AN APPROACH TO THE TREATMENT OF MODERATE TO SEVERE PSORIASIS WITH ROTATIONAL THERAPY

Background. There are four standard approaches for treating moderate to severe psoriasis: UVB plus tar, PUVA, methotrexate, and etretinate. Although patients with psoriasis receive these therapies for many years, there is no commonly accepted approach for the initial and subsequent selection of the alternatives. Objective. Our purpose was to develop a theoretical and practical basis for using these treatments that will minimize the risks of their long-term toxicities and prolong their safe long-term use. Methods: A review of the published side effects of the treatments and cumulative clinical experience are used to develop an approach for the treatment of severe psoriasis. Results. It is proposed that patients receive each form of therapy for 1 to 2 years and then switch to the next form of treatment. By rotating each of the three or four treatments at these time intervals, it may well be 4 or 5 years before needing to return to the first therapy, thereby minimizing cumulative toxicity by long periods off each treatment. Conclusion: Rotation of available therapies for moderate to severe psoriasis may minimize long-term toxicity and allow effective treatments to be maintained for many years.