Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Dermatol. Feb 2, 2016; 5(1): 17-51
Published online Feb 2, 2016. doi: 10.5314/wjd.v5.i1.17
Psoriasis treatment: Unconventional and non-standard modalities in the era of biologics
Vikram K Mahajan
Vikram K Mahajan, Department of Dermatology, Venereology and Leprosy, Dr. R. P. Govt. Medical College, Kangra, Tanda 176001, Himachal Pradesh, India
Author contributions: Mahajan VK contributed to concept, literature review and analysis, drafting and critical revision, editing and final approval.
Conflict-of-interest statement: No potential conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Dr. Vikram K Mahajan, MBBS, MD, Department of Dermatology, Venereology and Leprosy, Dr. R. P. Govt. Medical College, Kangra, Tanda 176001, Himachal Pradesh, India.
Telephone: +91-1892-287161 Fax: +91-1892-267115
Received: August 17, 2015
Peer-review started: August 19, 2015
First decision: October 13, 2015
Revised: October 25, 2015
Accepted: December 17, 2015
Article in press: December 18, 2015
Published online: February 2, 2016

Psoriasis is a potentially debilitating inflammatory dermatosis affecting 0.2%-4.8% of the population worldwide causing a significant occupational, personal or psychosocial morbidity to these patients for life. The basic aim of psoriasis therapy is to control the disease to maximum possible extent and improve the patient’s quality of life. Management of triggers for flare-ups, lifestyle modifications, and dietary supplements are often recommended. Intermittent or rotational therapy with frequent alterations in treatment options is usually needed to reduce toxicity of anti-psoriatic drugs in the absence of safer alternatives. Currently, several biological agents categorized as either T-cell targeted (e.g., Alefacept, Efalizumab) or cytokine modulating (e.g., Adalimumab, Infliximab, Etanercept) are available for treating severe psoriasis. However, their high cost is often precluding for most patients. The usefulness of systemic (methotrexate, cyclosporine, acitretin or several other therapeutic agents) or topical (tar, anthralin, corticosteroids or calcipotriol ointments, phototherapy with or without psoralens) therapies has been well established for the management of psoriasis. The literature is also replete with benefits of less used non-standard and unconventional treatment modalities (hydroxycarbamide, azathioprine, leflunomide, mycophenolate mofetil, isotretinoin, fumarates, topical calcineurin inhibitors, peroxisome proliferator-activated receptors agonists, statins, sulfasalazine, pentoxifylline, colchicine, grenz ray therapy, excimer laser, climatotherapy and balneophototherapy, peritoneal dialysis, tonsillectomy, ichthyotherapy, etc.). These can be used alternatively to treat psoriasis patients who have mild/minimal lesions, are intolerant to conventional drugs, have developed side effects or achieved recommended cumulative dose, where comorbidities pose unusual therapeutic challenges, or may be as intermittent, rotational or combination treatment alternatives.

Keywords: Acetretin, Azathioprine, Balneophototherapy, Calcineurin inhibitors, Calcipotriol, Calcium dobesilate, Climatotherapy, Colchicine, Cyclosporine, Dapsone, Excimer laser, Fumarates, Grenz ray therapy, Hydroxycarbamide, Ichthyotherapy, Isotretinoin, Leflunamide, Methotrexate, Mycophenolate mofetil, Pentoxifylline, Peritoneal dialysis, Phototherpy, Plaque psoriasis, Peroxisome proliferator-activated receptors agonists, Statins, Sulfasalazine, Tonsillectomy

Core tip: The clinicians must be aware of all available antipsoriasis therapies in view of variable therapeutic outcome(s) that may test one’s ingenuity in managing some “difficult to treat” psoriasis patients. The nonstandard and off-label therapies will remain an important alternative to more widely used measures in rotational/intermittent treatment(s) or until a therapy that is affordable, safe, effective, and more importantly, remittiv becomes available.