Mild-to-Moderate Psoriasis - part 10 potx

and facial areas, their side effects may mitigate use in these areas. Topical tacrolimus offers the potential for an anti-inflammatory effect, while avoid- ing the atrophy and acneiform eruptions commonly associated with the use of topical corticosteroids (48). Several studies have shown the benefits of tacrolimus for facial and intertriginous psoriasis (49,50). One study showed excellent improvement at the end of an eight-week treatment period, with 65.2% of the tacrolimus ointment group, versus 31.5% of the vehicle group, giving a clear or almost clear response (50). Adverse events were similar in the 0.1% tacrolimus ointment and vehicle groups. In a study of pimecroli- mus in 57 patients with moderate to severe inverse psoriasis, 54% of the pimecrolimus group versus 21% of the placebo group had an Investigator’s Global Assessment score of 0 or 1 (cle ar or almost clear) at week 2 (51). By week 8, 71% of the pimecrolimus group had an Investigator’s Global Assess- ment score of 0 or 1. Pimecrolimus was safe and well-tolerated, with adverse events similar between groups. Topical tacrolimus and pimecrolimus are ineffective for standar d plaque psoriasis. Safety Recently, concern has been raised due to the development of tumors asso- ciated with these agents. Nine cases of tumor adverse events and 21 cases of tumor adverse events with pimecrolimus and tacrolimus, respectively, have been reported to the U.S. Food and Drug Administration’s Adverse Event Reporting System (52). Although systemic tacrolimus used during pregnancy may result in fetal malformations and preterm deliveries, the bioavailability of topical tacrolimus is less than 5% of the orally adminis- tered form, making the potential for tumors with standar d topical therapy extremely low indeed (53–55). Both topical and systemic tacrolimus prep- arations are pregnancy category C (56). Coal Tar This agent is messy, malodorous, and stains clothing and other fabrics, lead- ing to poor patient compliance despite being inexpensive. Liquor carbonis detergens is better tolerated and may be compounded in various vehicles (57). We frequently use 10% to 20% liquor carbonis detergens with one-fourth strength betamethasone valerate in a hydrophilic emollient base at night for thin plaque psoriasis or as an adjunct to phototherapy. It is important to instruct patient not to apply tar preparations prior to their phototherapy to avoid ‘‘tar smarts.’’ Safety From a safety standpoint, skin irritation, acneiform eruptions, and fol- liculitis are common. The carcinogenicity of coal tar has clearly been 254 Berthelot et al. demonstrated by in vitro and animal studies, and appears to be potentiated by concomitant use of UV radiation (58). In addition, cases of skin cancer have been linked with coal tar use, especi ally on the genitalia (59). Tar preparations are frequently used by dermatologi sts as shampoos for the treatment of scalp psoriasis. In addition, a vast array of over-the-counter tar-containing products are advertised and still used by psoriasis patients. Coal tar is safe to apply during pregnancy (pregnancy class A), and a retrospective study of 23 pregnant patients during which the dermatological use of tar was clear was not associated with any adverse outcomes (60). Anthralin Anthralin, or dithranol, has historically been used as part of the Ingram regimen (daily coal-tar bath, UVB, followed by application of an anthralin– salicylic acid paste) (3). Anthralin, like coal tar, commonly causes irritation, and also has a significant problem with the staining of skin, fabric, and bathroom tile, and therefore it has largely been abandoned outside of photo- therapy and outpatient regimens. Short contact regimens (minutes to 1–2 hours) and more cosmetically acceptable formulations are used in the out- patient setting as monotherapy or in combination with other agents to reduce these side effects. Short contact anthralin therapy, using concentra- tions of 1% or greater, entail application of five minutes on the first day and then increasing by five minutes every other day until minimal irritation develops, after which the period of application is maintained until clearing (61). Staining of the skin and irritation may be lessened by application of triethanolamine before removal of the anthralin (62). Micanol 1 is a 1% anthralin formulation in a temperature-sensitive vehicle that releases active medication at skin surface temperature (63). It is possibly more acceptable to patients because staining of household fabrics and furniture is minimized. Studies have demonstrated efficacy of Micanol 1 in short- and long-term r egimens, as well as utility in scalp psoriasis refractory to other treatments. Safety Anthralin should be used with care because of potential for irritation and staining. Thus, it must be applied only to plaques and not to surrounding normal skin, as irritation and staining of the skin may develop. Anthralin is pregnancy category C and no reproduction studies, human or animal, or reports of adverse fetal effects have been published (59). While studies have shown that anthralins is a tumor promoter producing transient changes in the growth or differentiation of the epidermis, no significant increase in pre-malignant or malignant skin tumors have been noted in over 50 years of usage (64). Therapeutic Options for Mild-to-Moderate Psoriasis 255 Emollients and Keratolytics These agents are recommended as concomitant therapy for the treatment of psoriasis. Hydration of the dysfunctional epidermal barrier helps decrease erythema, pruritus, and scaling wi thin lesions (65). In general, while oint- ments are the most effective, patient preference and compliance is better with less greasy emollient bases (66). In addition, in certain body areas (e.g., legs) and patient populations (e.g., elderly), emollients should be used as an adjunct to topical steroid usage, especially after bathing. The only combination keratolytic creams commercially available in the United States are lactic acid/urea based (67). Outside the United States, a combination of 0.05% betamethasone dipropionate ointment and 3% sali- cylic acid is available (68). Salicylat e-containing preparations should not be applied before light therapy given their photoprotective effects. We usually limit the use of these products for hands, feet, elbows, and knees to aid in exfoliation on the penetration of concomitant topical agents. Safety While keratolytics containing salicylic acid are generally regarded as safe, their use should be limited to less than 20% BSA to avoid salicylate toxicity, classically characterized by tinnitus, dizziness, gastrointestinal distress, and psychiatric disturbances (69). Keratolytics are pregnancy class C (safety for use during pregnancy has not been established) and application to the face, genitalia, and eyes should be avoided (70). PHOTOTHERAPY Although the majority of patients with mild-to-moderate psoriasis are treated successfully with topical agents , some may also require photother- apy. Because of its efficacy and safety profile, UVB continues to have widespread use in spite of the development of newer treatment modalities for psoriasis. Studies have shown that UVB in conjunction with other treat- ment modalities shows additional benefits, and results in lesion clearing with less frequent UVB radiation treatments. UVB therapy with a lubricating base results in shorter treatment periods, which means the surrounding skin will be exposed to smaller doses of UVB, with a diminished risk of actinic damage (71). UVB combination with tazarotene 0.1% gel may be more ben- eficial than UVB alone (40,41). Similarly, the addition of calcipotriene to UVB results in lesion clearing with less frequent UVB radiation treatments (22,23). UVB phototherapy combined with topical corticosteroids has shown no dose-sparing effect or therapeutic advantage, and may even shorten remission time. The use of broadband UVB has diminished in recent years with the introduction and widespread availability of narrow-band UVB, which has a quicker and more sustained onset of action. The excimer 256 Berthelot et al. laser is a beam of 308 nm light and has been successfully used to treat loca- lized plaques of psoriasis (‘‘targeted phototherapy’’), including those on the palms and soles (72). PUVA therapy is considered more durable than UVB, with some patients even achieving long-term remission without maintenance therapy. Methoxsalen is pregnancy category C and should be given to pregnant females only in cases where it is clearly needed. Because PUVA is mutagenic and induces sister chromatid exchanges, it should be considered a potential teratogen and women at risk of becoming pregnant who are treated with PUVA should consider using contraception (73). SUMMARY Biologic systemic therapies for psoriasis have dominated the literature, meet- ings, and marketing efforts over the past three years. However, topical therapy is likely to remain an essential form of therapy for the majority of psoriasis patients, either as monotherapy for patients with limited disease, or as an adjunctive therapy to phototherapy and systemic agents for more severe psoriasis. While writing a prescription for a single topical preparation, or combination of agents, is relatively quick and easy, time must be spent in educating each individual patient on the nuances of topical therapy in order to optimize the positive effects of these preparations, while minimizing their side effects. As the majority of patients with psoriasis are part of the spectrum of mild-to-moderate disease, it is hoped that the practical points outlined in this chapter will be of value for the practicing dermatologist. REFERENCES 1. Marchetti A, Feldman SR, Kimball AB, et al. Treatments for mild-to-moderate recalcitrant plaque psoriasis: expected clinical and economic outcomes for first- line and second-line care. Dermatol Online J 2005; 11(1):1. 2. Krueger GG, Feldman SR, Camisa C, et al. Two considerations for patients with psoriasis and their clinicians: what defines mild, moderate, and severe psoriasis? What constitutes a clinically significant improvement when treating psoriasis? J Am Acad Dermatol 2000; 43(2 Pt 1):281–285. 3. Lebwohl M, Ali S. Treatment of psoriasis. Part 1. Topical therapy and photo- therapy. J Am Acad Dermatol 2001; 45(4):487–498; quiz 499–502. 4. Katz HI. Corticosteroids. Dermatol Clin 1995; 13(4):805–815. 5. Lebwohl M, Sherer D, Washenik K, et al. A randomized, double-blind, placebo- controlled study of clobetasol propionate 0.05% foam in the treatment of nonscalp psoriasis. Int J Dermatol 2002; 41(5):269–274. 6. Katz HI, Hien NT, Prawer SE, et al. Superpotent topical steroid treatment of psoriasis vulgaris—clinical efficacy and adrenal function. J Am Acad Dermatol 1987; 16(4):804–811. Therapeutic Options for Mild-to-Moderate Psoriasis 257 7. Peters BP, Weissman FG, Gill MA. Pathophysiology and treatment of psoriasis. Am J Health Syst Pharm 2000; 57(7):645–659; quiz 660–661. 8. Miller JJ, Roling D, Margolis D, et al. Failure to demonstrate therapeutic tachy- phylaxis to topically applied steroids in patients with psoriasis. J Am Acad Dermatol 1999; 41(4):546–549. 9. Tan M-H, Meador SL, Lebwohl MG. The safety and efficacy of limited applica- tion of fluticasone propionate ointment, 0.005% in patients with psoriasis of the face and intertriginous areas. Presented as a poster at the 57th Annual Meeting of the American Academy of Dermatology, New Orleans, Louisiana, March 19–24, 1999. Poster Abstract Book, abstract 463. 10. Katz HI, Prawer SE, Medansky RS, et al. Intermittent corticosteroid mainte- nance treatment of psoriasis: a double-blind multicenter trial of augmented betamethasone dipropionate ointment in a pulse dose treatment regimen. Dermatologica 1991; 183(4):269–274. 11. Katz HI, Hien NT, Prawer SE, et al. Betamethasone dipropionate in optimized vehicle. Intermittent pulse dosing for extended maintenance treatment of psori- asis. Arch Dermatol 1987; 123(10):1308–1311. 12. Prawer SE, Katz HI. Guidelines for using superpotent topical steroids. Am Fam Physician 1990; 41(5):1531–1538. 13. Greaves MW, Weinstein GD. Treatment of psoriasis. N Engl J Med 1995; 332(9): 581–588. 14. Marks R. Tinea incognito. Int J Dermatol 1978; 17(4):301–302. 15. Lebwohl M, Ting PT, Koo JY. Psoriasis treatment: traditional therapy. Ann Rheum Dis 2005; 64(suppl 2):ii83–ii86. 16. Inoue Y, Isobe M, Shiohara T, et al. Inhibitory activity of CX-659S, a novel dia- minouracil derivative, against the rebound phenomenon following withdrawal of corticosteroid therapy for chronic contact hypersensitivity responses. Int Arch Allergy Immunol 2003; 131(2):143–152. 17. Long CC, Finlay AY. The finger-tip unit—a new practical measure. Clin Exp Dermatol 1991; 16(6):444–447. 18. Dubertret L, Wallach D, Souteyrand P, et al. Efficacy and safety of calcipotriol (MC 903) ointment in psoriasis vulgaris. A randomized, double-blind, right/left comparative, vehicle-controlled study. J Am Acad Dermatol 1992; 27(6 Pt 1): 983–988. 19. Lebwohl M, Siskin SB, Epinette W, et al. A multicenter trial of calcipotriene ointment and halobetasol ointment compared with either agent alone for the treatment of psoriasis. J Am Acad Dermatol 1996; 35(2 Pt 1):268–269. 20. Lebwohl M, Yoles A, Lombardi K, et al. Calcipotriene ointment and halobeta- sol ointment in the long-term treatment of psoriasis: effects on the duration of improvement. J Am Acad Dermatol 1998; 39:447–450. 21. Wall AR, Poyner TF, Menday AP. A comparison of treatment with dithranol and calcipotriol on the clinical severity and quality of life in patients with psori- asis. Br J Dermatol 1998; 139(6):1005–1011. 22. Hecker D, Lebwohl M, Siskin S. Topical calcipotriene in combination with UVB phototherapy for psoriasis. Int J Dermatol 1997; 36:302–303. 23. Molin L. Topical calcipotriol combined with phototherapy for psoriasis: the results of two randomized trials and a review of the literature. Calcipotriol- UVB Study Group. Dermatology 1999; 198:375–381. 258 Berthelot et al. 24. Brands S, Brakman M, Bos JD, et al. No additional effect of calcipotriol oint- ment on low-dose narrow-band UVB phototherapy in psoriasis. J Am Acad Dermatol 1999; 41:991–995. 25. Rim JH, Choe YB, Youn JI. Positive effect of using calcipotriol ointment with narrow-band ultraviolet B phototherapy in psoriatic patients. Photodermatol Photoimmunol Photomed 2002; 18(3):131–134. 26. Torras H, Aliaga A, Lopez-Estebaranz JL, et al. A combination therapy of cal- cipotriol cream and PUVA reduces the UVA dose and improves the response of psoriasis vulgaris. J Dermatol Treat 2004; 15(2):98–103. 27. Fenton C, Plosker GL. Calcipotriol/betamethasone dipropionate: a review of its use in the treatment of psoriasis vulgaris. Am J Clin Dermatol 2004; 5(6): 463–478. 28. Koo J. Diluting Dovonex. Psoriasis Forum 1995; 1:6. 29. Patel B, Siskin S, Krazmien R, et al. Compatibility of calcipotriene with other topical medications. J Am Acad Dermatol 1998; 38(6 Pt 1):1010–1011. 30. Georgiou S, Tsambaos D. Hypercalcaemia and hypercalciuria after topical treat- ment of psoriasis with excessive amounts of calcipotriol. Acta Derm Venereol 1999; 1:79–86. 31. Mortensen L, Kragballe K, Wegmann E, et al. Treatment of psoriasis vulgaris with topical calcipotriol has no short-term effect on calcium or bone metabolism: a randomized, double-blind, placebo-controlled study. Acta Derm Venereol 1993; 73:300–304. 32. Stewart DG, Lewis HM. Vitamin D analogues and psoriasis. J Clin Pharm Ther 1996; 21(3):143–148. 33. Fogh K, Kragballe K. Vitamin D3 analogues. Clin Dermatol 1997; 15(5):705–713. 34. Darley CR, Cunliffe WJ, Green CM, et al. Safety and efficacy of calcipotriol ointment (Dovonex) in treating children with psoriasis vulgaris. Br J Dermatol 1996; 135(3):390–393. 35. Guenther LC. Optimizing treatment with topical tazarotene. Am J Clin Dermatol 2003; 4(3):197–202. 36. Lebwohl M. Strategies to optimize efficacy, duration of remission, and safety in the treatment of plaque psoriasis by using tazarotene in combination with a cor- ticosteroid. J Am Acad Dermatol 2000; 43(2 Pt 3):S43–S46. 37. Lebwohl MG, Breneman DL, Goffe BS, et al. Tazarotene 0.1% gel plus corticos- teroid cream assay and clinical activity in psoriasis. Arch Dermatol 1985; 121:63–67. 38. Bowman PH, Maloney JE, Koo JY. Combination of calcipotriene (Dovonex) oint- ment and tazarotene (Tazorac) gel versus clobetasol ointment in the treatment of plaque psoriasis: a pilot study. J Am Acad Dermatol 2002; 46(6):907–913. 39. Hecker D,Worsley J, Yueh G, et al. Interactions between tazarotene and ultra- violet light. J Am Acad Dermatol 1999; 41:927–930. 40. Koo JY. Tazarotene in combination with phototherapy. J Am Acad Dermatol 1998; 39(suppl):S144–S148. 41. Koo JY, Lowe NJ, Lew-Kaya DA, et al. Tazarotene plus UVB phototherapy in the treatment of psoriasis. J Am Acad Dermatol 2000; 43(5 Pt 1):821–828. 42. Koo J, Behnam SE, Behnam SM. The efficacy of topical tazarotene monother- apy and combination therapies in psoriasis. Expert Opin Pharmacother 2003; 4(12):2347–2354. Therapeutic Options for Mild-to-Moderate Psoriasis 259 43. Guenther LC, Poulin YP, Pariser DM. A comparison of tazarotene 0.1% gel once daily plus mometasone furoate 0.1% cream once daily versus calcipotriene 0.005% ointment twice daily in the treatment of plaque psoriasis. Clin Ther 2000; 22(10):1225–1238. 44. Weinstein GD, Koo JY, Krueger GG, et al. Tazarotene cream in the treatment of psoriasis: two multicenter, double-blind, randomized, vehicle-controlled stu- dies of the safety and efficacy of tazarotene creams 0.05% and 0.1% applied once daily for 12 weeks. J Am Acad Dermatol 2003; 48(5):760–767. 45. Weinstein GD, Krueger GG, Lowe NJ, et al. Tazarotene gel, a new retinoid, for topical therapy of psoriasis: vehicle-controlled study of safety, efficacy, and duration of therapeutic effect. J Am Acad Dermatol 1997; 37(1):85–92. 46. Tang-Liu DD, Matsumoto RM, Usansky JI. Clinical pharmacokinetics and drug metabolism of tazarotene: a novel topical treatment for acne and psoriasis. Clin Pharmacokinet 1999; 37(4):273–287. 47. Carroll CL, Fleischer AB Jr. Tacrolimus ointment: the treatment of atopic der- matitis and other inflammatory cutaneous disease. Expert Opin Pharmacother 2004; 5(10):2127–2137. 48. Winterfield LS, Menter A, Gordon K, et al. Psoriasis treatment: current and emerging directed therapies. Ann Rheum Dis 2005; 64(suppl 2):ii87–ii90; discus- sion ii91–ii92. 49. Freeman AK, Linowski GJ, Brady C, et al. Tacrolimus ointment for the treat- ment of psoriasis on the face and intertriginous areas. J Am Acad Dermatol 2003; 48(4):564–568. 50. Lebwohl M, Freeman AK, Chapman MS, et al. Tacrolimus Ointment Study Group. Tacrolimus ointment is effective for facial and intertriginous psoriasis. J Am Acad Dermatol 2004; 51(5):723–730. 51. Gribetz C, Ling M, Lebwohl M, et al. Pimecrolimus cream 1% in the treatment of intertriginous psoriasis: a double-blind, randomized study. J Am Acad Dermatol 2004; 51(5):731–738. 52. www.fda.gov/ohrms/dockets/ac/05/slides/2005–4089s2_01_07_Pitts.ppt (Accessed April 5, 2005). 53. Kainz A, Harabacz I, Cowlrick IS, et al. Review of the course and outcome of 100 pregnancies in 84 women treated with tacrolimus. Transplantation 2000; 70(12):1718–1721. 54. Skaehill PA. Tacrolimus in dermatologic disorders. Ann Pharmacother 2001; 35: 582–588. 55. Ormerod AD. Editorial comments: topical tacrolimus and pimecrolimus and the risk of cancer: how much cause for concern? Br J Dermatol 2005; 153(4):701–705. 56. Soter NA, Fleischer AB Jr., Webster GF, et al. Tacrolimus ointment for the treatment of atopic dermatitis in adult patients: Part II, safety. J Am Acad Dermatol 2001; 44(suppl 1):S39–S46. 57. Kanzler MH, Gorsulowsky DC. Efficacy of topical 5% liquor carbonis detergens vs. its emollient base in the treatment of psoriasis. Br J Dermatol 1993; 129(3):310–314. 58. Arnold WP. Tar. Clin Dermatol 1997; 15(5):739–744. 59. Andrews PE, Farrow GM, Oesterling JE. Squamous cell carcinoma of the scrotum: long-term followup of 14 patients. J Urol 1991; 146(5):1299–1304. 260 Berthelot et al. 60. Tauscher AE, Fleischer AB Jr., Phelps KC, et al. Psoriasis and pregnancy. J Cutan Med Surg 2002; 6(6):561–570. E-pub 2002 Oct 9. 61. Miller AC. Anthralin cream as short contact therapy for psoriasis. Cutis 1985; 35(6):578–582. 62. Ramsay B, Lawrence CM, Bruce JM, et al. The effect of triethanolamine appli- cation on anthralin-induced inflammation and therapeutic effect in psoriasis. J Am Acad Dermatol 1990; 23(1):73–76. 63. Volden G, Bjornberg A, Tegner E, et al. Short-contact treatment at home with Micanol. Acta Derm Venereol Suppl (Stockh) 1992; 172:20–22. 64. Yuspa SH. Cutaneous chemical carcinogenesis. J Am Acad Dermatol 1986; 15(5 Pt 1):1031–1044. 65. Bernstein JE, Parish LC, Rapaport M, et al. Effects of topically applied capsaicin on moderate and severe psoriasis vulgaris. J Am Acad Dermatol 1986; 15(3): 504–507. 66. Housman TS, Mellen BG, Rapp SR, et al. Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehicle preference. Cutis 2002; 70(6):327–332. 67. Stern RS. Psoriasis. Lancet 1997; 350(9074):349–353. 68. Guenther LC. Fixed-dose combination therapy for psoriasis. Am J Clin Dermatol 2004; 5(2):71–77. 69. Brien JA. Ototoxicity associated with salicylates. A brief review. Drug Saf 1993; 9(2):143–148. 70. Lebwohl M. The role of salicylic acid in the treatment of psoriasis. Int J Dermatol 1999; 38(1):16–24. 71. Berne B, Blom I, Spangberg S. Enhanced response of psoriasis to UVB therapy after pretreatment with a lubricating base. A single-blind controlled study. Acta Derm Venereol 1990; 70(6):474–477. 72. Housman TS, Pearce DJ, Feldman SR. A maintenance protocol for psoriasis plaques cleared by the 308 nm excimer laser. J Dermatol Treat 2004; 15(2): 94–97. 73. Stern RS, Lange R. Outcomes of pregnancies among women and partners of men with a history of exposure to methoxsalen photochemotherapy (PUVA) for the treatment of psoriasis. Arch Dermatol 1991; 127:347–350. Therapeutic Options for Mild-to-Moderate Psoriasis 261 Index 1a,25-Dihydroxycholecalciferol, 60 5-Methoxypsoralen (5-MOP), 131 8-Methoxypsoralen (8-MOP), 131 Absorption spectrum, 131 Acetonide side groups, 45 Acitretin, 157, 235 Adalimumab, 233 Adjunctive therapy, 256 Alefacept, T-cell-like, 234 Alopecia cicatricialis, 196 Anhydrous vehicle, 78–79 advantageous characteristics of, 84–85 Anthralin, 255 application of, 120 combination therapy of, 120 disadvantages of, 120 efficacy of, 120 in psoriasis treatment, 119–121 side effects of, 121 topical, 236 Anthralin therapy, 255 short contact, 120 Anthralin treatment regimens, of plaque psoriasis, 120 Anti-inflammatory agents, nonsteroidal, 177 Antiemetics, 134 Antifungals imidazole, 199 treatment, 199 Antipsoriatic treatment, 202 Arthritis mutilans, 227 psoriatic, types of, 227 Asymmetric oligoarthritis, 227 Axial disease, 227 Basal cell carcinoma (BCC), 131 Beau’s lines, 223, 230 Betamethasone dipropionate b.i.d., 77 cream, 95 ointment, 76, 256 once-daily, 78, 80 Betamethasone dipropionate plus salicyclic acid, 62 Betamethasone dipropionate/ calcipotriene combination, 84–85 with biologics, 85–86 clinical trials and analyses of, 77 effectiveness of, 77 formulation of, 76 with other systemic agents, 86 263 [...]... phase timing of, 167–168 Index [Psoriasis] types of, 31 vehicle for, 35 vitamin D analogs in, 1 and vitamin A analogues in, 5 Psoriasis Activity and Severity Index (PASI), 15, 30–31, 77, 116, 150, 199, 251 of Goeckerman patients, 117 reduction in, 78 Psoriasis plaques, 107 on face, 109 on intertriginous areas, 110 Psoriasis Quality-of-Life Questionnaire (PQOL) items, 10 41 items of, 14, 24 application... reactions, 139 Koo–Menter Psoriasis Instrument (KMPI) components of, 10 discussions on, 27 PQOL-12 score calculation within, 26 quality-of-life measure for, 13 use in psoriasis, 27 Leukocyte function-associated antigen (LFA), 234 Leukonychia, 225, 226 267 Lichen planopilaris, 197 simplex chronicus, 180 striatus, 230 Lidex1, 95 Light therapy, 213 Likert-type scale, 14 Linear psoriasis, 230 Linear verrucous... B (UVB) for, 2 palmar-plantar, 31 pathogenic causes of, 92 patients compliance in, 5–6, 47 indication of, 13 psychosocial needs of, 3–5 recalcitrant, remission time of, 118 self-assessment in, 10 13 phototherapy for, 2, 14, 31 physician assessment in, 13 physician’s approach to, 4 pimecrolimus, use of, 109 plaque, 91, 107 , 109 , 110, 202, 247 plaque evaluation of, 64 pustular, 108 scalp, 5, 116, 195,... derivative, 106 ointment, 107 Pityriasis amiantacea, 197 Placebo, 62, 65 Plaque psoriasis, 107 , 187, 202, 247 anthralin treatment regimens of, 120 chronic, 207 treatment of, 91 fluocinonide cream in, 93 Plaques, 184 chalky, 225 nail fold, 226 Polyarthritis, symmetric, 227 Potassium hydroxide preparation, 185 Potencies, range of, 33 Potential dose-sparing effects., 252 PQOL See Psoriasis Quality-of-Life Questionnaire... plaque-type psoriasis, 150 Symmetric polyarthritis, 227 Systemic antifungal treatment, 202 Systemic calcium metabolism, 201 Systemic tacrolimus, 213 T-cell, 42, 126, 233, 234 apoptosis, 126 infiltration, 212 like alefacept, 234 T-cell lymphoma, cutaneous, 111 T lymphocytes, 107 Tacalcitol, 59 Tachyphylaxis, 47, 76, 211 Taclonex1, 76 Tacrolimus ointment, 107 108 and pimecrolimus use, 111 topical, 54, 108 ... p 86) Figure 9.1 Telangectasia, ear (See p 106 ) Figure 9.2 Striae distensae (See p 106 ) Figure 9.3 Psoriasis plaques on face (A) before therapy; (B) after therapy (See p 109 ) Figure 9.4 Psoriasis plaques on intertriginous areas (A) before therapy; (B) after therapy (See p 110) Figure 10. 1 PASI scores of 25 consecutive Goeckerman patients treated at the UCSF Psoriasis Treatment Center (See p 117) Figure... manifestations of scalp psoriasis: (A) psoriasis of the scalp; (B) scarring psoriatic alopecia; (C) hairline psoriasis (See p 196) Figure 17.1 Patient with inverse psoriasis involving the intragluteal fold (See p 208) Figure 18.2 Pitting in nail psoriasis (See p 225) Figure 18.3 Oil spot in nail psoriasis (See p 225) Figure 18.4 (See p 226) Onycholysis in nail psoriasis Figure 19.1 Mild psoriasis (See p... 14–15 confirmatory analysis of, 15–16 rating of, 14 refining and reducing to 12 item instrument, 15 12-item Psoriasis Quality-of-Life Questionnaire (PQOL-12), 10, 24 background on, 14 development of, 15 item descriptive statistics for, 17, 25 minimally important difference (MID) of, 24, 26 multicentered office-based study of, 15 responsiveness of, 24 validity and reliability of, 16 psychometric properties... agent for, 36 tazarotene application in, 99 100 Temovate1, 176 therapies, categories of, 163 topical tacrolimus for, 54 use of, 109 topical therapies for, 1, 32, 115 algorithm of, 33 treatment of, 106 , 116, 245 agents in, 5 anthralin in, 119–121 calcipotriene in, 1 with corticosteroids in, 1–2, 41 effective agents in, 1–2 inverse, 108 lactic acid in, 122 mild-to-moderate, 119–121 salicylic acid in, 121–122... Telangectasia, ear, 106 Temovate cream, 176 Temperature-sensitive vehicle, 255 Therapeutic effects, 252 Therapy combination, 34, 37 complications from, 231–236 Goeckerman, 116 methotrexate, 66 rotational, 37 sequential, 38 short contact, 100 topical, 31 amount of, 34 occlusion used to, 36 techniques to enhance, 36–37 triple combination, 100 Thymidylate synthesis, 214 TNF-a See Tumor necrosis factor-alpha Toenails, . treatment of psoriasis. Arch Dermatol 1991; 127:347–350. Therapeutic Options for Mild-to-Moderate Psoriasis 261 Index 1a,25-Dihydroxycholecalciferol, 60 5-Methoxypsoralen (5-MOP), 131 8-Methoxypsoralen. 139 Koo–Menter Psoriasis Instrument (KMPI) components of, 10 discussions on, 27 PQOL-12 score calculation within, 26 quality-of-life measure for, 13 use in psoriasis, 27 Leukocyte function-associated. Feldman SR, Kimball AB, et al. Treatments for mild-to-moderate recalcitrant plaque psoriasis: expected clinical and economic outcomes for first- line and second-line care. Dermatol Online J 2005; 11(1):1. 2.