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Putting Out Psoriasis Flares

One of the frustrating aspects of living with a chronic disease like the skin disorder psoriasis is that, out of nowhere, symptoms can get abruptly worse. Whereas treatment can lead to a remission of several years and the disappearance of the itchy, red plaques that characterize psoriasis, other times the disease can come back as soon as someone stops therapy. Occasionally, psoriasis worsens even when someone is in treatment.

When psoriasis worsens significantly, it is said to "flare." According to the National Psoriasis Foundation Medical Advisory Board, a psoriasis flare has occurred when the disease is 125 percent worse than it was before. The frequency and severity of flares depends upon the individual and how they are being treated.

Therapy for psoriasis includes topical creams, light therapy, medications that suppress the immune system, and biologic therapies, which target the immune system malfunctions that cause the disease to occur. Below, Jerry Bagel, MD, a dermatologist at the Psoriasis Treatment Center of Central New Jersey, and Paul Yamauchi, MD, PhD, a dermatologist in private practice in California, explains when flares usually occur and how people can cope with them.

What is psoriasis?
PAUL YAMAUCHI, MD, PhD: Psoriasis is an autoimmune disease, meaning that even though your immune system's important for fighting off infections and tumors, in psoriasis, your immune system is so active it produces too much inflammation and skin, thereby causing your skin to grow too fast. Consequently, you form these inflammatory lesions on your skin that are called psoriasis.

JERRY BAGEL, MD: There are essentially four different types of psoriasis. The most common type of psoriasis is plaque-type psoriasis, where the shape of the lesion is like a plaque; it's a raised, elevated piece of skin with sharply demarcated borders that have a shiny scale on the surface that's red. If it's covering less than 5 percent of the body's surface area, it's localized psoriasis. If it's between 5 and 15 percent, it's moderate or moderate to severe psoriasis. If it's covering more than 15 or 20 percent of the body surface area it becomes severe.

On what parts of the body is psoriasis found?
PAUL YAMAUCHI, MD, PhD: Psoriasis most commonly affects the elbows, the knees and the scalp, but it can occur in any part of the body. It can even affect the nails where you get little pits in the nails.

What can trigger psoriasis?
JERRY BAGEL, MD: The most common is strep infections, such as strep throat, ear infections and urinary tract infections. In addition, stress factors play an essential role in the initial onset of psoriasis or exacerbating existing psoriasis. Many patients can trigger the onset of psoriasis with a stressful event such as loss of a loved one, car accident, severe medical problem, divorce, loss of job.

In addition, there are certain medications that can make psoriasis worse. When the patient goes off of prednisone, their psoriasis can get significantly worse. Lithium and antimalarials can also make psoriasis worse. And some people believe that beta blockers, which are used in hypertension and in migraine headaches, can make psoriasis worse.

What is a psoriasis flare?
JERRY BAGEL, MD: The definition of a psoriasis flare is when a person with psoriasis gets worse. If a patient has localized psoriasis, and they move to moderate or severe psoriasis, that's clearly a flare. And at that point, different treatments need to be implemented.

When does psoriasis flare?
JERRY BAGEL, MD: Psoriasis can flare independently of any known risk factors. But in general, people tend to get worse in the winter than they do in the summer. In the summer people with psoriasis can go outside and get extra exposure to ultraviolet light, which is helpful, whereas in the wintertime they tend to be inside. In addition, in the winter their skin tends to be drier. They can be more itchy, scratch more, and the trauma that occurs from scratching can result in exacerbating psoriasis.

PAUL YAMAUCHI, MD, PhD: A person on certain psoriasis medications can improve quite dramatically, but when you stop the medication, the psoriasis comes right back; it's sometimes rip-roaring and that can be very frustrating.

How often do flares occur?
JERRY BAGEL, MD: The frequency of flares is dependent upon the individual. Some people can have low-grade psoriasis, and then it flares. If they treat it appropriately, they can do well for a few years. Other people are treated for a flare, go into remission, and flare again two to three months later because their psoriasis is that severe. But if you want an average, I think many people with severe psoriasis, who have it over 20 percent of their body, stay clear with good treatment for about six months, and then they flare again.

What is the pattern of flares for people with mild psoriasis?
JERRY BAGEL, MD: The treatment of localized psoriasis is topical therapy. Topical steroids are pretty much the mainstay of topical therapy, but we have used vitamin D derivatives such as Dovonex (calcipotriene) for the past 15 years with lots of benefit.

In general, these treatments are suppressive, so they do not result in much remission. Some people might stay clear for a couple of weeks and others people might not respond to topicals at all.

How soon after phototherapy do people flare?
JERRY BAGEL, MD: People who have more than 10 percent of their body surface area covered with psoriasis are candidates for phototherapy, which includes narrow band UVB and PUVA, as well as broadband UVB, but we're not using that as much now because narrow band works better. If patches are thin, people can come in three times a week for about 25 treatments and clear. If you pick your patients properly, you're probably going to get a six-month remission. But most people won't get six months' remission if they have real thick plaques. If you go with PUVA, where you have to take pills before you come in for ultraviolet light, one go-around would involve about 25 treatments. You can expect six months' remission, and many patients stay clear on PUVA for about a year.

Do people flare after taking the immunosupressant medications cyclosporin and methotrexate?
JERRY BAGEL, MD: Cyclosporin and methotrexate are suppressive so when a patient is discontinued from both of those two medications, their psoriasis will recur in about six weeks and will be as bad as it was before they started their treatment.

How often do people flare on biologic treatments?
JERRY BAGEL, MD: In the 40 percent of people who do very well with one 12-week course of Amevive (alefacept), they can stay very clear for six months. In fact, I've had some people stay clear for a year. And I see people continue to get better up to 12 to 24 weeks after they've discontinued the last dose, and when they start to flare, it's a very slow recurrence of their psoriasis, close to back to where it was in the beginning.

PAUL YAMAUCHI, MD, PhD: There are biologics that must be given continuously. Raptiva (efalizumab), when abruptly stopped, can potentially result in a flare-up of the psoriasis. With Enbrel (etanercept), if a patient had to stop it, and the psoriasis did not flare up, patients can be in remission at least three months.

Does a flare during any type of treatment mean the therapy isn't working?
JERRY BAGEL, MD: It takes time for most medications to help people with psoriasis. Depending upon the medication, it could take two weeks to eight weeks. So just because your psoriasis might be getting worse initially does not mean that the therapy's not working.

When should patients change therapies when flares occur?
JERRY BAGEL, MD: Primary therapy does not necessarily have to be stopped if people are getting worse. It depends if the flare is significant. If it's the natural progression of the disease getting worse and hasn't responded to therapy yet, you just hang in there or add something else because it's not working quickly enough. But if you see someone who's doing well on therapy and then they get significantly worse, yes, then you should probably switch your therapy around.