dermatologic disorders Flashcards
when to refer to MD
multiple or extensive burns Human or animal bites Multiple or extensive cuts, bruises, or abrasions Rash that is extensive, weeping, or infected Tumors or growths Yellow skin Deep infection (cellulitis) Large blisters of unknown origins Exposed deep tissue, muscle, or bone
anatomy of the skin
epidermis
dermis
subQ
primary skin lesions
flat, nonpalpable changes in skin color: macule, patch
elevation formed by a fluid in a cavity: vesicle, bulla, pustule
elevated, palpable solis masses: papule, plaque, nodule, tumor, wheal
secondary skin lesions
material on skin surface: scale, crust, keloid
loss of skin surface: erosion, ulcer, excoriation, fissure
vascular skin lesions
cherry angioma, telangiectasia, petechiae, eccyhmosis
basic vehicles for derm products
ointment, cream, lotion, gel, soln/spray
very important to realize basic properties
ointments
Semi-solid preparations intended for external application to skin and mucous membranes.
Four classes: Hydrocarbon, Absorption, Water-removable, Water-soluble
Advantages: Hydrates, Removes scales, Greatest bioavailability of active ingredient
Disadvantages: Greasy
Preferred Area of Use: Smooth skin with short or sparse hair
properties of ointments
Occlusive: promotes retention of water in the skin, forms a hydrophobic barrier that prevents moisture in the skin from evaporating.
Humectant: causes water to be retained because of its hygroscopic properties.
Emollient: Softens the skin, Soothes irritation in skin or mucous membranes
Protective: Protects injured or exposed skin surfaces from harmful or annoying stimuli
application of creams/ointments
finger tip units - 1/2 gram of cream/ointment
amount needed depends on area of patient, area being applied to, how often and how long
creams and lotions
Ointment bases of the water-removable class Consisting of oil-in-water emulsions or aqueous microcrystalline dispersions of long fatty acids or alcohols Water washable and more cosmetically and aesthetically acceptable than ointments*** LOTIONS are basically watered-down creams
lotions solutions or sprays
Advantages: Easy to apply to hairy areas, scalp, High patient acceptance
Disadvantages: Drying, Lower bioavailability
Preferred Area of Use: Intertriginois and hair-bearing skin, face
cream properties
Advantages: Good cosmetic appearance, High patient acceptance
Disadvantages: Not as hydrating as ointments
Preferred Area of Use: Smooth or hair-bearing skin, Intertriginous areas
gels
semi-solid systems consisting of either suspensions made up of small inorganic particles or large organic molecules interpenetrated by a liquid
Advantages: Non-greasy, Easy to apply to hairy areas, High patient acceptance
Disadvantages: Drying
gels/lotions/solution/foam preferred area of use
hair bearing skin
oleaginous bases
white petrolatum, vaseline, plastibase
absorbs NO water, not water washable - soap is required
absorption bases
aquaphor, aquabase, polysorb
can absorb* several times it;s weight of water*
not water washable
water-in-oil emulsion bases
nivea, eucerin, hydrocerin
absorbs less water than absorption bases
not water washable
oil-in-water emulsion bases
hydrophilic ointment, dermabase, hydrocerin, unibase, cetaphil lotion, vanicream
water washable***
add water = lotion
water soluble base
polyethylene glycol ointment
water washable
minimal therapeutic effect
primarily used for drug delivery
choice of bases
Condition of the skin - Desired effect** from the base
Area of application
Patient acceptability
The nature of the incorporated medication - Bioavailability, Stability, Compatibility
drug-induced skin disorders
Hypersensitivity/allergic rxn - rash, hives, scarlet fever
Photosensitivity
Toxic Reaction: Erythema multiforme, Stevens-Johnson Syndrome, toxic Epidermal Necrolysis
treatment of ADRs
stop the drug!
systemic antihistamines, systemic or topical CSs, soothing baths or soaks
derm SEs
photosensitivity,
treatment of photosensitivity
Prevention*** with sunscreens/clothing - SPF ≥ 30 Systemic analgesics Systemic antihistamines for itching Prevent infection Moisturizers Cooling creams and gels (Aloe)
drug-induced skin disorders
Toxic Skin Reactions: Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis
Characteristics: Epidermal detachment, Erosive mucosal lesions
Underlying mechanism: Drug protein complex reaction leads to T-cell activation which migrates to the dermis and releases cytokines
drugs associated with SJS/TEN
Sulfonamides, Cephalosporins, Penicillins, Fluoroquinolones, Anticonvulsants***, Allopurinol, NSAIDs, Others…
features of SJS/TEN
Usually occurs within first 4 weeks of tx
Prodromal NVD, myalgias, sore throat, arthralgias - Flu-like symptoms
Involvement of mucous membranes
Widespread blisters and lesions
Full thickness epidermal detachment - Risk of infection
treatment of SJS/TEN
Stop offending agent***, IV fluids / nutrition, Pain control, Eye carem, Nasal saline, Oral hygiene and anesthetics, Topical antiseptics, Wound care
questions to ask a patient who presents with a skin rash or lesion
Onset, duration, getting better or worse
Parts of body involved
Symptoms
Exposure to new drugs or irritants
cellulitis
infection near break in skin
Red, warm, swollen
Refer to PCP**
Tx with… Oral antibiotics, IV antibiotics in severe cases
imeptigo
Topical Staph skin infection Most common in children Direct spread Refer to PCP** Tx with… Topical or oral antibiotics
topical candida infection
Common in moist areas in humid conditions
Tx with… Topical antifungals, Dry affected areas
tinea pedis
Often spread in pools/showers
Moist environments promote growth
Dermatophyte infection
Tx with… Topical antifungals
tinea corporis
body ring worm Commonly transmitted in day-care Hot/humid environments promote growth Small, circular, red scaly areas Tx with… Topical antifungals
head lice
Children 3-12 yo
Scalp redness and scaling
Pruritus
Refer to PCP
tx with… Permethrin 1%, Malathion (Ovide), Oral Ivermectin (Stromectol), Spinosad (Natroba), Topical Ivermectin (Sklice)
Other considerations! Somewhat expensive OTC medications (Make sure patient knows how to use); Prevention! (Others in house, Washing everything!)
scabies
Sarcoptes scabiei infestation
Primarily in children and adolescents (LTCF)
Raised lines caused by mites burrowing under skin***
Extreme pruritus
Refer to PCP
Tx with… Permethrin 5%, Crotamiton (Eurax Cream), Oral Ivermectin (Stromectol)
herpes zoster (shingles)
Adults > 40 yo
Especially in pts who previously had chicken pox
Potentially contagious while blisters are present
Triggered by stress, old age, immunosuppression
Extreme pain along dermatome
Tender red papules - progresses to scabs
Refer to PCP
Tx with…
-Oral valacyclovir or famciclovir
-Manage acute pain and postherpetic neuralgia - Oral opioids for acute pain, Gabapentin for PHN, Lidoderm patches - once lesion have healed
skin cancer
Better screening tests means its becoming more “prevalent” Patients becoming more aware of it Lots of prevention education available Basal cell carcinoma (most common) Squamous cell carcinoma (sun-exposed) Melanoma (most deadly) Caucasians w/ light eye and hair color Refer to PCP Tx with… Removal of lesion, Chemotherapy, Radiation
xerosis
dry skin
Common features: Fall and winter, Feet, lower legs, Hands, elbows, face, Rough, dry, scales, cracks, Itching is common Sx
who is at risk - elderly (decreased activity of sweat and sebaceous glands; very warm, dry environments) and frequent bathing
treatment options: emollients (first line for itching, restores barrier and skin function), agents for itching, alter bathing habits (no more than 3 times/week, tepid water (3-5 degrees above body temp), for 3-5 minutes, pat dry, apply copious amounts of emollients within 3 minutes, apply at least 3 times daily)
emollients for xerosis
Vaseline, Nivea, Keri, Lubriderm, AmLactin, Eucerin
Ointments vs. Creams vs. Lotions
agents to reduce itching for xerosis
Menthol and camphor - ½ to 1%, Create a sensation of cooling
Pramoxine - 1%, Local anesthetic
Aluminum Acetate - 0.2%, Alter C-fiber nerve transmission
Hydrocortisone - 0.5% and 1%, Anti-inflammatory
acute dermatitis
red patches or plaques
Pebbly surface or blisters (vesicles)
Itching is common
subacute dermatitis
dry, less red than acute, crusting, oozing, mild thickening
Red scaling, fissured, patches or plaques
Slight to moderate pruritis, pain, stinging or burning
chronic dermatitis
Epidermal thickening Exaggerated skin markings lichenification Scaling Less itching Well demarcated, lichenified, thichened plaques Excoriations, fissures, scaling Itching predominates - Minor irritations or trauma worsens itching Treatment – same as subacute Use emollients (ointments for dry lesions) Avoid long-term corticosteroids UV light
acute contact dermatitis
Look at pattern
Look at part of body involved
Main symptom is itching
Two types: Allergic and Irritant
acute contact dermatitis - irritant
Non-immunologic reaction to frequent contact with everyday substances
Reaction within a few hours
Common irritants ???
More common than allergic
poison ivy
example of acute dermatitis
Direct exposure: Broken plant, Resin – 2 weeks
Indirect exposure: Clothing, dog, smoke, Does not spread from lesions
Prevention is the key: Ivy-Block (Protectant; barrier, Re-apply every 4 hours)
Dermatitis occurs 24 to 48 hrs after exposure.
Pruritis is intense - secondary infections, cool water
Wash skin and nails within 10 minutes. - wash clothing as well
Topical therapy OK if less than 10% BSA involved.
treatment options: Remove source, Soaks, Calamine Lotion, Topical antihistamines, Oral Antihistamines, Topical Corticosteroids, Oral Corticosteroids
soaks for treating acute dermatits
For oozing, weeping, crusting lesions
Wet dressings useful for drying acutely inflammed, wet areas
treatment of acute dermatits
Domeboro (5% aluminum acetate) - Packets in cool water
Acetic Acid: 60 ml vinegar in 1 qt warm water
Saline: 1 tsp salt in 2 cups water
Water
Apply linen or cheesecloth for 30 minutes bid – qid; remove when dry
topical corticosteroids for treatment of acute dermatitis
MOA: Anti-inflammatory, Anti-pruritic, Suppress immune response
Apply bid to qid x 3 – 14 days
choice of vehicle based upon: Location of lesions, Type of lesion, Severity of lesion/degree of inflammation, Degree of skin penetration desired
Classified according to potency which corresponds to anti-inflammatory activity and vasoconstrictive potency
-Very-high - High – Mid – Low (Grades I to VII)
Vehicle impacts delivery and potency of corticosteroids
Only 1% is absorbed when applied to normal intact skin
Occlusion enhances penetration** - Plastic wrap + T-shirt / bandage, Increases penetration 10X, Leave on for six hours
topical corticosteroids side effects
Thinning of skin Dilated blood vessels Bruising Skin color changes Risk of HPA suppression with long-term use of high-potency agents Development of tolerance (tachyphylaxis)
low potency topical CSs
grades 5 - 7 Examples: Hydrocortisone; Desonide Use on face, groin, genitals, axilla Mild anti-inflammatory effect Safest for long-term maintenance use
mid-potency topical CSs
Grades 3 - 5
Examples: Betamethasone, Triamcinolone, Mometasone
Used on most skin surfaces for exacerbations
Moderate anti-inflammatory effect
Safer for longer usage than high potency
high/very-high potency topical CSs
Grades 1 -2
Examples: Fluocinolide, Halobetasol, Clobetasol
Used for very severe lesions and on thicken skin when maximum penetration is needed - Psoriasis
Do NOT use on face.
Avoid using super-potent agents for > 2 wks.
Limit to no more than 50 grams per week.
topical calcineurin inhibitors
MOA: blocks pro-inflammatory cytokine genes Can be used on any area Equivalent to mid-potency corts No risk of atrophy Few side effects - burning \$\$\$\$$ Now considered 2nd-line tx Intermittent use only** Recent concern regarding long -term use - Risk of malignancies, Risk of resp infect in children under 2 yrs
crisaborole 2% ointment
Phosphodiesterase-4 Inhibitor (non-steroidal) Alternative to TCS and TCIs Mild or moderate AD BID for 28 days \$\$$
treatment of acute dermatitis - systemic
CSs
-avoid dose packs (not long enough)
-start at prednisone 40-60 mg QD; taper q 3 days
-minimum of 10-14 days
non-sedating antihistamines - loratadine, desloratadine, fexofenadine
sedating antihistamines - diphenhydramine, cetirizine, hydroxyzine, doxepin
atopic dermatitis
Most common form of eczema Usually presents in infancy 1 in 5 children 1 in 12 adults 80% mild; 80% mod-severe Pruritis Red papules or plaques Scaling excoriations Overall dryness of skin Redness and inflammation Prone to infections due to scratching Usually Staph aureus Tx with antibiotics Bleach baths
atopic triad
atopic dermatitis - asthma - allergic rhinitis
Atopic march – Often first disease of atopic/allergic triad to be observed
50%-75% also develop allergic rhinitis and/or asthma
Unknown if early intervention in infants or children might halt or slow atopic march
atopic dermatitis - infant
Red, papular skin rash on cheeks and skin.
Lesions often crust over time.
Lesions later appear on neck, trunk and groin.
Itching often results in irritability.
atopic dermatitis - child
Face, neck, flexural creases of arms and legs.
Skin often appears dry, flaky, rough, cracked, and may bleed from scratching.
Sleep disturbance is common.
Greater risk of secondary skin infections
atopic dermatitis - adult
Hands and neck.
Flexor surfaces of the arms and legs.
Excoriation and lichenification from chronic scratching.
Sleep disturbance; Altered QOL; depression
triggers of atopic dermatitis
Allergens, Chemicals, Bathing, Detergents, Smoke, Dust, Infections
stepwise management of AD
non-pcol: lukewarm or tepid baths; emollients, ellimination of irritants, modify environment, consider bleach baths, fingernails, clothing
topical: CSs, calcineurin inhibitor therapy, strength/duration of use based on severity
systemic: phototherapy, oral immunosuppressant therapy, injectable biologic agents
dupilumab
Dupixent
First biologic indicated for mod-severe AD.
300 mg SC q 2 weeks.
$37,000 per year
stasis dermatitis
Patients > 50 years Poor circulation Most common around ankles Aching, swellings, discomfort Red, scaly, crusted plaques Swelling; edema Secondary infection and ulcers common Hyperpigmentation - Retention of Fe++ in skin
treatment of stasis dermatitis
Topical corticosteroids: for itching
Emollients: for all pts
Oral antihistamines: ???
Oral antibiotics for local infections - Cephalexin 250-500 mg TID; Bandage any weeping lesions until healed
To relieve edema… Elevate feet and legs, Support stockings, Compressive bandages
cost considerations
low cost: oral CS, antihistamines
medium cost: topical CSs (typically price increases by potency)
high cost: calcineurin inhibitors
patients at risk for topical fungal infections
Infants Elderly Immunosuppressed Incontinent; Inc freq of BM Obese** Warm and humid climates
treat or refer topical fungal infections
most can be treated with OTC, refer if any systemic sxs, refer if patients is immunocomp
slow to grow - slow to go - treat 4 weeks or longer
treatment options for topical fungal infections
Hygeine !!!
OTC Products: Miconazole (Micatin; Lotromin), Clotrimazole (Lotrimin; Cruex; Desenex), Terbinafine (Lamisil)
Rx Products: Nystatin (Mycostatin), Ciclopirox (Loprox), Ketoconazole (Nizoral)
diaper rashes treatment options
Remove irritant (freq diaper changes) Air dry Keep clean (mild soap and water) Antifungal agents +/- corticosteroid Apply protectants !!! - Zinc oxide, Destin™, Aveeno™, A&D Ointment™, Butt Paste, can be applied over anti-fungal, if necessary
seborrhic dermatitis
Erythema with greasy yellow scaling
Hairline, scalp, nose, neck, ears, back
Itching
Cradle cap in infants - Baby oil to soften, Baby shampoo, No drug tx usually required
treatment options:
-medicated shampoo: Scalp and hair line, Use 2-3 times per week, then weekly to control, pyrithione zinc; selenium; ketoconazole (Try OTC first, Rx strengths (2X), Removes scales, Reduces cell turnover)
-Topical corticosteroid - Low strength: Reduces inflammation and itching, Ideal for lesions on face and ears**, Use BID, then prn
acne - definition
A chronic inflammatory disease of the sebaceous glands and hair follicles of the skin characterized by comedones, papules, and pustules
pathophys of acne
Keratinous obstruction of sebaceous follicle outlet
Traps sebum
Comedone** – hair follicle plugged with sebum, keratin & dead skin
Bacterial colonization in trapped sebum**
Bacteria
-Propionibacterium acnes** naturally colonize the skin and sebaceous glands
-proliferates in sebum environment
-Bacteria converts TG to FFA which irritates local cell resulting in inflammation
can be non-inflam (whiteheads, blackheads) or inflammatory (pupules, pastules, ruptures contents)
non-inflammatory acne
whitehead - trapped contents
blackhead - trapped contents, dilated opening, melanin accumulates
inflammatory acne
papules - red, inflammed
pustules - yellow, inflammed
ruptured contents
secondary ance
excoriations, erythematous macules, hyperpigmented macules, scars
treating complications
dermabrasion, chemical peels, laser resurfacing, $$$
goals of therapy of acne
long-term control, prevent scars
MOAs of acne agents
antimicrobial, antiiflammatory, decreased serum production, keratolytic/comedolytic
treatment of acne - ALL patients
follow a regular skin cleansing regimen using a mild facial soap BID
minimize* the use of products that cause irritation or stinging (aftershave, alcohol-based cleansers)
Use tepid, not hot*, water to clean affected areas
No quick fix - weeks to months
treatment of comedonal, noninflammatory acne (mild)
topical retinoids (adapalene)
treatment of mild-moderate papulopustular inflammatory acne
adapalene + benzoyl perozide (BP) or
clindamycin + BP
treatment of severe papulopustular OR moderate nodular acne
oral isotretinoin
treatment of nodular or conglobate acne
oral isotretinoin
Maintenance therapy of acne
adapalene*
adapalene
Formulation: gel, cream, solution
MOA: retinoid
daily at HS, burning/stinging
tazorotene
formulation: cream, gel
MOA: retinoid
daily, start with lower strength, very drying, category X
tretinoin
formulation: cream, gel, solution
MOA: retinoid
daily at hs, sting, burn, dryness, photosensitivity, 4-6 weeks until improvement
azelaic acid
formulation: cream
MOA: antibacterial, keratolytic
adjunct, well tolerated
benzoyl peroxide
formulation: cream, gel, lotion
MOA: antiseptic, comedolytic/keratolytic, anti-inflammatory
BID, dry skin/irritation, can bleach skin/hair, start w lower strength, avoid contact with clothing
clindamycin
formulation: gel, solution, lotion
MOA: antibiotic
daily or BID
erythromycin
formulation: gel, solution
MOA: antibiotic
BID, expires in 30 days
clindamycin + BP
formulation: cream
MOA: antibiotic
limits resistance
oral antibiotics for acne
Decreases bacteria and inflammation** - Weeks are required to see improvement
Most effective when inflammation is present.**
Risk of allergy, photosensitivity, GI upset, thrush
Risk of resistance developing - Limit tx to 6-8 weeks, if possible
After inflammation is controlled, acne can often be controlled with topical retinoids and/or benzoyl peroxide for long periods
options for oral antibiotics for acne
Minocycline 50-100 mg daily - BID - 20 mg dose – only anti-inflammatory activity Doxycycline 50-100 mg daily - BID Erythromycin 250 mg QID Azithromycin 250 mg 3 times a week TMP/ SMZ (Bactrim) - 1 DS tab daily
oral tetracyclines for acne
Risk of photosensitivity
Interaction with OCs
Do not take with dairy products or antacids
Minocycline is most lipophillic** Dizziness; Hyperpimentation (scars)
Discoloration of teeth
Avoid in children and during pregnancy*
oral anti-androgens for acne
Hormone Treatment
-Estrogens and anti-androgens
-Generally NOT used in males
-Ideal for females who’s acne flares during menstral cycle***
Decreases androgen production (reduces sebum & comedone formation)
Low-dose Oral Contraceptives: Ortho-Tri-Cyclen®, Estrostep®; Contain non-androgenic progestins, Any OC is likely to be effective, 6 month trial may be necessary, Risk vs. benefit
Spironolactone - 50-200 mg per day
Intra-lesion corticosteroids
Oral corticosteroids - Short course for highly inflammatory acne
isotretinin for severe acne
vitamin A derivative
provides resolution in up to 80% of cases
reduces sebum production and shrinks sebaceous glands
Used when patients have failed other treatments or when it relapses soon after discontinuing other therapies**
Very expensive
10mg, 20 mg, 40 mg capsules
dosing: 0.5 - 2 mg/kg/day in 2 doses (with food) for 15 - 20 weeks - Some dermatologists recommend a cumulative dose of 120-150 mg/kg, Acne will get worse before it gets better, If acne flares after > 2 months off tx, a 2nd course may be used, Effectiveness increases with higher doses
counseling tips: avoid pregnancy / proper use of contraceptives, adverse effects, do not take vitamin A supp (includes nutr supp), use moisturizer, lip balm, and artificial tears, use a sunscreen, take with food
ipledge program
isotretinoin
Patients, physicians, and pharmacies must register with a centralized clearinghouse
Dispensing occurs only after the pharmacist has received an authorization code.
Can only dispense a 30 day* supply with no refills
Pharmacists will get a “do not dispense after date” - 7 days past office visit
Females must have a negative pregnancy test every month while on therapy
rosacea
A common, chronic, progressive inflammatory dermatosis based upon vascular instability.
Primarily affects the central part of the face.
Characterized by facial flushing/blushing, facial erythema, papules, pustules, and telangiectasia
Ages of 25 and 70 years
People with fair complexions.
women > men
Rosacea is chronic, persisting for years with periods of exacerbation and remission.
telangiectatic rosacea
Visibly dilated blood vessels*
Very red skin
papulopustular rosacea
Resembles acne*
Often referred to as “adult acne”
phytmatous rosacea
Enlarges sebaceous glands
Especially the nose*
More common in males
ocular rosacea
Watery eyes
Bloodshot eyes
trigger factors for rosacea
Foods Temperature** Weather Beverages Medical conditions Emotional influences Physical exertion Skin products drugs: vasodilators, topical CSs, nicotinic acid, ACEI, CCB, statins
lifestyle mods to treat rosacea
Avoid triggers* known to exacerbate. Avoid excessive exposure to the sun. Use mild soaps and cleansers. Stress adherence to topical meds. Topical meds should be allowed to penetrate the skin for 5-10 min before applying make-up.
treatment overview of mild rosacea
Avoid triggers
Topical antibiotics
Topical retinoids
treatment overview of moderate rosacea
Oral antibiotics
Topical retinoids
treatment overview of severe rosacea
Oral Isotretinoin
Laser treatments
metronidazole for rosacea
Treatment of choice of topical antibiotics
Apply BID
Some burning/stinging
azelaic acid for rosacea
Finacea® Gel 15%
antibacterial, comedolytic, and antiinflammatory effects
less acidic / better absorbed than acne formulation
$$$
oral antibiotics for rosacea
For patients with moderate to severe rosacea
Doses vary depending on severity
Used alone or in combination with topical agents
brimonidine for rosacea
new treatment Mirvasco® 0.33% gel-Alpha-2 adrenergic agonist -Tx for persistent facial erythema -Insurance coverage? Ophthalmic drops for ocular rosacea
oral antibiotic options for rosacea
doxycycline 50-100 mg daily or BID Minocyclcine 50-100 mg BID For pts with moderate to severe cases Doses vary depending severity Used alone or in combination with topical antibiotics
tretinoin for rosacea
Used for more severe cases
May worsen erythema and telangiectasias
isotretinoin for rosacea
Only used for most severe cases
Weigh risks vs. potential benefits
laser therapy for rosacea
Used to remove blood vessels and reduce excessive redness
A minimum of 3 treatments is usually required
May also be used in more severe cases* to retard build up or remove unwanted tissue and reshape the nose
psoriasis basic information and clinical presentation
Chronic autoimmune inflammatory skin disorder
T-lymphocyte mediated disease
Keratinocyte proliferation
Thickened, red patches covered by silvery-white scales
Results from a rapid skin growth - 7 X faster than normal
2% of US population
Onset usually prior to 40yo
Usually a series of exacerbations/remissions
Not curable !!! - Long remissions are possible
major types of psoriasis
Plaque psoriasis Palmoplantar psoriasis Scalp / nail / pubic psoriasis Inverse psoriasis Pustular psoriasis Guttate psoriasis Erythrodermic psoriasis Psoriatic arthritis
psoriasis classification
Limited - under 5% BSA Generalized -Moderate 5-10% BSA -Severe >10% BSA 80% of pts have mild to moderate 20% have severe disease
psoriasis comorbidities
Psoriatic arthritis
Crohn’s Disease
Psychiatric disorders
Metabolic Syndrome - CV disease / stroke
psoriasis triggers
Stress Environment (cold) Injury Infection Smoking Drugs (NSAIDs, ACE, Lithium…) Diet
goals of therapy for psoriasis
Reduce inflammation and slow down rapid skin cell division
Achieve clearing of lesions
Use topical therapy over systemic therapy whenever possible (treatment is based on patient’s health, age, lifestyle, and severity of psoriasis)
Prolong periods between exacerbations
PASI
Psoriasis Area Severity Index
- Used in most clinical trials
- Very subjective
- PASI-75 is standard for efficacy - over 75% reduction from baseline PASI; Some pts still not satisfied w/results
general measures of psoriasis treatment
Sun
Baths
Emollients
Keratolytics
treatment overview of psoriatic arthritis
anti-TNF +/- MTX
treatment overview of mild-moderate psoriasis
topical
topical + phototherapy
topical + systemic
topical therapy for psoriasis
Most effective when used to treat localized plaques psoriasis covering under 20% of BSA
70% of patient receive only topical therapy
emollients - used for all patients with psoriasis
CSs - decreases scaling, erythema, pruritis; Economical; Shampoo available for scalp; High potency ointment preferred for scaly lesions; Risk of tachyphylaxis
calipotriene/calcitrol - Inhibit proliferation of lesions, Potency equivalent to mid potency corts, Well tolerated; No tachyphylaxis
Cort + Vit D analog - Calcipotriene + Betamethasone (Taclonex™); Ointment + Topical Suspension
Cort + tazarotene - CS sparing effect
calcineurin inhibitor - For areas not suitable for corts; Face and flexures
topical corticosteroids for psoriasis
Development of tolerance to the anti-inflammatory activity with repeated use (tachyphylaxis)
May alternate with other topical medications to avoid tolerance
Occlusion enhances penetration**
-Plastic wrap + T-shirt
-Increases penetration 10X
-Leave on for six hours
High / Very-High Potency
Used for very severe lesions and on thicken skin when maximum penetration is needed.
Do NOT use on face.**
Avoid using super-potent agents for > 2 wks.
Limit to no more than 50 grams per week.
Mid-potency products used after initial tx
patient education on topicals for psoriasis
Apply a small amount. - just enough to cover the affected area**
Gently apply - do not rub aggressively.**
Wash hands before and after applying.
Leave on only for the prescribed length of time.
Protect clothing and bed linens.
Stress adherence!**
if topical therapy fails for psoriasis
1st line if UV tx available: UVB Phototherapy Alone, UVB + Acritretin, PUVA, UVB + Methotrexate
1st line if UV tx not available: Acritretin, Biologic Agent, Methotrexate, Cyclosporine
role of phototherapy in psoriasis treatment
Targeted phototherapy for limited* and resistant* plaques
For patients with mild-moderate* disease who do not completely respond to topical agents
Used in combination with systemic/biologic tx for pts with severe* disease
Role in maintenance* therapy
Overall role has increased in recent years**
immunomodulatory effect of phototherapy for psoriasis treatment
UVA - Penetrates thicker lesions better than UVB; Very effective
NB-UVB (BB-UVB – out of favor) - Tx of choice for initial therapy – thinner lesions; 20-25 tx given 2-3 per week; Cost-effective
phototherapy overview
Risks: UVA > UVB Side effects: skin aging, skin cancer - Squamous cell Coal Tar + UVB light therapy Light enhances the activity of coal tar Goeckerman therapy – all day occlusive coal tar followed by light therapy PUVA: Psoralen + UVA Methoxsalen -0.6-0.8 mg/kg PO 2 hours before UVA tx -2 – 3 tx per week -Photosensitizer -Controls 90% of patients - Superior to UVB alone -Potentially more risks; skin damage
treatment overview of mod-severe psoriasis
systemic agent +/- topical agent or phototherapy; consider BRM esp if comorbidities exist
more potent systemic agent or (less commonly) 2 or more systemic agents in rotation +/- topical agent
biological response modifier (BRM) +/- other agents (can also consider BRM earlier - even as first line, but costly)
tx for severe psoriasis
Phototherapy: PUVA + psoralen* Biologic Therapy: First-Line** -Tumor Necrosis Factor Inhibitors -T-Cell Activation Inhibitors Systemic Therapy: Second-Line** -Oral retinoids -Cyclosporine -Methotrexate
biologic/systemic tx for severe psoriasis
Patients with recalcitrant, widespread, plaque psoriasis or patients with comorbidities
Patients with psoriatic arthritis
12 week courses of therapy
May induce long-term remissions
Often very expensive $$$$$ - $20 K to $30K per year
Risk of long term side effects may be significant - May be life threatening, Rotation of therapies may minimize side effects
adalimumab, infliximab, etanercept, golimumab (psoriac artritis only), alefacept, eflizumab, ustekinumab, secukinumab
Comparison of ADRs and risks
-Common: HA, nausea, fatigue, chills, flu-like Sx, Injection site discomfort
-Activation of infections: TB
-Long-term concerns: risk of malignancies, MS in pts with FH
Monitor: Signs and symptoms of infection or bleeding
systemic therapy for severe psoriasis
acritretin - oral retinoid, 3-6 mo until max effect, SE similar to accutane, cat X
MTX - immunosuppressant, reasonable cost, monitor CBC, LFTs, oral, cat X
cyclosporine - Calcineurin inhibitor, Avoid grapefruit juice, Max tx: 2 yrs, Renal toxicity
apremilast: Start at 10mg and titrate up over 5 days, PDE-4 inhibitor, Psoriatic arthritis, Specialty Rx
