Term
| Basic Information and Clinical Presentation: Psoriasis |
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Definition
chronic autoimmune skin disorder
T-lymphocyte mediated inflammatory disease
thickened red patches covered by silvery-white scales
results from a rapid skin growth (7x's faster than normal)
usually a series of exacerbations and remissions
it is not curable - long-term remissions are possible
5% of patients will also have joint paint - psoriatic arthritis |
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Term
| Common sites of psoriasis |
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Definition
scalp
elbows
trunk
lower extremities
usually symmetrical |
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Term
| Pathophysiology of psoriasis |
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Definition
defects in epidermal cell cycle
38 hour vs. normal 300 hour cycle |
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Term
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Definition
stress
cold environment
smoking
diet
injury
infection
drugs (ACE, NSAID, lithium) |
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Term
| Goals of Therapy for Psoriasis |
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Definition
reduce inflammation and slow down rapid skin cell division
achieve a clearing of the lesions
use topical therapy over systemic therapy if possible
treatment is based on patients: health, age, lifestyle, and severity of psoriasis
prolong periods between exacerbations |
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Term
| General treatment measures |
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Definition
Sun exposure - beneficial, but avoid prolonged exposure and sunburn
Baths - warm water soak with bath oils or oatmeal can soften lesions and reduce itching
Emollients - should be applied 3 - 4 times daily
Treatment is a step-wise approach |
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Term
| Step One - topical therapy |
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Definition
Most effective at treating localized plaques covering less than 20% of BSA
70% of patients will only receive topical therapy |
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Term
| List of mild topical therapies |
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Definition
emollients
keratolytics
corticosteroids
vitamin D analogues
tazarotene |
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Term
| Topical Salicylic Acid for Psoriasis |
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Definition
Mild, first line therapy
Available as a gel or lotion in strengths ranging from 2 - 10%
Used 2 - 3 times daily
Acts as a keratolytic that:
-sloughs off dead skin
-removes the scale and smooths the skin |
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Term
| Overview of Moderate Psoriasis Treatment |
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Definition
First-line topical therapy - same as mild
Second-line topical therapy
-coal tar
-anthralin
-topical calcineurin inhibitors
Phototherapy
-UVB +/- coal tar or anthralin
-only if topical treatment is inadequate |
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Term
| Overview of Treatment for Severe Psoriasis |
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Definition
Phototherapy
-PUVA + psoralen
First-line systemic therapy
-tumor necrosis factor inhibitors
-T cell activation inhibitors
Second-line systemic therapy
-methotrexate
-oral retinoids
-cyclosporin |
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Term
| Basic Treatment Scheme for Moderate to Severe Psoriasis |
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Definition
combination therapy
rotational therapy
sequential therapy
helps to reduce ADR's and long-term risks associated with treatment |
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Term
| Mechanism of Action of Topical Corticosteroids |
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Definition
anti-inflammatory
anti-pruritic
anti-proliferative
immunosuppressant
decreases scaling, erythema, pruritis |
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Term
| Choosing a topical corticosteroid for psoriasis |
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Definition
they are all relatively inexpensive
surface area to be covered
severity of the condition
vehicle to be used
fluocinolone shampoo - Capex |
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Term
| Application of Topical Corticosteroids for Psoriasis |
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Definition
Only 1% can be absorbed when applied to normal skin
Occlusion helps to enhance penetration
-plastic wrap and T-shirt
-increases penetration 10x's
-leave on for 6 hours |
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Term
| Disadvantages of Topical Corticosteroids |
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Definition
Can develop tolerance to the anti-inflammatory activity with repeated use (tachyphylaxis)
May alternate with other topical medications to avoid tolerance |
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Term
| Use of Very High/High Potency Corticosteroids for Psoriasis |
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Definition
Use only for very severe lesions and on thickened skin when maximum penetration is needed
Do NOT use on the face
Avoid using a super-potent agent for more than 2 weeks
Limit to no more than 50 grams per week
Switch to mid-potency products after initial treatment |
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Term
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Definition
Dovonex cream & ointment 0.005%
Topical vitamin D3 derivative that inhibits cell proliferation and enhances cell differentiation by inhibiting cytokine production
Potency is similar to mid-potency corticosteroids
Minimal toxicity: irritation and rash
Does not alter serum Ca levels
No tachyphylaxis - use for off weeks from corticosteroids
Apply twice daily for 6 - 8 weeks
Expensive |
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Term
| Patient Education for Calcipotriene |
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Definition
Apply a small amount - just enough to cover the affected area
Apply gently - do not rub aggressively
Wash hands before and after applying
Leave on for only the prescribed length of time
Protect bed clothes and linens |
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Term
| Second line topical therapy for psoriasis |
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Definition
Coal Tar
Anthralin
Topical calcineurin inhibitors |
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Term
| Coal Tar for Psoriasis Treatment |
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Definition
Induces transient epidermal hyperplasia, then slows cell growth by inhibiting DNA
Available as creams, lotions, ointments, gels, and shampoos |
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Term
| Disadvantages of Coal Tar |
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Definition
Smell
Staining of clothing
Messy to use
May discolor hair and skin |
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Term
Crude Coal Tar 2 - 10%
LCD Solution 5 - 20% |
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Definition
Used for compounded Rx's
Apply in the evening and allow to remain on at night
Cover area to protect clothing and linens |
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Term
| Coal Tar Shampoo 0.5 - 10% |
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Definition
Pentax, Denorex, Tegrin, Polytar, DHS tar, Neutrogena T/Gel
Leave on scalp for 5 - 10 minutes then rinse off
May stain white hair |
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Term
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Definition
| soak in bath for 10 - 20 minutes |
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Term
| Phototherapy for Psoriasis |
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Definition
Immunomodulatory effect
Approximately 20% of patients will require more than topical therapy
For patients with disease on great than 20% of BSA |
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Term
| Coal Tar & UVB Phototherapy for Psoriasis |
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Definition
Light enhances the activity of the coal tar
Goeckerman therapy - all day occlusive coal tar followed by light therapy
Narrow band UVB is now utilized
UVB radiation alone or with topical agents can cause skin aging and skin cancer |
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Term
| PUVA therapy for Psoriasis |
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Definition
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Term
| Methoxsalen for Psoriasis |
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Definition
0.6 - 0.8 mg/kg given orally 2 hours before UVA exposure
2 - 3 treatments per week
Acts as a photosensitizer
Controls 90% of patients - superior to UVB alone
Potentially more risks, skin damage |
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Term
| When to use systemic therapy for psoriasis |
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Definition
Patients with recalcitrant, widespread plaque-psoriasis
May induce long-term remissions
Often very expensive - make sure patient can afford
Risk of long-term side effects may be significant
-may be life threatening
-rotation of therapies may minimize side effects |
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Term
| T-cell activation inhibitors for psoriasis |
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Definition
Alefacept (Amevive) - admin IV or IM on a weekly schedule
Efalizumab (Raptiva) - admin SC on a weekly schedule
Ustekinumab (Stelara) - admin SC weeks 0 and 4, then every 12 weeks |
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Term
| TNF-aplha inhibitors for psoriasis |
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Definition
Adalimumab (Humira) - admin SC once weekly
Infliximab (Remicade) - admin IV every 2 weeks
Etanercept (Enbrel) - admin SC twice weekly |
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Term
| Risks of Systemic Therapy in Psoriasis |
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Definition
Headache, nausea, fever, chills, fatigue, flu-like symptoms, injection site discomfort
Long-term: risk of malignancies
Monitor: signs and symptoms of infection or bleeding |
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Term
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Definition
Systemic therapy for psoriasis
Oral retinoid, similar to Accutane
10 - 50 mg daily
Dry skin, mouth, lips
Arthralgias
Monitor LFTs |
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Term
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Definition
Systemic therapy for psoriasis
Immunosuppresant
Dosed weekly
Cost is reasonable
Monitor LFTs and CBC
Pregnancy category X |
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Term
| Side Effects of Methotrexate |
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Definition
Nausea
Sunburn
Mouth ulcers
Bone marrow suppression
Risk of liver toxicity |
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Term
| Cyclosporine (Sandimmune; Neoral) |
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Definition
Systemic therapy for psoriasis
Immunosuppressant
Dosed twice daily
Very expensive
Monitor renal function |
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Term
| Side effects of Cyclosporin |
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Definition
Nephrotoxicity (max 2 years)
Gingival hyperplasia
Hypertension
GI upset
Parasthesias |
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Term
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Definition
systemic therapy for psoriasis
immunosuppressant
dosed twice daily
very expensive
monitor renal function |
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Term
| Side effects of Tacrolimus |
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Definition
Diarrhea
Parasthesias
Insomnia
Nephrotoxicity
GI upset |
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