Psoriasis Diagnosis and management - Welcome to … · 2018-06-22 · upper respiratory tract streptococcal infection 1,2 1. ... – Patients may become febrile, hypo/hyperthermic

CHAPTER:5PSORIASIS

BYMrs. K.SHAILAJA., M. PHARM.,LECTURERDEPT OF PHARMACY PRACTICE,SRM COLLEGE OF PHARMACY

OVERVIEW 2

5. Case studies

4. Managing psoriasis

3. Diagnosing psoriasis

2. Clinical presentation

1. Epidemiology and pathophysiology

WHAT IS PSORIASIS? 3

– Inflammatory and hyperplastic disease of skin1

– Characterised by erythema and elevated scaly plaques1

– Chronic, relapsing condition

– Course of disease often unpredictable

5

19

21

29

31

71

79

94

0 20 40 60 80 100

Other

Fatigue

Burning sensation

Bleeding

Tightness of skin

Skin redness

Itching

Scaling

Percentage of respondents (n = 17,425)

SYMPTOMS OF PSORIASIS 4

Most frequently experienced symptoms

SOCIAL IMPACT OF PSORIASIS

40

48

57

0 10 20 30 40 50 60Percentage of respondents with severe psoriasis (n = 502)

5

Psoriasis mistaken for other disease

Trouble receiving equal treatment in

service establishments (e.g. hair salons,

public pools)

Psoriasis mistaken as contagious

PSORIASIS AFFECTS EMOTIONAL STATE

54

75

81

88

0 20 40 60 80 100

Depression

Feelings of unattractiveness

Feelings of embarrassment

Concern that disease would worsen

Percentage of 18-to-34-year-old respondents with severe psoriasis (n not reported)

6

EPIDEMIOLOGY

• Common skin disorder

• Prevalence variable: ~ 0.3–2.5%1

• Prevalence equal in males and females2

• Estimated incidence: ~ 60 per 100,000 per year3

1. Plunkett A et al. Australas J Dermatol 1998; 39: 225–232. 2. Griffiths CEM et al. In: Burns T et al., eds. Rook’s textbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Bell LM et al. Arch Dermatol 1991; 127: 1184–7.

7

AGE OF ONSET

• Mean age: ~ 23–37 years1

• Current theory: 2 distinct peaks with possible genetic associations1

– Early onset (16–22 years)2

• More severe and extensive

• More likely to have affected first-degree family member

– Late onset (57–60 years)2

• Milder form

• Affected first-degree family members nearly absent

1. Plunkett A et al. Australas J Dermatol 1998; 39: 225-232. 2. Henseler T et al. J Am Acad Dermatol 1985; 13:450-6.

8

GENETIC INFLUENCE

• Evidence suggests strong genetic association

– Studies of monozygotic twins show concordance for psoriasis (e.g. 64% in a Danish Study)1

– Multiple susceptibility loci have been identified2

• Disease expression – likely result of genetic and environmental factors2

1.Brandup F et al. Acta Dermato-Vernerol 1982; 62L: 229–36. 2. Barker J. Clin Exp Dermatol 2001; 26(4): 321–5.

9

COMMON TRIGGER FACTORS FOR PSORIASIS1

• Infections (e.g. streptococcal, viral)• Skin trauma (Koebner phenomenon)• Psychological stress • Drugs (e.g. lithium, beta blockers)• Sunburn• Metabolic factors (e.g. calcium deficiency)• Hormonal factors (e.g. pregnancy)

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

10

PSORIASIS IS A T-CELL MEDIATED, AUTOIMMUNE DISEASE1

• Current hypothesis:

– Unknown skin antigens stimulate immune response• Antigen-specific memory T-cells are primary mediators

– Leads to impaired differentiation and hyperproliferation of keratinocytes

1. Lee M et al. Australas J Dermatol 2006; 47: 151–9.

11

PATHOPHYSIOLOGY 12

CLINICAL PRESENTATION: CLASSIC PSORIASIS

13

– Well-defined and sharply demarcated1,2

– Round/oval-shaped lesions1,3

– Usually symmetrical1,3

– Erythematous, raised plaques1–3

– Covered by white, silvery scales1–3

1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

COMMON SITES AFFECTED BY PSORIASIS

14

• Can affect any part of the body –typically scalp, elbow, knees and sacrum1

• Extent of disease varies

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

TYPES OF PSORIASIS

• Chronic plaque• Guttate• Flexural• Erythrodermic

• Pustular– Localised and generalised

• Local forms– Palmoplantar

– Scalp

– Nail (psoriatic onychodystrophy)

15

1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed. Australian medicines handbook. Adelaide: AMH, 2010.

CHRONIC PLAQUE PSORIASIS 16

– Most common type –affects approximately 85%1

– Features pink, well-defined plaques with silvery scale2

– Lesions may be single or numerous2

– Plaques may involve large areas of skin2

– Classically affects elbows, knees, buttocks and scalp3

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.




GUTTATE PSORIASIS 20

– Numerous and small lesions – ~ 1 cm diameter1,2,3

– Pink with less scale than plaque psoriasis1

– Commonly found on trunk and proximal limbs1,3

– Typically seen in individuals < 30 years4

– Often preceded by an upper respiratory tract streptococcal infection1,2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

FLEXURAL PSORIASIS 21

– Lesions in skin folds1

– Particularly groin, glutealcleft, axillae and submammary regions

– Often minimal or absent scaling1,2

– May cause diagnostic difficulty when genital or perianal region is affected in isolation

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. SchonMP et al. N Engl J Med 2005; 352(18): 1899–912.

ERYTHRODERMIC PSORIASIS 22

– Generalised erythemacovering entire skin surface1,2

– May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon1,3

– Patients may become febrile, hypo/hyperthermicand dehydrated3

– Complications include cardiac failure, infections, malabsorption and anaemia1

– Relatively uncommon

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

PUSTULAR PSORIASIS 23

– Two forms:

• Localised form

• More common1,2

• Presents as deep-seated lesions with multiple small pustules on palms and soles1,2

• Generalised form

• Uncommon3

• Associated with fever and widespread pustules across inflamed body surface3

1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds. Rook’s textbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

PALMOPLANTAR PSORIASIS1 24

– Can be hyperkeratotic or pustular

– May mimic dermatitis –look for psoriatic manifestations elsewhere to aid diagnosis

– Possibly aggravated by trauma

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

SCALP PSORIASIS 25

– Varies from minor scaling with erythema to thick hyperkeratotic plaques1,2

– May extend beyond hairline1,2

– Patient scratching may produce asymmetric plaques2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

NAIL PSORIASIS1 26

– May be present in patients with any type of psoriasis

– Can take several forms:

• Pitting: discrete, well-circumscribed depressions on nail surface

• Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate

• Onycholysis: nail separates from nail bed at free edge

• ‘Oil-drop sign’: pink/red colour change on nail surface


NAIL PSORIASIS 27

NAIL PSORIASIS 28

NAIL PSORIASIS 29

PSORIATIC ARTHRITIS 30

– Approximately 5–20% have associated arthritis1

– Five major patterns of psoriatic arthritis:2

• Distal interphalangealinvolvement

• Symmetrical polyarthritis

• Psoriatic spondylarthropathy

• Arthritis mutilans

• Oligoarticular, asymmetrical arthritis

– Clinical expressions often overlap2

1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

DIAGNOSING PSORIASIS

• Other dermatological disorders can resemble psoriasis

• Diagnosed clinically according to appearance, distribution, history of lesions and family history

• Important to consider non-cutaneouscomplications1

1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

31

DIFFERENTIAL DIAGNOSIS1,2

• Localisedpatches/plaques

– Tinea– Eczema– Superficial basal cell

carcinoma and Bowen’s disease

– Seborrhoeic dermatitis– Cutaneous T-cell lymphoma

(mycosis fungoides)

• Guttate– Pityriasis rosea– Drug eruption– Secondary syphilis

• Flexural– Tinea– Eczema– Candidiasis– Seborrhoeic dermatitis

• Erythrodermic– Eczema– Cutaneous T-cell lymphoma– Pityriasis rubra pilaris– Lichen planus– Drug

• Palmoplantar– Tinea

32

1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

LOCALISED PATCHES/PLAQUES 33

– Tinea corporis1

• Affects body

• Lacks symmetrical lesions

• Presence of peripheral scale and central clearing


Tinea coporis Psoriasis


– Discoid eczema1

• Individualised patches more pruritic than psoriasis

• Lack silvery scale

• Less vivid colour than psoriasis


Discoid eczema Psoriasis


– Superficial basal cell carcinoma/Bowen’s disease1,2

• Asymmetrical lesions, either single or few in number

• Perform biopsy if lesions resistant to topical psoriasis treatment, or to confirm diagnosis

1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

Bowen’s disease Psoriasis


– Seborrhoeic dermatitis

• Characterised by yellowish scaling and erythema1

– Localised to many of the same areas as psoriasis

• Diffuse scaling differs from sharply defined psoriasis plaques2

• Affects furrows of face (facial psoriasis is generally restricted to hairline)1

1. Marks R et al. Dermatology within the pharmacy. Australia: Department of Dermatology, St Vincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

Dermatitis

Psoriasis


– Cutaneous T-cell lymphoma (mycosis fungoides)

• Red, discoid lesions1

• Asymmetrical and less scaly than psoriasis1

• Lesions may present with fine atrophy and be resistant to antipsoriatic therapy2

• Biopsy to confirm diagnosis

1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

Mycosis fungoides

Psoriasis


– Pityriasis rosea1

• Difficult to distinguish from acute guttate psoriasis

• Presents first as single large patch, progresses to a truncal rash of multiple red scaly plaques (‘Christmas tree’ distribution)

• Resolves over 8–12 weeks


< Psoriasis ^ Pityriasis rosea


– Secondary syphilis

• Search for characteristic primary syphilitic lesion, lymphadenopathy, and lesions of face, palm and soles1

• Conduct serology and skin biopsies to confirm1,2

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003.

< Psoriasis ^ Secondary syphilis


– Atopic eczema1,2

• Often associated with asthma and hay fever

• Lacks classic psoriatic nail involvement and sharply demarcated scaly plaques

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor. 16 April 2010: 29–36.

< Psoriasis ^ Atopic eczema


– Candidiasis1,2

• Characteristic peripheral pustules and scaling differ to psoriasis

• Yeast cultures are diagnostic

– Seborrhoeic dermatitis2

1. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

Flexural psoriasis

PALMOPLANTAR PSORIASIS 42

– Tinea manum1

• Ringworm of hands

• Fine powdery scale, particularly involving palms and palmar creases

• Usually asymmetrical


Tinea corporis Psoriasis


– Hand and foot eczema

• Hyperkeratotic forms difficult to distinguish from psoriasis1,2

• Biopsies can assist diagnosis1

• Look for history of atopy, a lack of psoriasis elsewhere on body, and evidence of eczema elsewhere on skin1

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003.

Eczema

Psoriasis


– Pompholyx of palms and soles (dishydroticeczema)1

• Presents as clear vesicles – contrast to white/yellow pustules in pustularpsoriasis

• Accompanied by intense pruritus


Eczema

Psoriasis

DETERMINING PSORIASIS SEVERITY

• Psoriasis Area and Severity Index (PASI)1

– Score indicates severity of disease at a given time

– Single number that considers severity of lesions and extent of disease across four major body sites (head, trunk, upper limbs and lower limbs)

– Score ranges from 0 (no disease) to 72 (maximal disease)

1. Dubertret L. Psoriasis from clinic to therapy. France: Med’com, 2005.

45

MANAGING PSORIASIS

• Before starting treatment– Establish relationship of trust with patient1

– Provide patient with information

• Emphasise benign nature of disease2,3

• Explain that psoriasis tends to be chronic and recurrent2,3

1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

46

MANAGING PSORIASIS

• Determine clinical setting before selecting treatment, considering

– Disease pattern, severity and extent1,2

– Sites of disease2

– Coexistent medical conditions1

– Patient’s perception of disease severity1

– Time commitments and treatment expense1,2

– Previous treatments for psoriasis1

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

47

MANAGING PSORIASIS

• Goals of management– Tailor management to individual and address both medical and

psychological aspects1–3

– Improve quality of life3

– Achieve long-term remission and disease control3

– Minimise drug toxicity3

– Evaluate and monitor efficacy and suitability of individual treatments3

– Remain flexible and respond to changing needs1–3

1.Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

48

TREATMENT OPTIONS FOR PSORIASIS

• Stepwise approach is advised1

• Treatments include:1,2,3

– General measures and topical therapy

– Phototherapy

– Systemic and biological therapies

• Combination therapies may reduce toxicity and improve outcomes2

1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

49

TREATING PSORIASIS: GENERAL MEASURES1,2

• Reduce/eliminate potential trigger factors:– Stress

– Smoking

– Alcohol

– Trauma

– Drugs

– Infections


50

TOPICAL THERAPIES

• Approximately 70% of patients with mild-to-moderate psoriasis can be managed with topical therapies alone1

• Tailor to needs of patient2

• Potency, delivery vehicle and patient motivation may affect compliance1

• Application may be time-consuming for patients1


51

TOPICAL THERAPIES: EMOLLIENTS

• Include aqueous cream, sorbolene cream, white soft paraffin and wool fats1

• Regular use can:– alleviate pruritus2

– reduce scale2

– enhance penetration of concomitant topical therapy2

– hydrate dry and cracked skin3

• Soap should be avoided4

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Rossi S, ed. Australian medicines handbook. Adelaide: AMH, 2010. 4. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

52

TOPICAL THERAPIES: KERATOLYTICS

• Over-the-counter products include:1– Salicylic acid

– Urea

• Help dissolve keratin to soften and lift psoriasis scales1,2

• May enhance penetration of other actives1


53

TOPICAL THERAPIES: COAL TAR

• Help reduce inflammation and pruritus1

• May induce longer remissions2

• Use limited by distinctive smell and ability to stain clothing and skin1,2

• May cause local skin irritation2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

54

TOPICAL THERAPIES: DITHRANOL

• Anti-proliferative properties1

• Particularly effective in thick plaque psoriasis1

• Initiate therapy at very low concentrations – can burn skin2

• Not suitable for face, flexures or genitals1,3

• Stains clothes permanently and skin temporarily1,2,3

1. Dermatology Expert Group. Therapeutic Guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R,ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

55

TOPICAL THERAPIES: TAZAROTENE

• Topical synthetic retinoid1,2

• For treatment of chronic plaque psoriasis1,2

• Applied once daily in evening1,2

• Commonly causes local irritation1,2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. ZoracProduct Information, 30 March 2007.

56

TOPICAL THERAPIES: CORTICOSTEROIDS

• Possess anti-inflammatory, antiproliferative and immunomodulatory properties1,2

• Reduce superficial inflammation within plaques3

• Potency choice depends on disease severity, location and patient preference2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009.

57

TOPICAL THERAPIES: CORTICOSTEROIDS

• Adverse effects associated with long-term use include:1,2

– Skin atrophy and telangiectasia

– Hypopigmentation

– Striae

– Rapid relapse or rebound on stopping therapy

– Precipitation of pustular psoriasis

– Pituitary-adrenal axis suppression through significant systemic absorption (rare)


58

TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX®)

• Synthetic vitamin D analogue1

• For chronic plaque-type psoriasis1

• Reverses abnormal keratinocyte changes by:1– Inducing differentiation

– Suppressing proliferation of keratinocytes

1. Daivonex Product Information, 23 September, 2006.

59

TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX®)

• Response may require 4–6 weeks1,2

• Adverse effects include erythema and irritation3

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. DaivonexProduct Information, 23 September, 2006.

60

TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONEDIPROPIONATE OINTMENT (DAIVOBET®)

• For plaque-type psoriasis1

• Combination of calcipotriol and a potent topical corticosteroid (betamethasone dipropionate)1

– Stable formulation for both actives1

• Provides rapid, effective psoriasis control1,2

1. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.

61


Adapted from Kaufmann R et al. Dermatology 2002; 205(4): 389–93.

62

– Combination of calcipotriol and betamethasone dipropionate in Daivobet is more effective than either active constituent used alone

• 39.2% mean reduction in PASI score after 1 week


• Once-daily treatment with the potential to improve compliance1,2

• Can be used intermittently in 4-weekly cycles with Daivonex® used in between for maintenance1

• Most common adverse events include pruritus, rash and burning sensation1

1. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.

63

TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE GEL

• Newly TGA approved product not yet available in Australia

• Specially formulated for the scalp1

• Provides rapid, effective control of scalp psoriasis1,2,3

– More effective than treatment with individual actives alone

– 53.2% (more than half) of patients had absent or very mild disease after just two weeks of gel application1

• Once-daily formulation may encourage compliance2

1. Daivobet ®Gel Product Information, 14 July 2010. 2. van de Kerkhof et al. BJD 2008; 160: 170–6. 3. Jemec GBE et al. J Am Acad Dermatol 2008; 59:455-463.

64

OTHER THERAPIES

• Phototherapy

• Systemic therapies

• Biological agents

65

PHOTOTHERAPY

• For psoriasis resistant to topical therapy and covering > 10% of body surface area1

• Immunomodulatory and anti-inflammatory effects2

• Three main types of phototherapy:2– Broadband UVB

– Narrowband UVB

– PUVA (administration of psoralen before UVA exposure)

• Treatment usually administered 2–3 times/week1,2

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

66

SYSTEMIC THERAPIES

• Reserved for patients with widespread or severe psoriasis1

• Potentially serious adverse effects and drug interactions2

• Many require PBS authority prescription from dermatologist3

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Department of Health and Ageing. Schedule of Pharmaceutical Benefits. http://www.pbs.gov.au (accessed online 14 August 2010).

67

SYSTEMIC THERAPIES: METHOTREXATE

• Most commonly used systemic treatment for psoriasis1

• Slows epidermal cell proliferationand acts as immunosuppressant1

• Closely monitor kidney, liver and bone-marrow function2

• Perform PASI score before starting treatment

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Methoblastin Product Information, 11 August 2004.

68

SYSTEMIC THERAPIES: CYCLOSPORIN

• Immunosuppressive agent1

• For patients with severe psoriasis that is refractory to other treatments2

• Requires ongoing monitoring of blood elements, and renal and liver function2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Neoral Product Information, 22 October 2009.

69

SYSTEMIC THERAPIES: ACITRETIN1

• Oral retinoid

• For treatment of all forms of severe psoriasis

• Once-daily oral therapy

• Teratogenic – pregnancy must be avoided

1. Neotigason Product Information, 18 March 2008.

70

BIOLOGICAL AGENTS

• Proteins derived from living organisms that exert pharmacological actions1

• For adults with moderate-to-severe chronic plaque-type psoriasis who are candidates for phototherapy or systemic therapy2–5

• Most administered sub-cutaneously2–5

1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Humira Product Information, 18 September 2009. 3. StelaraProduct Information, 15 July 2009. 4. Remicade Product Information, 17 September 2008. 5. Enbrel Product Information, 16 February 2010.

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Documents

Psoriasis Diagnosis and management - Welcome to … · 2018-06-22 · upper respiratory tract streptococcal infection 1,2 1. ... – Patients may become febrile, hypo/hyperthermic