Pharmacotherapy Psoriasis

8/18/2019 Pharmacotherapy Psoriasis

http://slidepdf.com/reader/full/pharmacotherapy-psoriasis 1/37

Pharmacotherapy

PSORIASIS

Yani Mulyani, M.Si, apt

Yani Mulyani - STFB



Komponen

Definisi

Pathofisiology

Clinical Presentation

Diagnosis

Desired outcome

Treatment

Evaluation of theurapeutic outcomes

Yani Mulyani - STFB



Definisi

• Jenis penyakit gangguan imun, yang mempengaruhitampilan pada kulit

• Penyakit tidak menular ini ditandai oleh lesiperadangan yang ditutupi dengan keropeng putih

perak dari kulit mati.• Psoriasis disebabkan sel-sel kulit menua dalam waktu

kurang dari seminggu.

• Karena tubuh tidak dapat melepaskan kulit tua secepat

sel-sel baru meningkat ke permukaan, pengelupasankulit mati menimbulkan keropeng yang berkembang dilengan, punggung, dada, siku, kaki, kuku, lipatan antarapantat, dan kulit kepala.

Yani Mulyani - STFB



Tingkatan Psoriasis

• Mild/Ringan, jika mempengaruhi kurang dari

5% dari permukaan tubuh,

• Sedang/moderat, jika 5-30% dari kulit yang

terlibat, dan

• Parah/severe , jika penyakit memengaruhi

lebih dari 30% dari permukaan tubuh.

Yani Mulyani - STFB



What is the genetic risk of psoriasis?

• 41% if both parents have psoriasis

14% if one parent

4% if no genetic link

Yani Mulyani - STFB



Penginduksi Psoriasis

Penyebab Diinduksi Oleh

The main climatic trigger of psoriasis

is? Cold, dry weather

The primary drug triggers of psoriasis

are?

ACE inhibitors

Beta-blockers

Chloroquine

Progesterone

Lithium

Indomethacin

Corticosteroid withdrawel

The primary infectious triggers of

psoriasis are?

Streptococcal (strep throat, tonsillitis)

HIV

HPV (ED form)

NSAID that can improve psoriasis? Meclofenamate

Yani Mulyani - STFB



ICAM, Intracellurar ce;; adhesion molecules

APCs, Antigen Presenting Cell

LFA, Leucocyte function associated type 3Yani Mulyani - STFB



Phatofisiology

T Cell,diproduksibanyak

T cell diikatkuat oleh

ICAM padasel endhotel

MerangsangPelepasanAntigen APC,Aktivated TCELL

Kehadiran LFA-3-CD2,MeningkatProliferation TCell . SaatAktivasi T Cell,MeningkatInterleukin,

Cytokines,dll,..yangmenginisiasiInflamasi diKULIT

PSORIASIS

Yani Mulyani - STFB



In which layer of the skin does

psoriasis begin?

In the basal layer ofthe epidermis where

keratinocytes form.

Yani Mulyani - STFB



Clinical Presentation

Yani Mulyani - STFB



Yani Mulyani - STFB



Yani Mulyani - STFB



Psoriasis: Clinical Presentation

Type CharacteristicsPlaque psoriasisGuttate psoriasis

Erythrodermicpsoriasis

PustularpsoriasisNail psoriasis

Palmar/PlantarpsoriasisPsoriatic arthritis

Scalp psoriasis

Dry scaling patches (AKA common psoriasis) 75%Drop-like dots, occurs after strep or viral infection 12%

Exfoliation of fine scales (total body “dandruff”),widespread, often accompanied by severe itching andpain 7%Pus-like blisters, noninfectious, fluid contains white bloodcells 2%Seen on toenails and fingernails, starts as numerous pits,

at times progresses to yellowing, crumbly, and thickenednail; nails may sloughErythema, thickening and peeling of the skin, blistering isoften present. Can lead to disability.Inflammation, swelling, and joint destruction

Plaque-type lesionYani Mulyani - STFB



Psoriatic Plaque

Yani Mulyani - STFB



Chronic Plaque Psoriasis

Yani Mulyani - STFB



Erythrodermic Psoriasis

Yani Mulyani - STFB



Nail changes

Yani Mulyani - STFB



Guttate Psoriasis

Yani Mulyani - STFB



Nail Changes

• In 78% of psoriatic patients

• Fingernails>Toenails

• Four changes

1. Onycholysis (= separation from nail bed)

2. Pitting*

3. Subungual debris accumulation

4. Color alterations

*Pitting rules out a fungal infectionYani Mulyani - STFB



DIAGNOSIS

Physical examination

BSA (body surface Area)

Psoriasis Area and Severity Index

Yani Mulyani - STFB



OLA Photonumeric Guidelines(overall lesion assessment)

0 = none

5 = very severe4 = severe3 = moderate

1 = minimal 2 = mild

Yani Mulyani - STFB



Desired Outcome

Caranya???

• Mencegah Aktivasi T Cell

• Menghambat Kerja dari

Inflammatory agent

• Menurunkan Imun

• Mengurangi pembentukan

Keratin

• Membuang Keratin yangg

terbentuk

Outcome

Yani Mulyani - STFB



1 Leonardi, 2003; 2 Market Measures/Cozint LLP, June 2003.

Othertherapies

54%

Topicalsonly

46%

The Majority of Moderate-Severe Psoriasis Patients Are

Under-Treated

• 50% of patients with moderate orworse disease are currentlyuntreated1

– 46% have topical therapy only• Reason dermatologists

do not use moreaggressive therapies2

–

Safety concerns – Time consuming

– Cost

Yani Mulyani - STFB



Psoriasis: Treatment

• Lubrication

• Removal of scales

•

Slow down lesion proliferation• Pruritus management

• Prevent complications

• Lessen patient stress• Season and climate

Yani Mulyani - STFB



Treatment

Non Pharmacology

Pharmacology Treatment

Yani Mulyani - STFB



Non Pharmacology

• Mengurangi stress

• Memberikan Pelembab

• Menggunakan Jenis

sabun khusus• Sunscreen

Yani Mulyani - STFB



Pharmacology Treatment

Korticosteroid

Keratolytic

Keratonycte proliferation inhibitor

Phototherapy (UV a dan UV B)

Photochemotherapy (Broadband UV B)

Systemic Therapies

BRM (biologic response modifiers)

Yani Mulyani - STFB



Algorithm Treatment Of Psoriasis

Mild to Moderate

Yani Mulyani - STFB



Algorithm Treatment Of Psoriasis

For Severe

Yani Mulyani - STFB



Step 1

Anthralin Calcipotriene

Coal Tar

Tazarotene Intralesional Steroid

Topical Steroid

Climatotherapy Moisturizers Keratolytics

Step 2

PUVA PUVA +Step 1 agent

Acitretin

Step 3

Methotrexate Cyclosporine

Rotational:12-24 months

of eachstep 3 agent

Supplementary

Tx

Step 4

Enbrel/Remicade/Amevive/Raptiva

Yani Mulyani - STFB



Corticosteroid

Betamethasone

Amcinonide

Triamcinolone

Fluticasone,

Dll

Yani Mulyani - STFB



Corticosteroids

Level of Potency Corticosteroid Commercial Products

Ultra-high Halobetasol propionate

Clobetasol propionate

Betamethasone dipropionate

Diflorasone diacetate

Ultravate crm/oint

Temovate crm/oint

Diprolene oint

Psorcon oint

High Halcinonide

Amcinonide


Mometasone furoate

Diflorasone diacetateFluocinonide

Desoximetasone

Halog crm

Cylocort oint

Diprolene AF crm

Elocon oint

Florone ointLidex crm,gel,oint

Topicort crm,oint,gel

Mild to high Halcinonide

Triamcinolone acetonide


Fluocinonide

Halog oint,crm,soln

Aristocort A oint

Diprosone crm

Lidex-E crmYani Mulyani - STFB



Corticosteroids

Level of Potency Corticosteroid Commercial Products

Mild Hydrocortisone valerate


Flurandrenolide

Mometasone furoateFluocinolone acetonide

Westcort

Kenalog crm and oint

Cordran oint

Elocon crmSynalar oint

Low to mild Hydrocortisone valerate


Flurandrenolide


Hydrocortisone butyrateFlucolone acetonide

Westcort crm

Kenalog crm and oint

Cordran crm

Diprosone lotion

Locoid crmSynalar crm

Low Alclometasone dipropionate

Betamethasone valerate

Fluocinolone acetonide

Hydrocortisone, dexamethasone,

prednisolone, methylprednisolone

Aclovate crm and oint

Valisone lotion

Synalar soln and crm

Yani Mulyani - STFB



Inhibitor keratinocyte

Calcipotriene

Tazarotene

Anthralin

Coal tar

Asam salisilat

Yani Mulyani - STFB



Phototherapy

Yani Mulyani - STFB





( l bl TNF t )Yani Mulyani STFB

Documents

Pharmacotherapy Psoriasis