Systemic treatment
       Systemic Therapy

         Systemic therapy is used in the treatment of psoriasis when the disease is of
moderate or severe in nature. The criteria for classification of psoriasis as mild, moderate and severe are based on the body surface area. If psoriasis involves more than 15% of body surface area, systemic therapy may be used. With the knowledge that psoriasis has systemic implications due to its inflammatory nature, systemic therapy is more advisable from the very onset of disease. This may help to delay the effects in other organ system of the body. When psoriasis is of moderate or severe type systemic drugs are used. There are a number of drugs available for the systemic therapy of psoriasis such as 1. Methotrexate2. Systemic corticosteroids 3.Retinoids4. Biologicals. All these drugs are highly useful to make the psoriasis under control. However it requires guidance of an experienced person to during the treatment period as strict monitoring is absolutely necessary during treatment with these drugs.


         Methotrexate is one of the widely used and effective drug in the treatment of
psoriasis. Recent studies have shown that the efficacy of methotrexate is due to its effect on the inflammatory nature of the disease rather than its anti proliferation effect. Some people even consider methotrexate as “ Poor man’s biological” . However, utmost care should be taken to monitor the patient who on treatment with methotrexate. Even before treatment, patient should be assessed for the suitability to start the drug.
As general principle the drug should be avoided in these who are having liver disease, anemia, hypoproteinaemia, malignancies and alcoholism . The drug may be given to alcoholic if they are ready to give up the habit and will adhere to it.
During treatment regular follow up with clinical examination and various Lab tests to detect untoward effects is highly essential.


         Systemic corticosteroid is a very useful drug in the treatment of psoriasis. It is given in special situations such as pustular psoriasis, psoriatic arthritis, exfoliative psoriasis when there is haemodynamic instability and in palmoplantar psoriasis where the livelihood is at state. Though useful, it has untoward effect too. So the drug is given only if it is absolutely necessary. If the drug is given for a long time, patient must be monitored for development, of side effects such as diabetes mellitus, hypotension, osteoporosis, etc. If found either stop the drug or remedial measures are to be adopted.


         Cyclosporine had a major impact on treatment of psoriasis. Psoriasis is considered as T cell diseases. T cell are immune regulator cells. In nut shell , some/ many abnormalities in T cell modulation results in phenotypic expression of psoriasis in a genetically predisposed individual. This understanding has led to the use of Cyclosporine in psoriasis.
Cyclosporine therapy is limited to moderate to severe psoriasis. It is usually considered as a “ disease burster”. When used, the drug gives a rapid clearance of lesions and hence it can be used in situations where the control of disease is urgent. One example of such a situation is marriage of the patient. Once the disease is under control other drugs must be added or substituted for maintenance.
Before therapy, the patient should be evaluated for the suitability of treatment by the drug. Usually patients are screened for any kidney diseases, dyslipidemia ( changes in cholesterol) hypertension and malignancy. Strict vigilance should be exercised for development of any untoward effects during therapy.
The drug is theoretically contraindicated in pregnant, the use of it has not produced serious problems except prematurity. In children also it is a safe drug.

       Biological's in psoriasis

         Recent advances in research in psoriasis further theron light in the understanding of psoriasis. This had lead to the understanding of how T cell function in psoriasis. This knowledge is exported in the development of newer treatments of psoriasis. The result in various designer drugs generally known as biological's. These drugs belong to a class known as monoclonal antibodies. The common drugs belonging to the group are etarnecept , infliximab , adalimab, efalizumab, alifacept and ustekinumab. More and more drugs are added to this category.
One common concern about the drugs in the mind of patient is the cost. All these days are effective with rapid onset of action . The treatment should follow with maintenance therapy by the same drug periodically or substitution of other drugs.
Before treatment with these drugs , patient should be evaluated for the suitability of the treatment in that particular patient. These include various blood tests, X ray of chest to rule out tuberculosis, tests to rule out tuberculosis elsewhere. Any infection anywhere in the body is a serious concern as it may flare up to fulminant stage with treatment . So before treatment patient should be thoroughly evaluated for appropriateness of treatment and treatment and strictly followed up during and after therapy.

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