled studies with a large number of patients. No significant serious systemic side effects have been reported, although mild local irritation is a problem. A study published in The Lancet compared calcipotriol with betamethasone, and calcipotriol compared well. There are few side effects including local irritation, predominantly on the face and scalp. This drug, according to many
investigators, might be our next topical agent of choice for treatment of psoriasis. It is being used in place of topical steroids in Denmark and other countries where it is available. Calcipotriol is being used as a first-line treatment for many patients with psoriasis. It appears to be safe, and it does not produce the rebound that we experience with topical steroids. Calcipotriol will not necessarily replace systemic therapy. There will continue to be indications for PUVA therapy, methotrexate, and other modalities. Patients with severe disease are probably not going to be controlled with calcipotriol. Systemic Drugs for Psoriasis Systemic agents have been developed in the last 40 years for the treatment of psoriasis, and over the past few decades, our choices have been expanded. These agents all have associated side effects. Most agents show good to excellent response. PUVA therapy has progressed to one of the most efficient treatment modalities for psoriasis. Europeans employ a much more aggressive treatment protocol for PUVA than the USA. They treat patients four times a week starting at higher dosage levels: therefore, their patients clear fasten Combination therapy is used more often in Europe than in this country. Maintenance is largely used in the United States but, in Europe, maintenance is avoided. In Europe emphasis is on getting patients clear, getting them off therapy, and then awaiting another psoriasis flare. Psoralens It is hoped that research will bring us new psoralens. A 5-MOP has been developed in Europe. In studies in the USA, 5-MOP demonstrated an advantage over Psoralen-Ultra use, in that there is virtually no nausea from 5-MOP. Several studies performed over the past few years have shown that there is an increase in the incidence of squamous cell carcinoma with the use of psoralen. Basal cell carcinoma seems to be fairly stable, and there has not been an increase in the development of malignant melanoma. Europeans have a lower incidence of skin cancer from PUVA than in the USA. Ageing of the skin is a common side effect. Although eye damage is at present minimal, eye protection is still an important precaution.
128
REVIEW OF FIFTH INTERNATIONAL PSORIASIS SYMPOSIUM
AIDS and Psoriasis PUVA and retinoids are treatment options for patients with AIDS and psoriasis. Recent publications and experience in a small number of patients with AIDS have concluded that PUVA was well tolerated in HIV-positive patients, although probably not safe for use in patients with advanced AIDS. The condition of patients who were stable did not worsen with PUVA therapy. Phototherapy: Home Use Patients and insurance companies have been exerting pressure on practitioners to permit phototherapy in the home setting. In the long run, home treatment probably is less expensive, and patients can treat their disease more often. Insurance companies are encouraging home therapy rather than office-based treatment. The disadvantage cited by dermatologists is they inevitably lose control. There is a potential for toxicity, and if something goes wrong, the dermatologist will be blamed... not the insurance company and not the patient. Home therapy for UVB treatment is less problematic than PUVA therapy. PUVA therapy for hand and foot disease is reasonable for patients that can be trusted to do it properly. Home PUVA for total body treatment as it is done in the office is not advisable. Methotrexate An effective treatment for psoriasis, methotrexate might be safer and more efficient. Patients are living healthier lives and avoiding alcohol. Clinicians are watching drug interactions, adhering to guidelines, monitoring patients closely, and ceasing treatment if there is evidence of early liver disease. There is a difference of opinion between internists and dermatologists regarding methotrexate and liver biopsies. Dermatologists still favour pre-methotrexate liver biopsies because of problems with fibrosis, whereas rheumatologists do not generally perform them. Most rheumatologists are doing their first biopsies two years after treatment commences. Retinoids Tegison and Acitretin are safe and effective treatments for psoriasis. Retinoids are more effective in combination therapy, but do work as
monotherapy. The dosage of acitretin is similar to that of etretinate, although some patients respond to lower doses of acitretin. Adverse effects of tegison and acitretin are similar. Some acitretin treated patients who had not previously had etretinate show trace amounts of etretinate in their blood. After extensive investigation it was concluded not to be a contamination problem. There appears to be the possibility of acitretin metabolizing into etretinate, which is unfortunate, because this is what it was hoped could be avoided. Dermatologists were looking for retinoids that could be excreted rapidly and therefore could be used in women of childbearing age. Acitretin has been withdrawn "without prejudice", which means the manufacturer can reapply for approval. At present, however, approval for this drug is not being pursued. Follow-up studies demonstrated that approximately 40% of the patients on acitretin showed small amounts of etretinate in their serum. Whether these levels are significant or not is still not certain, but a waiting period of at least two years is recommended before permitting women to get pregnant who had been on this drug. One of our patients did not wait two years. She got pregnant within about 30 days after coming off acitretin at precisely the time we were receiving this information. She had a full-term pregnancy. We measured her blood levels, and she was one of the patients who did not have elevated blood levels of etretinate. She had a healthy baby who is doing fine by all parameters. Animal studies appear to indicate that when high amounts of alcohol are ingested with acitretin therapy, there is a greater likelihood of conversion to etretinate. With low levels of alcohol, there is virtually no converstion to etretinate. Investigators are looking at this phenomenon to see whether this is true in humans. Compliance with alcohol restriction is difficult to assure, which will present problems for approval of this drug. We have been interested in the liver function in patients on retinoids. There is a large study in progress, of which our group is a part, that will analyse the two-year follow-up on liver biopsy changes. We had 22 patients treated for two years with acitretin who had no changes in their followup liver biopsies. Two patients' conditions worsened (not significantly) and one patient actually improved. 129
HENRY H . ROENIGK
presents deeper concern, and that is why we often turn to combination therapy, which should really be called rotational, transitional, or cyclic therapy. We are using two drugs together for a short period: one as an accelerator to get the patient cleared and one as the maintainer. The best example of this is REPUVA, which is a favoured treatment in Europe. Retinoids serve as the accelerator to clear the disease, and PUVA is used to maintain the patient on a long-term basis. Most cHnicians cycle their patients and should continue to do so. It is important that patients not be left on methotrexate for 20 years. Certainly it is unacceptable for keep patients on PUVA therapy, regardless of its efficacy, for 10 to 15 years. They should be rotated, and if their psoriasis flares severely, they should be hospitalized and possibly placed on cydosporine until they stabilize, and then, be switched to retinoids or another agent. Patients on methotrexate often develop liver disorders. These patients should be taken off methotrexate and put on PUVA therapy or cydosporine. Occasionally it is necessary to hospitalize patients and start Goeckermann therapy to get the psoriasis under control.
Cydosporine Many studies on cydosporine have been published showing its benefit in psoriasis. Cydosporine is very effective for crisis therapy for severe psoriasis. Long term low dose maintenance therapy can result in renal damage. Careful monitoring of this drug, which is not FDA approved, is mandatory. Sulfasalazine This drug has been used for many years in the treatment of ulcerative colitis and rheumatoid arthritis. It is a mildly effective drug for psoriasis. There is an approximate 40% rate of improvement; many patients do not demonstrate a significant response but sometimes there will be a spectacular response and good clearing. Tumour Necrosis Factor The main action of TNF is to decrease keratinocytes and decrease the accumulation of neutrophils in the skin. A group from Japan treated 11 patients with reasonably good results but with significant systemic side effects during the therapy. First-Line Systemic Therapy The choice for first-line systemic therapy is often PUVA. Sulfasalazine is high on the list in terms of safety, not necessarily effectiveness; it is a safe, easy drug to use. Sometimes it can be used early in treatment to determine whether there will be a response. Retinoids are the next choice, especially in combination therapy. Next would be methotrexate, and finally cydosporine. All these drugs have problems, but in terms of efficacy, all of these agents are reasonable effective. Sulfasalazine is low in terms of efficacy, but most of the other agents result in good to excellent response in severe psoriasis.
The Future Our current therapies will be modified in the future. Investigators are looking at psoriasis as a model, especially with the use of cydosporine and its effect on T-cells. Unusual monoclonal antibody therapies are being developed specifically for autoimmune diseases, rheumatoid arthritis, and renal transplantation. But investigators are also looking for other ways to use these molecules once they become available. Therefore, psoriasis will be targeted as a disease for which they may be used. Immunomodulators to affect T-cell suppression or other changes in cell surface receptors are being considered in an attempt to modify the treatment or modify the disease and produce improvement.
Rotational Therapy Short-term toxicity is not a serious problem with these agents. However, long-term toxicity
130
REVIEW OF FIFTH INTERNATIONAL PSORIASIS SYMPOSIUM San Francisco, July 1991 HENRY H . ROENIGK
Chicago, USA This review was presented as a paper at The Annual Meeting of the Australasian College of Dermatologists, Perth, May 1991. Introduction
There has been a large volume of basic and clinical research devoted to understanding and treating the common skin disease, psoriasis vulgaris. Many important symposia have been held worldwide during the past 20 years to bring dermatologist and other scientist informatio,n on this research. Dr Eugene Farber, former Chairman of Dermatology at Stanford University, initiated these symposia in the 1970s and they have been held every four to five years since then in California. These symposia have resulted in bringing together basic science workers with clinical investigators and dermatologists caring for patients with psoriasis. The 5th International Psoriasis Symposium was Co-Directed by Henry H. Roenigk Jr, MD, of Chicago, II, and Howard I. Maibach, MD, of San Francisco, Ca. There were more than 350 scientific papers presented at plenary sessions, workshops, special symposia and summary presentations, helping to define the current status of psoriasis research and therapy. Many new and old therapies both topical and systemic were reviewed. The 6th International Symposium on Psoriasis will be held in July, 1994, in Chicago, II. Each new symposium offers new ideas and the hope that better therapy or a possible cure can be found for psoriasis. Pathogenesis
The concept of pathogenesis of psoriasis is a broad one. The cause of psoriasis is multifactorial and we have not identified one factor that seems to be predominant, although genetic considerations are certainly important. It appears that the Henry H. Roenigk Jr, MD. Walter J. Hamlin, Professor and Chairman, Department of Dermatology Northwestern University Medical School.
initiating event of psoriasis is probably injury and then an inflammatory reaction, combined with an immune response that sets off the process. Turnover time in psoriasis has long been an important factor, as has neutrophil migration. Cytokines and interleukins are currently a focus of attention and study, as are inflammatory factors that influence the growth of keratinocytes. Growth factor has become an important area of research, not only in psoriasis, but in a number of other conditions such as malignancies of the skin. There is an increased expression of growth factor in psoriasis. The cyclic nucleotide system has long been a subject of interest. Recently there has been consideration of other aspects of this system that appears to regulate the growth of keratinocytes, differentiation, and the inflammatory response. Drugs that can modify keratinocyte growth are thought to have an effect on improving psoriasis. The arachidonic acid system is one that has received much attention. However, there have not been great therapeutic advances from studies. Leukotriene B is an important mediator in the inflammatory process concerned with development of microabscesses and neutrophilic infiltration of the skin. Many investigators are now looking more carefully at the immune response and the T lymphocytes in the skin. This is the result of the beneficial therapeutic effect shown by cyclosporine in the treatment of psoriasis. Corticosteroids
Topical steroids are important in the treatment of psoriasis, although they are overused. As the hallmark of therapy for psoriasis, they are firstline therapy because they are effective, especially fluorinated steroid under occlusion. Superpotent steroids are effective for small areas but they are also overused, not just by the dermatologists, but 127
HENRY H . ROENIGK
by patients. There can be rebound psoriasis and unstable psorieisis including pustular and erythrodermic flares from superpotent corticosteroids. Vitamin D Extensive clinical studies from Denmark and other European countries were presented on topical Vitamin D and there are ongoing trials in the USA. Vitamin D deficiency in psoriasis has been studied, and although there is conflicting data, at least one study showed that in patients with severe psoriasis there were low concentrations of Vitamin D. This suggests that there is a deficiency of Vitamin D when disease is severe. In patients with moderate psoriasis, however, there does not appear to be any difference in serum Vitamin D levels when compared with controls. Several Vitamin D compounds have been studied by investigators. Vitamin D can inhibit keratinocyte growth, which has a beneficial therapeutic effect in psoriasis. This inhibition has been demonstrated in cultured keratinocyte studies. Vitamin D does affect proliferation and differentiation of keratinocytes. It has an effect on T lymphocytes and neutrophils. Several years ago, small dose-range studies were done with various doses of oral Vitamin D preparations. Many of these studies were uncontrolled. Oral Vitamin D for psoriasis has shown adverse effects on calcium metabolism and there was improvement in psoriasis but hypercalcemia developed in 40% of patients treated. Therefore, it was deemed not to be very safe. The oral approach to therapy has lost interest mainly due to its potential toxicity. Instead, attention was focused on topical compounds. Calcipotriol is the agent that appears to have been most widely studied. Other topical Vitamin D compounds have been tried and have been well tolerated, but these have been studied only in small clinical trials. The topical agent on the market in Europe is calcipotriol. There have been controlled studies with a large number of patients. No significant serious systemic side effects have been reported, although mild local irritation is a problem. A study published in The Lancet compared calcipotriol with betamethasone, and calcipotriol compared well. There are few side effects including local irritation, predominantly on the face and scalp. This drug, according to many
investigators, might be our next topical agent of choice for treatment of psoriasis. It is being used in place of topical steroids in Denmark and other countries where it is available. Calcipotriol is being used as a first-line treatment for many patients with psoriasis. It appears to be safe, and it does not produce the rebound that we experience with topical steroids. Calcipotriol will not necessarily replace systemic therapy. There will continue to be indications for PUVA therapy, methotrexate, and other modalities. Patients with severe disease are probably not going to be controlled with calcipotriol. Systemic Drugs for Psoriasis Systemic agents have been developed in the last 40 years for the treatment of psoriasis, and over the past few decades, our choices have been expanded. These agents all have associated side effects. Most agents show good to excellent response. PUVA therapy has progressed to one of the most efficient treatment modalities for psoriasis. Europeans employ a much more aggressive treatment protocol for PUVA than the USA. They treat patients four times a week starting at higher dosage levels: therefore, their patients clear fasten Combination therapy is used more often in Europe than in this country. Maintenance is largely used in the United States but, in Europe, maintenance is avoided. In Europe emphasis is on getting patients clear, getting them off therapy, and then awaiting another psoriasis flare. Psoralens It is hoped that research will bring us new psoralens. A 5-MOP has been developed in Europe. In studies in the USA, 5-MOP demonstrated an advantage over Psoralen-Ultra use, in that there is virtually no nausea from 5-MOP. Several studies performed over the past few years have shown that there is an increase in the incidence of squamous cell carcinoma with the use of psoralen. Basal cell carcinoma seems to be fairly stable, and there has not been an increase in the development of malignant melanoma. Europeans have a lower incidence of skin cancer from PUVA than in the USA. Ageing of the skin is a common side effect. Although eye damage is at present minimal, eye protection is still an important precaution.
128
REVIEW OF FIFTH INTERNATIONAL PSORIASIS SYMPOSIUM
AIDS and Psoriasis PUVA and retinoids are treatment options for patients with AIDS and psoriasis. Recent publications and experience in a small number of patients with AIDS have concluded that PUVA was well tolerated in HIV-positive patients, although probably not safe for use in patients with advanced AIDS. The condition of patients who were stable did not worsen with PUVA therapy. Phototherapy: Home Use Patients and insurance companies have been exerting pressure on practitioners to permit phototherapy in the home setting. In the long run, home treatment probably is less expensive, and patients can treat their disease more often. Insurance companies are encouraging home therapy rather than office-based treatment. The disadvantage cited by dermatologists is they inevitably lose control. There is a potential for toxicity, and if something goes wrong, the dermatologist will be blamed... not the insurance company and not the patient. Home therapy for UVB treatment is less problematic than PUVA therapy. PUVA therapy for hand and foot disease is reasonable for patients that can be trusted to do it properly. Home PUVA for total body treatment as it is done in the office is not advisable. Methotrexate An effective treatment for psoriasis, methotrexate might be safer and more efficient. Patients are living healthier lives and avoiding alcohol. Clinicians are watching drug interactions, adhering to guidelines, monitoring patients closely, and ceasing treatment if there is evidence of early liver disease. There is a difference of opinion between internists and dermatologists regarding methotrexate and liver biopsies. Dermatologists still favour pre-methotrexate liver biopsies because of problems with fibrosis, whereas rheumatologists do not generally perform them. Most rheumatologists are doing their first biopsies two years after treatment commences. Retinoids Tegison and Acitretin are safe and effective treatments for psoriasis. Retinoids are more effective in combination therapy, but do work as
monotherapy. The dosage of acitretin is similar to that of etretinate, although some patients respond to lower doses of acitretin. Adverse effects of tegison and acitretin are similar. Some acitretin treated patients who had not previously had etretinate show trace amounts of etretinate in their blood. After extensive investigation it was concluded not to be a contamination problem. There appears to be the possibility of acitretin metabolizing into etretinate, which is unfortunate, because this is what it was hoped could be avoided. Dermatologists were looking for retinoids that could be excreted rapidly and therefore could be used in women of childbearing age. Acitretin has been withdrawn "without prejudice", which means the manufacturer can reapply for approval. At present, however, approval for this drug is not being pursued. Follow-up studies demonstrated that approximately 40% of the patients on acitretin showed small amounts of etretinate in their serum. Whether these levels are significant or not is still not certain, but a waiting period of at least two years is recommended before permitting women to get pregnant who had been on this drug. One of our patients did not wait two years. She got pregnant within about 30 days after coming off acitretin at precisely the time we were receiving this information. She had a full-term pregnancy. We measured her blood levels, and she was one of the patients who did not have elevated blood levels of etretinate. She had a healthy baby who is doing fine by all parameters. Animal studies appear to indicate that when high amounts of alcohol are ingested with acitretin therapy, there is a greater likelihood of conversion to etretinate. With low levels of alcohol, there is virtually no converstion to etretinate. Investigators are looking at this phenomenon to see whether this is true in humans. Compliance with alcohol restriction is difficult to assure, which will present problems for approval of this drug. We have been interested in the liver function in patients on retinoids. There is a large study in progress, of which our group is a part, that will analyse the two-year follow-up on liver biopsy changes. We had 22 patients treated for two years with acitretin who had no changes in their followup liver biopsies. Two patients' conditions worsened (not significantly) and one patient actually improved. 129
HENRY H . ROENIGK
presents deeper concern, and that is why we often turn to combination therapy, which should really be called rotational, transitional, or cyclic therapy. We are using two drugs together for a short period: one as an accelerator to get the patient cleared and one as the maintainer. The best example of this is REPUVA, which is a favoured treatment in Europe. Retinoids serve as the accelerator to clear the disease, and PUVA is used to maintain the patient on a long-term basis. Most cHnicians cycle their patients and should continue to do so. It is important that patients not be left on methotrexate for 20 years. Certainly it is unacceptable for keep patients on PUVA therapy, regardless of its efficacy, for 10 to 15 years. They should be rotated, and if their psoriasis flares severely, they should be hospitalized and possibly placed on cydosporine until they stabilize, and then, be switched to retinoids or another agent. Patients on methotrexate often develop liver disorders. These patients should be taken off methotrexate and put on PUVA therapy or cydosporine. Occasionally it is necessary to hospitalize patients and start Goeckermann therapy to get the psoriasis under control.
Cydosporine Many studies on cydosporine have been published showing its benefit in psoriasis. Cydosporine is very effective for crisis therapy for severe psoriasis. Long term low dose maintenance therapy can result in renal damage. Careful monitoring of this drug, which is not FDA approved, is mandatory. Sulfasalazine This drug has been used for many years in the treatment of ulcerative colitis and rheumatoid arthritis. It is a mildly effective drug for psoriasis. There is an approximate 40% rate of improvement; many patients do not demonstrate a significant response but sometimes there will be a spectacular response and good clearing. Tumour Necrosis Factor The main action of TNF is to decrease keratinocytes and decrease the accumulation of neutrophils in the skin. A group from Japan treated 11 patients with reasonably good results but with significant systemic side effects during the therapy. First-Line Systemic Therapy The choice for first-line systemic therapy is often PUVA. Sulfasalazine is high on the list in terms of safety, not necessarily effectiveness; it is a safe, easy drug to use. Sometimes it can be used early in treatment to determine whether there will be a response. Retinoids are the next choice, especially in combination therapy. Next would be methotrexate, and finally cydosporine. All these drugs have problems, but in terms of efficacy, all of these agents are reasonable effective. Sulfasalazine is low in terms of efficacy, but most of the other agents result in good to excellent response in severe psoriasis.
The Future Our current therapies will be modified in the future. Investigators are looking at psoriasis as a model, especially with the use of cydosporine and its effect on T-cells. Unusual monoclonal antibody therapies are being developed specifically for autoimmune diseases, rheumatoid arthritis, and renal transplantation. But investigators are also looking for other ways to use these molecules once they become available. Therefore, psoriasis will be targeted as a disease for which they may be used. Immunomodulators to affect T-cell suppression or other changes in cell surface receptors are being considered in an attempt to modify the treatment or modify the disease and produce improvement.
Rotational Therapy Short-term toxicity is not a serious problem with these agents. However, long-term toxicity
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