Psoriasis Treatment & Overview PDF

Psoriasis  Definition & Epidemiology  Psoriasis is a chronic, proliferative skin disease  Plaque psoriasis is the most prevalent psoriasis  It is characterized by well-delineated, thickened erythematous epidermis or dermal plaques covered with a distinctive silvery scale.  Geneti...

Psoriasis  Definition & Epidemiology  Psoriasis is a chronic, proliferative skin disease  Plaque psoriasis is the most prevalent psoriasis  It is characterized by well-delineated, thickened erythematous epidermis or dermal plaques covered with a distinctive silvery scale.  Genetics plays a role in its development and certain environmental factors can exacerbate this disease.  Although psoriasis can manifest at any age, a bimodal age distribution exists at ages 18 to 39 and 50 to 69 years.  Pathogenesis  Psoriatic plaques are defined by epidermal hyperplasia, leukocyte infiltration, and changes in dermal microvasculature  Differentiation and activation of immune-mediated response systems are disrupted in psoriasis, resulting in an increase in the number of proliferating keratinocytes.  Prognosis  patients with psoriasis experience a reduced quality of life related to an impairment of social, psychological, and physical functioning.  Although psoriasis is a treatable disease, there is no known cure  Shared decision-making :  patient preference should play a primary role in determining treatment because of the potentially awkward and messy topical treatments or systemic medications that have significant adverse effects  Aim of therapy  The goal of therapy should be to achieve complete clearing of psoriatic lesions or a satisfactory improvement for the individual patient.  Risk factors  Most patients report that hot weather, sunlight, and humidity help clear psoriasis, whereas cold weather has an adverse effect on its course.  Anxiety or psychological stress is believed to contribute adversely  Viral or bacterial infections may precipitate the onset or flare-up of psoriasis.  Trauma to the skin (i.e., cuts, burns, abrasions, etc.) can elicit the development of lesions.  Plaque psoriasis  Plaque psoriasis typically presents as sharply demarcated, erythematous, scaly patches or plaques, which are often symmetrical  The most commonly affected areas include the trunk, scalp, gluteal folds, elbows, and knees; however, plaque psoriasis can occur anywhere on the body including nail beds.  Erythrodermic psoriasis  The most severe form of the disease is erythrodermic psoriasis, a condition of acute inflammatory erythema and scales involving >90% of the body surface area (BSA).  Pustular psoriasis  Pustular psoriasis is generally localized to the palms and soles, but there is also a generalized version.  Guttate psoriasis  Lesions of guttate psoriasis are small, fine, erythematous scales, usually found on the trunk, arms, or legs, classically after β- hemolytic streptococcal pharyngitis  Psoriatic arthritis  Psoriatic arthritis is a seronegative inflammatory arthritis that occurs in ~25% of all patients with psoriasis.  Drug-Induced Psoriasis examples Drug category Amoxicillin, ampicillin, penicillin's, Antimicrobial agents sulfonamides, tetracycline's, vancomycin Corticosteroids (after withdrawal), Anti-inflammatory drugs NSAIDs (indomethacin, salicylates) Chloroquine, hydroxychloroquine Antimalarial agents Cimetidine, ranitidine H2 -antagonists Oxandrolone, progesterone Hormones Potassium iodide, mercury, Lithium Miscellaneous carbonate  Classification of Psoriasis  Psoriasis Area and Severity Index (PASI) is the most commonly used validated scoring index in clinical trials.  This scoring system quantifies the severity (i.e., induration, erythema, desquamation) and extent of psoriasis lesions.  Mild disease:  without face, genital, hand, or foot involvement in which topical therapies alone may be used to assist with clearance.  Moderate disease:  may require escalation of therapy to phototherapy or non- biologic systemic agents  Severe disease:  those who require escalation to biologic therapies  Non-pharmacologic Modalities  Psoriasis is often more emotionally or psychologically disturbing than is often recognized.  It may cause reluctance in patients to participate in sports and other outdoor activities that may expose their skin to sunlight.  Many patients alter their lifestyles or use nontraditional medications and modalities, often in desperation.  Psychological encouragement and support should be part of every treatment plan.  Treatment of Mild-Moderate Psoriasis  Topical therapies are the cornerstone of psoriasis treatment and are considered first line for mild disease  As a patient’s disease progresses, other treatment modalities may need to be added to obtain control.  Consideration for the addition of agents is often based on disease severity, cost, and convenience  Non-pharmacologic treatment is also very important.  Non-pharmacologic treatment options range from spa therapy to support groups  Topical Agents for the Treatment of Psoriasis (Mild to Moderate) Disadvantages Advantages Treatment Modality Provide minimal relief alone Basic adjunct for all Emollients treatments; safe, inexpensive, reduce scaling, itching, and related discomfort Provide minimal relief Reduce hyperkeratosis; Keratolytics (salicylic acid, individually; nonspecific; enable other topical urea) salicylism (tinnitus, nausea, modalities to better vomiting) with salicylic acid penetrate; inexpensive if applied extensively Temporary relief; less Rapid response; control Topical corticosteroids effective with inflammation and continued use, itching; best for expensive intertriginous areas and face; convenient, not messy; mainstay topical treatment modality for psoriasis Effective only for mild Particularly effective for Coal tar psoriasis or scalp “flaky” scalp lesions; psoriasis; inconvenient newer preparations are with difficult more cosmetically application; stains appealing; efficacy clothing and bedding, enhanced in carcinogenicity in combination with UVB animals Slow onset; As effective as Vitamin D analogs expensive; potential topical effects on bone corticosteroids, metabolism although slower (hypercalcemia); onset, without long- irritant dermatitis on term corticosteroid face and adverse effects; intertriginous areas; convenient, well contraindicated tolerated during pregnancy sunburn Effective as UVB (exacerbates maintenance psoriasis); photo- therapy; eliminates aging; skin cancers problems of topical corticosteroids  Treatment of Moderate-to-Severe Psoriasis Disadvantages Advantages Treatment Modality Hepatotoxicity; bone Effective for both skin Methotrexate marrow toxicity; folic lesions and arthritis, as acid protects against well as psoriatic nail stomatitis, disease contraindicated during pregnancy and lactation, use with caution during acute infections renal impairment; Used in patients with Cyclosporine contraindicated during extensive disease who pregnancy and are unresponsive to lactation, and with other agents; hypertension, hyperuricemia, hyperkalemia, acute infections  Immunomodulators  (etanercept, infliximab, adalimumab, certolizumab, secukinumab, ixekizumab, brodalumab, guselkumab, tildrakizumab, risankizumab)  Adv.:  Specific, targeted therapy; effective for both moderate- tosevere skin lesions and arthritis; maintains remission  Dis adv.:  Expensive; parenteral therapy (often administered in an office-based practice); longterm safety unknown; increased risk of serious infections  Phototherapy  Phototherapy with UV light has a long history of use in the treatment of psoriasis and other skin disorders.  In addition to its use in moderate-to-severe disease, phototherapy may also be considered for patients with mild disease refractory to topical therapies.  Before initiating phototherapy, it is important to assess the patient for any personal or family history of skin cancer.  Phototherapy carries an increased risk of cutaneous malignancy.  All patients should also be evaluated for their skin type (i.e., ease of sunburn and inherent skin color) and have their medication list reviewed for identification of any photosensitizing agents (e.g., thiazides, tetracycline's).  Once an initial dose has been determined, doses will be titrated up at a rate of 5% to 10% with each treatment until the minimum erythema dose at 24 hours has been reached or the patient has reached their maximum phototherapy dose.  Phototherapy is administered at a frequency of two to three times per week with time with psoriasis clearance typically occurring at 8 to 12 weeks.  Patients who miss doses of phototherapy may be required to restart at lower doses and titrate back up accordingly depending on the number of treatments missed.  Once a patient’s psoriatic lesions have cleared, patients may have their doses tapered or indefinitely continued as maintenance