Treatment Research in the past decade has led to "new, highly effective targeted therapies," with phase III data or regulatory approval. They make use of research into how immune cells like T cells and dendrocytes travel, and how they use chemical signals (cytokines) to interact with each other. The drugs follow two strategies: anti-T cell strategies and anticytokine strategies. Two drugs that target T cells are efalizumab and alefacept. Efalizumab (which is no longer marketed) is a monoclonal antibody which blocks the molecules that dendritic cells use to communicate with T cells. It also blocks the adhesion molecules on the endothelial cells that line blood vessels, which attract T cells. However, it suppressed the immune system's ability to control normally harmless viruses, which led to fatal brain infections. Alefacept also blocks the molecules that dendritic cells use to communicate with T cells, and even causes natural killer cells to kill T cells, as a way of controlling inflammation. Several monoclonal antibodies (MABs) target cytokines, the molecules that cells use to send inflammatory signals to each other. One of the main inflammatory signals in the body is tumor necrosis factor α (TNF-α), and three MABs -- infliximab, adalimumab and etanercept bind to TNF-α. Two more inflammatory signals are interleukin-23 and interleukin-12. A protein chain, p40, is the same on both of those interleukins, and the monoclonal antibody ustekinumab binds to that common protein to interfere with both of them. There can be substantial variation between individuals in the effectiveness of specific psoriasis treatments. Because of this, dermatologists often use a trial-and-error approach to finding the most appropriate treatment for their patient. The decision to employ a particular treatment is based on the type of psoriasis, its location, extent and severity. The patient’s age, sex, quality of life, comorbidities, and attitude toward risks associated with the treatment are also taken into consideration. In 2008, the FDA approved three new treatment options available to psoriasis patients: 1) Taclonex Scalp, a new topical ointment for treating scalp psoriasis; 2) the Xtrac Velocity excimer laser system, which emits a high-intensity beam of ultraviolet light, can treat moderate to severe psoriasis; and 3) the biologic drug adalimumab (brand name Humira) was also approved to treat moderate to severe psoriasis. Adalimumab had already been approved to treat psoriatic arthritis. Medications with the least potential for adverse reactions are preferentially employed. If the treatment goal is not achieved then therapies with greater potential toxicity may be used. Medications with significant toxicity are reserved for severe unresponsive psoriasis. This is called the psoriasis treatment ladder. As a first step, medicated ointments or creams, called topical treatments, are applied to the skin such as Zithranol-RR, which contains anthralin microencapsulated into a formulation of polar lipids that provide rapid release for short contact therapy (5-15 min). If topical treatment fails to achieve the desired goal then the next step would be to expose the skin to ultraviolet (UV) radiation. This type of treatment is called phototherapy. The third step involves the use of medications which are taken internally by pill or injection. This approach is called systemic treatment. Over time, psoriasis can become resistant to a specific therapy. Treatments may be periodically changed to prevent resistance developing (tachyphylaxis) and to reduce the chance of adverse reactions occurring. This is called treatment rotation. Antibiotics are generally not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis. Topical application of avocado oil based cream containing vitamin B12 has been shown to be an effective treatment without serious side effects[32], however presently no pharmaceutical companies are willing to produce this ointment. Cognitive behaviour therapy A psychological symptom management programme has been reported as being a helpful adjunct to traditional therapies in the management of psoriasis.[33]. In the UK The Psoriasis and Psoriatic Arthritis Alliance (PAPAA) a not-for-profit charity has funded research carried out by the University of Manchester, to develop a symptom management programme called Electronic Targeted Intervention for Psoriasis (eTIPs) using a modified Cognitive Behaviour Therapy model. This research follows research by Fortune D G et al.[34] on psychological stress, distress and disability in patients with psoriasis. Topical treatment Bath solutions and moisturizers, mineral oil, and petroleum jelly may help soothe affected skin and reduce the dryness which accompanies the build-up of skin on psoriatic plaques. Medicated creams and ointments applied directly to psoriatic plaques can help reduce inflammation, remove built-up scale, reduce skin turn over, and clear affected skin of plaques. Ointment and creams containing coal tar, dithranol (anthralin), corticosteroids like desoximetasone (Topicort), fluocinonide, vitamin D3 analogues (for example, calcipotriol), and retinoids are routinely used. Argan oil has also been used with some promising results. The mechanism of action of each is probably different but they all help to normalise skin cell production and reduce inflammation. Activated vitamin D and its analogues are highly effective inhibitors of skin cell proliferation. The disadvantages of topical agents are variably that they can often irritate normal skin, can be time consuming and awkward to apply, cannot be used for long periods, can stain clothing or have a strong odour. As a result, it is sometimes difficult for people to maintain the regular application of these medications. Abrupt withdrawal of some topical agents, particularly corticosteroids, can cause an aggressive recurrence of the condition. This is known as a rebound of the condition. Some topical agents are used in conjunction with other therapies, especially phototherapy. Phototherapy It has long been recognized that daily, short, non-burning exposure to sunlight helped to clear or improve psoriasis in some patients. Niels Finsen was the first physician to investigate the therapeutic effects of sunlight scientifically and to use selected portions of the solar spectrum in clinical practice. This became known as phototherapy. Sunlight contains many different wavelengths of light. It was during the early part of the 20th century that it was recognised that for psoriasis the therapeutic property of sunlight was due to the wavelengths classified as ultraviolet (UV) light. Ultraviolet wavelengths are subdivided into UVA (380–315 nm) UVB (315–280 nm), and UVC (< 280 nm). Ultraviolet B (UVB) (315–280 nm) is absorbed by the epidermis and has a beneficial effect on psoriasis. There are two types of UVB lamps: Narrowband UVB (311 to 312 nm), and Broadband (Wideband, or "FS" type) UVB (290-320 nm). UVB Broadband is more erythemal and therefore requires shorter exposure time, while UVB Narrowband does not include the spectrum of less than 300 nanometers, allowing much higher doses without erythema, and thus considered safer. The UVB Narrowband lamp was developed by Philips Lighting specifically to match the action spectrum of psoriasis, with a sharp emission peak at 311 nm, to have increased effectiveness compared to broadband lamps.[36] Exposure to UVB several times per week, over several weeks can help people attain a remission from psoriasis. Sometimes it is needed to continue the treatments once a week as maintenance, or the chronic disease will return. In hospitals, ultraviolet light treatment is frequently combined with topical (coal tar, calcipotriol) or systemic treatment (Retinoids) as there is a synergy in their combination. The Ingram regime involves UVB and the application of anthralin paste. The Goeckerman regime combines coal tar ointment with UVB. Because coal tar includes unknown ingredients that might cause cancer, and is a time intensive treatment, the use of coal tar has fallen out of favor. Photochemotherapy Psoralen and ultraviolet A phototherapy (PUVA) combines the oral or topical administration of psoralen with exposure to ultraviolet A (UVA) light. Precisely how PUVA works is not known. The mechanism of action probably involves activation of psoralen by UVA light which inhibits the abnormally rapid production of the cells in psoriatic skin. There are multiple mechanisms of action associated with PUVA, including effects on the skin immune system. PUVA is associated with nausea, headache, fatigue, burning, and itching. Long-term treatment is associated with squamous cell carcinoma (not with melanoma). Systemic treatment Psoriasis that is resistant to topical treatment and phototherapy is treated by medications that are taken internally by pill or injection. This is called systemic treatment. Patients undergoing systemic treatment are required to have regular blood and liver function tests because of the toxicity of the medication. Pregnancy must be avoided for the majority of these treatments. Most people experience a recurrence of psoriasis after systemic treatment is discontinued. The three main traditional systemic treatments are methotrexate, cyclosporine and retinoids. Methotrexate and cyclosporine are immunosuppressant drugs; retinoids are synthetic forms of vitamin A. Other additional drugs, not specifically licensed for psoriasis, have been found to be effective. These include the antimetabolite tioguanine, the cytotoxic agent hydroxyurea, sulfasalazine, the immunosuppressants mycophenolate mofetil, azathioprine and oral tacrolimus. These have all been used effectively to treat psoriasis when other treatments have failed. Although not licensed in many other countries, fumaric acid esters have also been used to treat severe psoriasis in Germany for over 20 years. Biologics are manufactured proteins that interrupt the immune process involved in psoriasis. Unlike generalised immunosuppressant therapies such as methotrexate, biologics focus on specific aspects of the immune function leading to psoriasis. These drugs (interleukin antagonists) are relatively new, and their long-term impact on immune function is unknown, but they have proven effective in treating psoriasis and psoriatic arthritis. They include Amevive, Enbrel, Humira, Remicade and Raptiva. Raptiva was withdrawn by its maker from the US market in April, 2009. Biologics are usually given by self-injection or in a doctor's office. They are very expensive and only suitable for very few patients with severe psoriasis. Ustekinumab (IL-12 and IL-23 blocker) shows hopeful results for psoriasis therapy. In the United Kingdom in 2005 the British Association of Dermatologists (BAD) published guidelines for use of biological interventions in psoriasis [37] .A UK national register called the BAD Biological Register (BADBIR) has been setup to collect valuable information on side effects and benefits and will be used to inform doctors on how best to use biological agents and similar drugs. Alternative therapy Climatotherapy involves the notion that some diseases can be successfully treated by living in a particular climate. Several psoriasis clinics are located throughout the world based on this idea. The Dead Sea is one of the most popular locations for this type of treatment. Another treatment is ichthyotherapy, which is practised at some spas in Turkey, Croatia (Altermedica) & Ireland. In this therapy, doctor fish are encouraged to feed on the psoriatic skin of people with psoriasis. The fish, which live in outdoor pools, only consume the affected areas of the skin. The outdoor location of the spa may also have a beneficial effect. This treatment can provide temporary relief of symptoms. A revisit to the spas every few months is often required. Treatment in this hot spring has been examined in two small clinical trials, with positive results.Oregon-grape (Mahonia Aquifolium) is said to be effective in the treatment of eczema and psoriasis.