Professional Documents
Culture Documents
Objectives
Psoriasis
Chronic skin disorder; "itch"
= psora
Incidence
Other derm conditions
Psoriasis
Epidermal hyperproliferation 2O to
activation of immune system
Altered maturation of skin
Inflammation
Vascular changes
Background
Epidemiology
Age
Genetic
Scandinavian/European descent
Risk Factors
Psoriasis, an inherited
disease
N
O
R
M
A
L
STRATUM
CORNEUM
STRATUM
GRANULOSUM
STRATUM
SPINOSUM
P
Disorganized
S
O Neutrophil
R accumulation
I
A
S Immaturity
I
S Proliferation
STRATUM
BASALE
DERMIS
10
11
Psoriasis: Associated
Factors
Genetic Factors:
- 30% of people with psoriasis have had
psoriasis in family
- Autosomal dominant inheritance
Nongenetic Factors:
- Mechanical, ultraviolet, chemical injury
- Infections: Strep, viral, HIV
- Prescription Drugs, stress, endocrine,
hormonal, obesity, alcohol, smoking
12
Clinical Presentation
13
14
Psoriasis: Clinical
Presentation
15
Psoriatic Plaque
16
17
Erythrodermic Psoriasis
18
Nail changes
19
Guttate Psoriasis
20
Nail Changes
22
Psoriatic Arthritis
In 10-20% of psoriasis patients
Peripheral interphalangeal joints
No elevated serum levels of
rheumatoid factors (as seen in
rheumatoid arthritis, yet has all
other features)
Often seen in patients with nail
23
and scalp psoriasis
0 = none
1 = minimal
2 = mild
3 = moderate
4 = severe
24
5 = very severe
25
Reason dermatologists
do not use more
aggressive therapies2
Safety concerns
Time consuming
Cost
Leonardi, 2003;
Other
therapies
54%
Topicals
only
46%
26
Psoriasis: Treatment
Lubrication
Removal of scales
Slow down lesion proliferation
Pruritus management
Prevent complications
Lessen patient stress
Season and climate
27
S te p 1
CoalTar
A n t h r a l in
Supplementary
Tx
T o p i c a l S t e r o id
C a lc ip o t r ie n e
C lim a t o t h e r a p y
T a z a ro te n e
M o is t u r iz e r s
I n t r a l e s i o n a l S t e r o id
K e r a t o ly t ic s
Step 2
P U V A +
S te p 1 a g e n t
PUVA
Step 3
A c it r e t in
M e th o tr e x a te
C y c lo s p o r in e
R o t a t i o n a l:
1 2 -2 4 m o n th s
o f e ach
s te p 3 a g e n t
Step 4
Enbrel/Remicade/Amevive/Raptiva
28
Treatment
Annual Cost
Steroids
500-2,000
Dovonex
2,000-8,000
UVB
1,850
PUVA
3,300
Soriatane
6,150
Methotrexate
1,500-2,150
Cyclosporine
4,800
Biologics
10,000-15,000
29
Emollients and
Moisturizers
Keratolytics = SKIN
LIFTERS
31
Tars
Coal Tar
Coal Tar
34
Corticosteroids
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
Betamethasone dipropionate
Mometasone furoate
Diflorasone diacetate
Fluocinonide
Desoximetasone
Halog crm
Cylocort oint
Diprolene AF crm
Elocon oint
Florone oint
Lidex crm,gel,oint
Topicort crm,oint,gel
Mild to high
Halcinonide
Triamcinolone acetonide
Betamethasone dipropionate
Fluocinonide
Halog oint,crm,soln
Aristocort A oint
Diprosone crm
Lidex-E crm
36
Corticosteroids
Level of
Potency
Corticosteroid
Commercial Products
Mild
Hydrocortisone valerate
Triamcinolone acetonide
Flurandrenolide
Mometasone furoate
Fluocinolone acetonide
Westcort
Kenalog crm and oint
Cordran oint
Elocon crm
Synalar oint
Low to mild
Hydrocortisone valerate
Triamcinolone acetonide
Flurandrenolide
Betamethasone dipropionate
Hydrocortisone butyrate
Flucolone acetonide
Westcort crm
Kenalog crm and oint
Cordran crm
Diprosone lotion
Locoid crm
Synalar crm
Low
Alclometasone dipropionate
Aclovate crm and oint
Betamethasone valerate
Valisone lotion
Fluocinolone acetonide
Synalar soln and crm
Hydrocortisone, dexamethasone,
prednisolone, methylprednisolone
37
Corticosteroids
Corticosteroids
Systemic absorption
Dermal atrophy
Telangiectasis
Ecchymoses
Peri-orbital acne
Poor wound healing
Pyogenic infections
39
Vitamin D3
Vitamin D3
Adverse Effects:
Hypercalcemia
Hypercalciuria
Mild calcitriol intoxication: renal
stones
Not for long term use, therefore
analogues were developed
41
Vitamin D3 Analogue
Calcipotriene (Dovonex)
Vitamin D3 Analogues
Calcipotriene (Dovonex)
43
Retinoids
Vitamin A derivatives
MOA:
1. Normalization of abnormal
keratinocyte differentiation
2. Reduction in keratinocyte
proliferation
3. Reduction in inflammation
44
Oral Retinoids
45
Soriatane : Dosage
46
Soriatane : Precautions
Soriatane
33% of patients had an elevation of AST (SGOT),
Hepatotoxicity ALT (SGPT) or LDH
Black Box Warning
Alopecia
50-75% of patients
49
Topical Retinoids
Tazarotene (Tazorac)
Third generation retinoid
Stable plaque psoriasis (up to 20%
of body surface area involvement)
Severe facial psoriasis
Water based emollient gel or
cream
50
Tazarotene (Tazorac)
Counseling points
Apply sunscreen
52
Methotrexate
FOLIC ACID
METHOTREXATE
54
Response to Methotrexate
Methotrexate: Precautions
Contraindicated:
Pregnancy, lactating mothers
Renal & liver problems
Preexisting severe anemia,
leukopenia,
thrombocytopenia
Alcoholics
Active infectious disease
56
Methotrexate: Dosage
Methotrexate: Adverse
Effects
Cyclosporine
Cyclosporine: Dosage
Cyclosporine:Adverse
Effects
Phototherapy
Phototherapy
Ultraviolet B
Relatively non-toxic
Can be used as a single-agent
Usually combined with lubricants
Ingrams regimen (Anthralin)
Goeckermans regimen (Tar)
63
Phototherapy
64
Phototherapy
65
Phototherapy
66
Phototherapy
67
PUVA
2.
3.
Oral PUVA
Psoralen = P in PUVA = a
photosensitizer
Methoxsalen (Oxsoralen-Ultra, 8-MOP)
10 mg capsules
Given 2 hours before UVA irradiation
Symptomatic control of severe,
recalcitrant disabling psoriasis, not
responsive to other therapy after
69
PUVA
Phototoxicity
First Generation
Biologicals
72
73
TNF Inhibitors
New Therapies
Alefacept (Amevive)
Inhibits CD45RO+
memory effector T
lymphocytes, by binding
to their CD2 receptor
also leads to apoptosis
Administered IV or IM
qweek x12 wks
AE: dizziness, chill,
nausea, cough
75
No binding
Amevive binds to activated T cells
76
Amevive response
77
Amevive Cautions
79
Raptiva
Efalizumab (Raptiva) is
a humanized
monoclonal antibody of
CD11a that works by
blocking T-cell binding
and trafficking into the
dermis and epidermis.
FDA approved October
29, 2003
80
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Raptiva