The Therapeutic Challenge of Treating Refractory Psoriasis: An Educational Article and Expert Opinion

Abstract

Background: Therapies that are commonly used in the treatment of refractory psoriasis include mycophenolate mofetil, methotrexate, acitretin, apremilast, and tofacitinib. The medications can be used in refractory psoriasis either as monotherapy or in combination with other medications. The use of biological medications such as infliximab and etanercept in the treatment of refractory psoriasis has been increasingly reported. Patients and methods: After one month, treatment with mycophenolate and topical calcipotriol was associated with improvement in the activity of skin disease and the arthritic symptoms, but there was no significant reduction the affected area of skin. Therefore, tazarotene 0.1% cream was added. At two months of treatment, both skin and joint symptoms were slightly worsening and the patient needed a non-steroidal anti-inflammatory medication to control joint symptoms. Acitretin was added in an initial dose of 10 mg daily with intention of increasing it to 25 mg daily gradually. However, on the fourth day after adding of oral acitretin the patient reported a significant reduction in the severity of the disease and the affected area that have not achieved long time ago. The patient also reported experiencing unpleasant taste that was attributed to acitretin. Conclusion: The current expert opinion suggests that the choice of the treatment of methotrexate and mycophenolate refractory psoriasis should be based on the available evidence, and it generally depends mostly on the availability and cost of the medications, and the experience of the treating physician with the available medications. In cases of resistance to methotrexate, and mycophenolate, acitretin can be added mycophenolate, and the use of newer safe biological agents such as etanercept and Infliximab can be considered.