Therapeutic Moisturizers as Adjuvant Therapy for Psoriasis Patients

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1 Am J Clin Dermatol 2009; 10 Suppl. 1: 7-12 REVIEW ARTICLE /09/ /$49.95/ Adis Data Information BV. All rights reserved. Therapeutic Moisturizers as Adjuvant Therapy for Psoriasis Patients Carlo Gelmetti Istituto di Scienze Dermatologiche, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy Abstract At any point in time, psoriasis affects 2 3% of the world s population and has one of the biggest impacts on quality of life of any dermatological disorder. Treatment is extremely costly and prevention of disease progression in severity and extent is crucial. Psoriasis treatment should include skin hydration (regular use of moisturizers and emollients), careful, gentle skin cleansing, and identification and avoidance of Koebner phenomenon triggers (excoriation, maceration) and infectious foci (Streptococcus pyogenes). Moisturizers have been shown to significantly improve skin conditions and quality of life for psoriasis patients. They are a valuable first-line treatment, as dry skin is common and adds to the irritability of the diseased skin. Most patients respond well to topical treatment with topical corticosteroids, emollients, coal tar, anthralin (dithranol) or calcipotriol. Emollients are the most prescribed products, providing transient relief from irritation and some possessing antiinflammatory properties. Moisturizers and emollients should be used in the following cases: minimal psoriasis, napkin psoriasis, psoriasis of the folds, psoriatic skin damaged by previous local treatments, and in pregnancy or women of childbearing age. According to population-based studies, at any point in time, Another type of underdiagnosed psoriasis is minimal psoriasis 2 3% of the world s population are affected by psoriasis. [1-3] with dry skin, which can be difficult to identify and diagnose Compared with other dermatological disorders, psoriasis has one (figure 2). According to the Overall Lesional Assessment scale of the highest impacts on quality of life (QOL) [4] and may be associated with increased risk for other diseases, such as cancer, (OLA), minimal psoriasis lesions are essentially flat with possibly arthritis, and cardiac disease. [2,5] In addition, psoriasis therapies are trace elevation, no scale and up to moderate erythema. [7] The lack costly, which must be factored into treatment along with objective of thick, silvery scales and the location in some areas where mild outcome parameters. The prevalence of psoriasis is increasing redness can be frequent can make a psoriasis diagnosis difficult. In worldwide: an epidemiology study in Italy estimated that inci- some areas (e.g. the scalp) the thin desquamation can be hard to dence in women rose from 1.39% to 1.44% between 1995 and see and, when observed, can also be interpreted as normal [6] dandruff. The associated erythema can be either very mild or 1. Psoriasis Types covered by the combination of scales and hair. Often this is misdiagnosed as atopic dermatitis, but a closer look reveals char- The real prevalence of psoriasis is underestimated because acteristics of typical psoriasis, such as well demarcated borders some phenotypes, especially in children, can be misdiagnosed. and an absence of vesicles at any magnification. On the other One type of psoriasis seen very commonly by pediatric dermatolohand, even in minimal psoriasis, Auspitz s sign can be easily gists is napkin psoriasis (figure 1a). However, as many as 90% of cases of napkin psoriasis are misdiagnosed as napkin dermatitis, provoked after rubbing the suspected lesion. In the past, psoriasis which can be very different, such as papulo-erosive diaper dermatitis was believed to be rare in children; however, present-day (figure 1b). clinicians see it commonly in children in their practices. [8]

2 8 Gelmetti Dry skin is a common condition with a high impact on patients lives, and may affect individuals who are otherwise healthy. Dry skin may be particularly problematic in cases of ichthyosis, atopic dermatitis or psoriasis and is frequently linked to impaired skin barrier function. [13] Treatments such as moisturizers, which hydraa b 3. Quality of Life Psoriasis can range in severity or phenotype from single lesions to devastating cases, with varying effects on patients QOL. Psoriasis can affect all aspects of QOL, including physical, psychological, social, sexual, and occupational elements. [10] There is a high rate of suicide ideation associated with psoriasis, highlighting the severity of impact on QOL. [4,10] The National Psoriasis Foundation has published a classification system rating patients by severity of disease, from mild to severe; [11] those with severe psoriasis would be expected to experience severe impact on their QOL. [12] A major question in understanding psoriasis is whether the QOL of psoriatic patients can be predicted on the basis of their phenotype or physical findings, that is, whether the degree of QOL impairment relates directly to the objective severity of the disease. A literature review on the global impact of psoriasis on QOL between 1993 and 2005 found that social stigmatization, high stress levels, physical limitations, depression, employment problems, and other psychosocial co-morbidities are not always correlated with objective measures of disease severity, such as body surface area involvement or plaque severity. [10] Thus, the psychosocial burden of psoriasis is a crucial factor, independent of disease severity, and must be taken into account when evaluating patient QOL. 4. Moisturizers and Emollients in Psoriasis Fig. 1. Napkin psoriasis (a) and papulo-erosive diaper dermatitis (b). In the former, red, well demarcated areas affect the intertriginous areas, while in the latter, erosions are superimposed to erythematous papules and are prevalently located in the convex areas. 2. Pathogenesis of Psoriasis Regarding pathogenesis of psoriasis, recently the emphasis has shifted from T cells to innate (natural) immunity as a possible determining factor. Psoriasis appears to have a polygenetic origin. [9] Similar to a theory explaining the increase in the prevalence of atopic dermatitis, Bos hypothesizes that urbanized populations have been under evolutionary pressure selecting for increased innate immunity responses, as these responses offer relative but immediate protection from epidemic infections. [9] This is supported by the fact that morbidity due to infections is high among non-urbanized indigenous people, such as Inuit, Aborigines and Ami, while the prevalence of psoriasis is low or even absent. [9] Thus, increased immunity response could be linked to incidence of psoriasis. Fig. 2. Minimal psoriasis. The lips are glossy and, in some places, scaly. Angular cheilitis is also present together with a tiny erythematous desquamative area around the nose.

3 Adjuvant Therapeutic Moisturizers in Psoriasis 9 skin against further damage, minimizing the risk of complications and allowing more rapid recovery. Water-in-oil emollients are useful in treating chronic, plaquetype psoriasis and exert a steroid-sparing effect. [24] An open-label study of 96 patients with chronic plaque-type psoriasis demonstra- ted the efficacy of the addition of water-in-oil emollients to a topical corticosteroid. [24] Once-daily application of both be- tamethasone dipropionate cream and either a water-in-oil based cream or lotion was shown to be significantly more effective than once-daily application of betamethasone dipropionate cream alone (p = 0.05). The use of oil baths with emollients has also been shown to be a useful component of maintenance therapy in dry skin conditions, atopic eczema, psoriasis, and inflammatory dermatoses. [25] When used alone in patients with psoriasis, emollients have also been shown to inhibit the Koebner response (i.e. devel- opment of psoriatic lesions at the site of an injury). [26] Also, an emollient containing 10% urea was shown to be effective in the treatment of plaque-type psoriasis, reducing epidermal hyper- proliferation and inducing differentiation. [27] In addition to an efficient hydrating and lipid-replenishing effect on the skin, it is essential to minimize the risk of skin irritation or sensitization in the selection of emollients for dry skin conditions. [22] Emollients containing urea, lactic acid, and propyl- ene glycol may cause irritation. [19] te the skin, and emollients, which soften the skin, improve skin barrier function and may reduce exacerbations in dermatologic conditions. [13,14] The general conception of moisturizers is that they work from the top down, infusing moisture into the skin. In fact, moisturizers restore skin structure and function so that it is moisturized from the bottom up. [15] Most moisturizing products are composed primarily of water (65 85%), which functions as a solvent for hydrophilic moisturizing ingredients. The water evapo- rates during and shortly after application, leaving behind lipid components that help restore the skin moisture content. Emollient creams contain more oil and less water than other creams and lotions. [15] The therapeutic effect of moisturizers extends beyond a cos- metic impact in many skin disorders. Emollients and hydrating agents that soothe the stratum corneum can help relieve the clinical manifestations of dry skin. [16] In psoriasis, the use of moisturizers and emollients is an important part of the treatment strategy, as such treatments help to repair skin barrier function and permit rehydration of the stratum corneum. [17,18] Also, moisturizers have been shown to exert a steroid-sparing effect in patients with atopic dermatitis and psoriasis. [19] In these diseases, moisturizers can enhance the efficacy of topical corticosteroids and may prevent disease exacerbation. [19] In particular, certain moisturizers with a higher lipid content have been shown to significantly improve skin condition as assessed by clinical parameters. [19] Moisturizers represent a valuable first-line treatment option for many dermatologic diseases. Skin with psoriasis plaques has been shown to respond to moisturizers to a similar extent to healthy skin, although baseline values for distensibility and electrical capacitance were significantly lower for plaques. [20] Moisturizers were demonstrated to increase distensibility in both lesions and adjacent healthy skin, indicating that clinical differences between lesional and paralesional skin do not affect the efficacy of moisturizers. [20] Emollients used to treat ichthyoses, xeroderma and disorders of keratinization, atopic dermatitis, psoriasis, and photodamaged skin are the most prescribed products in dermatology. [21] Emollients can correct scaling disorders and may have suppressive effects on epidermal thickening; they are also known to have anti-inflammatory activity and provide transient relief from irritation. [21] Skin hydration tests, using corneometry to measure the electrical capacitance of the skin, have shown an increase in hydration values of more than 30% in patients with atopic diathesis using emollients daily for 4 weeks. [22] In an open-label study, the effects of an emollient cream were evaluated in treating patients with dermatoses characterized by dryness, roughness, scaling, and cracking of the skin. [23] The results showed that the emollient protected the 5. Treatment of Psoriasis Treatment of psoriasis should begin with an assessment of skin disease history, followed by recommendation of products that cleanse, soothe, and protect the skin (figure 3). Once inflammation Disease remission No signs or symptoms Flare Fig. 3. Psoriasis treatment algorithm. Assessment of disease history Include psychological distress and impact on family Emollients, moisturizers and education Control inflammation (topical/systemic drugs and/or UV) Maintenance therapy For disease persistence/ frequent recurrences Severe refractory disease Adjuvant therapy

4 10 Gelmetti Flare-ups should be addressed with medication, including vitamin D and its derivatives, retinoids, tars, topical calcineurin inhibitors, and corticosteroids, depending on the severity of the lesions, their location, and previous treatments, as well as adjuvant therapy (figure 3). Systemic therapy, including UV therapy, cyclosporine, methotrexate, biologics and other drugs, is required in a minority of patients, usually those with resistant or erythrodermic disease, pustular psoriasis or arthropathic psoriasis (figure 4). For patients who fail to respond, daycare or inpatient care may be appropriate. Phototherapy with UVB may be combined with topical agents. In this instance, since phototherapy is known to warm and dry the has been controlled, basic therapy for psoriasis should comprise skin hydration (regular use of moisturizers and emollients) with careful, gentle skin cleansing as well as identification and avoid- ance of Koebner phenomenon triggers (e.g. excoriation, maceration) and infectious foci (e.g. S. pyogenes). Koebner phenomenon can occur when the skin is dry enough to evoke lesions, which are then vulnerable to bacterial infection, triggering a psoriasis flare, particularly in children. skin, adjuvant treatment with emollients should be considered as an important part of the patient s management. While common plaque psoriasis can be treated effectively with topical agents such as coal tar, topical corticosteroids, anthralin (dithranol) or calcipotriol (figure 4), in milder forms simple petro- latum with salicylic acid may be sufficient to clear the skin of psoriatic scales (figure 5). With truly minimal psoriasis, emollients can bring about the same results. Emollients are highly indicated in these cases, as they prevent new dry skin lesions, consequent Koebner phenomena, and psoriasis flare-ups. Treatment should always be tailored according to patient age and the extent and distribution of psoriasis. Successful management of psoriasis in children, in particular, requires appropriate education of the child and parents regarding the course of the disease and treatment options; environmental triggers should also be sought out and eliminated whenever poss- ible. [8] 6. Safety of Psoriasis Treatment in Pregnancy Categories established by the US FDA indicate safety of drug use in pregnancy, ranging from A (safest) to X (least safe); with Fig. 4. Common plaque psoriasis. Fig. 5. Minimal psoriasis of the folds.

5 Adjuvant Therapeutic Moisturizers in Psoriasis 11 the caveat that regardless of FDA category, no drugs should be administered during pregnancy unless their benefits outweigh their risks. Topical agents such as dithranol (FDA category C) can be used on localized lesions, but tazarotene, calcipotriol, and tacrolimus (category X) should be avoided in pregnancy [28] (table I). Acitretin, methotrexate, and psoralens are to be avoided in pregnancy, while cyclosporine (category C) is judged to be relatively safe (although long-term data are lacking). [28] Recent meta-analyses suggest a small but significant associa- tion between the use of systemic corticosteroids during the first trimester and oral clefts. [29] No similar evidence exists for topical or inhaled corticosteroids, possibly owing to lower systemic expo- sure. Biological treatments for psoriasis are rated as FDA safety category B (adalimumab, etanercept, and infliximab) or C (efalizumab); however, there are no controlled studies in pregnant women and these are not recommended in pregnancy. [28] If one needs to use retinoids in women of childbearing age, it is recommended to use topical retinoids or isotretinoin combined with phototherapy rather than acitretin because of a shorter washout period with the former. Similarly, if one needs other immunosup- pressive therapy, cyclosporine should be considered rather than methotrexate, again because of a shorter washout period. [28] It is also recommended to induce a disease remission or to optimize control of psoriasis before conception. [28] In the interest of safety, we recommend using only moisturizers and emollients, local corticosteroids or local dithranol in pregnancy. Relatively safe options include cyclosporine for systemic treatment (not in breastfeeding mothers) and very potent cortico- Table I. Safety of psoriasis treatments in pregnancy or breastfeeding Safety category Topical treatments Systemic treatments Safe Moisturizers UVB Emollients Steroids Dithranol Relatively safe Coal tar Cyclosporine a Very potent corticosteroids (in small quantities) Unsafe Retinoids a,b Retinoids a,b Calcipotriol derivatives Methotrexate a,b Psoralen + UVA Unknown Fumaric acid esters a effects Biologic agents a Hydroxycarbamide a a To be avoided in breastfeeding women. b Recommended minimum systemic drug-free interval before conception: methotrexate 3 months in men and women, retinoids 2 years in women. steroids in small quantities for topical use. Treatment should be individualized for each patient, and minimized overall as much as possible in this population. 7. Conclusions Moisturizers and emollients are advocated in the following cases: minimal psoriasis, napkin psoriasis, psoriasis of the folds, psoriasic skin damaged by previous local treatments, in pregnancy, and in women of childbearing age. These groups constitute a large proportion of psoriasis patients. Moisturizers and emollients are useful adjuvant treatments and help remove scaly skin, which may make treatment more difficult. A more supple skin is more comfortable for the patient and also diminishes the risk for skin cracks and fissures, and consequent Koebner phenomenon. In patients insufficiently responsive to treatment, it should be investigated whether they have used mois- turizers in addition to topical medications such as corticosteroids. The use of corticosteroids and retinoids without concurrent mois- turizers may exacerbate dry skin, whereas increasing the elasticity of the skin prevents skin fissures and cracks, and the aggravation of psoriasis symptoms. Finally, a highly efficient moisturizer can often constitute suffi- cient treatment without the use of drugs associated with adverse effects. Moisturizers and emollients can often potentiate a topical treatment outcome, enhancing the efficacy of topical corticosteroids and preventing disease exacerbation as well as alleviating irritated skin. [19] Moisturizers and emollients are thus the safest option in alleviating signs and symptoms of psoriasis alone or as adjunctive to drugs. Acknowledgments No sources of funding were used to assist in the preparation of this review. The author has no conflicts of interest that are directly relevant to the content of this review. References 1. Plunkett A, Marks R. A review of the epidemiology of psoriasis vulgaris in the community. Australas J Dermatol 1998; 39 (4): Naldi L. Epidemiology of psoriasis. Curr Drug Targets Inflamm Allergy 2004; 3 (2): Psoriasis statistics. National Psoriasis Foundation [online]. 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