Ciclosporin for psoriasis

The use of ciclosporin reflects the importance of your immune system in the psoriatic process. It is a drug that is used to alter the body’s immune response and hence helps to prevent the rejection of transplants. A transplant patient with psoriasis noticed that the psoriasis improved dramatically with ciclosporin, and it was tried with success in non-transplant patients. It has an effect on only part of the immune system, specifically suppressing a chemical called interleukin-2, so it does not increase the risks of infection in the way that other immunosuppressant drugs (e.g. steroids) do. There are some concerns about a possible increased risk of developing cancer after long-term treatment, so careful follow-up is usually advised even after treatment has ended. Transplant patients do have an increased risk of some cancers, but they have much larger doses of ciclosporin.

Like all drugs, ciclosporin has the potential for side-effects, the main problems being possible kidney damage and high blood pressure. Both of these unwanted effects are reversible (i.e. kidney function and blood pressure will return to normal) if they are detected early, so regular monitoring is essential. We hope that you are also having regular blood tests to look at your kidney function. The blood pressure often does rise a little with this drug, but as long as your kidneys are OK you can continue with the treatment. It can be so successful that patients are reluctant to stop it, so occasionally an additional drug can be given to control the blood pressure without long-term risks.

There are a number of lesser side-effects that can be a great nuisance. These include pins and needles in the fingers, a mild tremor (shaking or trembling) and nausea, but these usually occur early in treatment and improve if it is continued. More troublesome
can be extra hair growth and enlargement of the gums. The former can be particularly upsetting for women as it is not just scalp hair that grows but other body hair as well, and they may stop treatment because of it. Enlargement of the gums is more common if dental hygiene is poor so can be minimised by regular visits to the dentist.

Ciclosporin does interact with a number of oral treatments but not with topical ones. This interaction means that the side-effects of ciclosporin are more likely to occur, or it may not work at all. This is because the other drugs can alter enzymes in the body that affect how quickly you get rid of ciclosporin – too quickly and it will not work, too slowly and you will get many more unwanted effects. You must tell any doctor who is treating you that you are taking

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Avoid buying over-the-counter drugs in shops where there is no pharmacist to advise you, and do not take herbal or other remedies for which the effects are unknown. The common problem drugs are:

• antibiotics – erythromycin (a common antibiotic) should be avoided but penicillin is safe;
• antifungals – itraconazole is a drug used to treat fungal and yeast infections such as ringworm or thrush;
• painkillers – aspirin and related drugs including ibuprofen (Advil, Brufen and Nurofen) and mefenamic acid (Ponstan) should be avoided, but paracetamol is safe;
• antimalarials – chloroquine can interact so avoid it if travelling abroad;
• blood pressure tablets – diltiazem is one to avoid;
• tablets for epilepsy – carbamazepine and phenytoin.

How long will I have to take ciclosporin for?

This depends on how severe your psoriasis is and how well you tolerate and respond to the drug. There are two ways to use ciclosporin – short-term/intermittent or long-term maintenance. In general, if your psoriasis is not too severe, you will be offered treatment for 4–12 weeks to try to clear your skin. Once your skin has cleared, the ciclosporin will be stopped, but you could have other short courses if it recurs. If your psoriasis is severe or keeps coming back very soon after a short course, you will probably need maintenance treatment. In this case, you could start in the same way but the dose will be reduced as your skin clears, down to the lowest dose that keeps it clear or keeps it at a level you are happy with.

Using a moisturiser will always help your skin to feel more comfortable. There are good reports of using calcipotriol cream (Dovonex) with low-dose ciclosporin, so you could try this.

Hydroxycarbamide for psoriasis

There is a drug called hydroxycarbamide (it used to be called hydroxyurea) that is used in cases like yours. It does not cause any liver or kidney problems but can affect the bone marrow and hence your ability to produce new blood cells. This is thought to be more of a risk than that posed by the other drugs, so it is not used as a first choice. Treatment is usually given in courses of up to 8 weeks, but weekly blood tests are needed to check for side-effects.