Essential Insights On Treating Psoriatic Lesions In The Lower Extremity

M. Joel Morse, DPM

   The two-compound ointment containing calcipotriene 50 mcg/gm plus betamethasone dipropionate 0.5 mg/gm (Dovobet or Daivobet and Taclonex, Leo Pharma) combines a vitamin D analogue and a corticosteroid. Patients apply this once each day and it is indicated for the topical treatment of psoriasis in adults 18 years and older. Patients can use the ointment acutely for four to eight weeks to bring psoriasis under control. After this, patients can maintain control of the disease with once-a-day application as needed.10

What You Should Know About Phototherapy And Lasers

Phototherapy is a mainstay in the treatment of extensive plaque type psoriasis. It is rarely in use in the podiatry community due to the facts that podiatrists rarely treat extensive plaque psoriasis and the cost of ultraviolet phototherapy equipment.

   Phototherapy is available as psoralen plus UVA, broadband UVB and narrowband UVB. The typical regimen is three times a week for three months. For some people, psoriasis can deteriorate upon exposure to sunlight.37 Psoralens increases the skin’s sensitivity to ultraviolet light, including sunlight. One would use psoralens to improve the effectiveness of ultraviolet light therapy for psoriasis.

   Some studies have found that the earliest changes in psoriatic lesions concern abnormal microvasculature. In these scenarios, laser therapy could be a possible treatment.38,39

   One study looked at the Nd:YAG 1064 nm laser as this laser can penetrate up to the deeper abnormal psoriatic vasculature.38 The effects are comparable to treatment with the well established calcipotriol/betamethasone dipropionate ointment. The study found the use of the Nd:YAG laser was not of additional value in the array of treatment modalities for chronic localized plaque psoriasis.

   In another study, researchers found the monochromatic excimer light (308-nm) to be an effective and safe treatment modality for patients with mild to moderate psoriasis vulgaris and palmoplantar psoriasis.39 The excimer laser is an example of targeted phototherapy and one can use it when a patient has more localized areas of plaques as one would find on the foot. An excimer laser uses a combination of an inert gas and a reactive gas to create an excited dimer or excimer, which gives rise to laser light in the ultraviolet range.40

   Pulsed dye laser therapy can be effective in clearing psoriasis plaques but the mechanism of action is only partially understood.41 This therapy might be an alternative treatment for nail psoriasis.42

Key Insights On The Potential Of Biologics

Biologics comprise a new class of treatment for psoriasis and patients take them by intravenous infusion.

   Different from the traditional systemic drugs that impact the entire immune system, biologics target specific parts of the immune system. The biologics treat psoriatic diseases by blocking the action of T cells or by blocking proteins (such as tumor necrosis factor-alpha or interleukins 12 and 23) in the immune system. These cells and proteins all play a major role in developing psoriasis and psoriatic arthritis.43

   The more common biologics include: infliximab (Remicade, Janssen Biotech); etanercept (Enbrel, Amgen and Pfizer); adalimumab (Humira, Abbott Laboratories); and ustekinumab (Stelara, Janssen Biotech).

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