Lecture 32 Psoriasis Flashcards
What is psoriasis (why do people get it)?
chronic and relapsing inflammatory skin disorder with strong genetic skin basis, classed as a papulosquamous condition - described as patches, silver scale, erythema/violaceous hues, increased epidermal cell turnover
How its gotten: genetics, environmental, immunologic
stress can initially flare or exacerbate it, it can appear in areas of skin that have been injured or traumatized ⇒ called the Koebner phenomenon ex. sunburns
Meds: lithium, antimalarials (chloroquine and hydroxychloroquine), BBs, NSAIDs, systemic steroids
streptococcus infection is associated with guttate this
smoking, obesity, alcohol consumption can increase risk or exacerbate condition
How is psoriasis assessed and diagnosed?
the clinical presentation is visual combined with asking about FHx,, Assessing: Clinician tools - PASI (psoriasis area and severity index) ⇒ score over 10 is severe,, PGA (physician global assessment)
Pt reported tools - DLQI (dermatology life quality index) ⇒ sum score of each Q, max score of 30 and minimum of 0, higher the score the greater the impairment of QoL
Biopsy - taking sample of skin to look at pathology
What are the prescription therapies for psoriasis?
Topical: salicylic acid 5-20%, coal tar, corticosteroids (50 different types), calcineurin inhibitors, Vitamin D3 analogues, topical retinoids
Systemic: phototherapy = UVB, methotrexate, cyclosporine, retinoids, apremilast, biologics
Salicylic acid for tx of psoriasis
product is used to break down thick scale and psoriatic plaques,, especially helpful in scalp, elbows, and knees
Coal tar for tx of psoriasis (MOA, AE)
MOA: suppresses keratinocyte proliferation, reduces inflammation
AE: can stain clothing, bed linen, light-colored hair
makes skin more sensitive to sun so be sure to wash it off thoroughly, use sunscreen and monitor sun exposure
remains active on skin for 24 hours and pt at increased risk of sunburn
can cause dermatitis or folliculitis
Topical corticosteroids for tx of psoriasis (Dose, forms)
Dose: is applied once to twice daily to thick active lesions ⇒ can decrease frequency once clinical improvement occurs, limit duration of high potency agents to 2-4 weeks
Forms: to minimize AEs and maximize compliance, site of application is considered in choosing one: for scalp or external ear canal ⇒ solution, foam, shampoo or spray
Face - use low potency
for thick plaques on extensor surfaces use potent preparations
Calcineurin inhibitors for tx of psoriasis (Drugs, MOA, how to use)
Drugs: tacrolimus (Protopic, 0.03%, 0.1%), pimecrolimus (Elidel 1%)
MOA: reduces T-cell activation and proliferation through inhibition of this enzyme
indicated for unresponsive to 1st line tx or in areas of body where skin thinning is a concern
Using: use BID until clear
it does NOT cause skin thinning
more expensive
not as powerful as topical steroids
Preview
Topical Vitamin D analogues for tx of psoriasis (Drugs, MOA, indications, AE)
Drugs: calciprotriol (Dovonex 0.005%, Silkis - calcitriol 3 micrograms/g ointment), calcipotriol + betamethasone dipropionate (Dovobet, Enstilar = aerosol foam)
MOA: effect on differentiation and proliferation of keratinocytes, inhibits T-cell activity, oral this doesn’t have the same effect
Indication: mild-moderate plaque type involving </= 35% body SA
AE: skin irritation, hypercalcemia
manufacturer says only 4-8 week duration but we use longer
DO NOT APPLY within 2 hours of UVB or immediately before PUVA
DO NOT USE IN PREGNANCY, BREAST FEEDING, KIDNEY PROBLEMS, LARGE SA
UV Light tx for psoriasis
uses narrow band this (311 nm)
shown to be one of most effective at clearing these lesions
tx can be continued in pregnancy
most studies show no increased risk of skin cancer
Dose/Use: usually 2-3 tx per week, most pt clear after 20-30 sessions and can then maintain pt on a regimen of every 1-2 weeks or stopping
Methotrexate for tx of psoriasis (MOA, dose, AE, contra)
MOA: inhibits dihydrofolate reductase and DNA synthesis
Dose: 15-20 mg PO once weekly, need folic acid supplementation (1-5 mg QD) to prevent toxicity and possibly dextromethorphan as well for AEs
AE: hepatotoxicity, pulmonary fibrosis, pancytopenia, GI issues (N/V/D), teratogenic, renal toxicity
Contra: do not consume alcohol while on med, do not administer live vaccines, stop 3 months before pregnancy
Cyclosporine for tx of psoriasis (MOA, Dose, indication, AE, contra)
MOA: inhibit calcineurin, decreases T-cell proliferation
Dose: by weight
Indication: moderate-severe this, good/rapid clearance in acute flares, allows time to switch to other agents
AE: renal failure, HTN, tremor, H/A, paresthesia, hypertrichosis, gingival hyperplasia, myalgia, lethargy, hyperkalemia, hyperlipidemia
requires blood monitoring periodically,, not used very much chronically due to limit of 1-2 year tx MAX
Contra: do not admin live vaccines
Acitretin for tx of psoriasis (MOA, dose, indication, AE, monitor, contra)
MOA: antiproliferative effect = reduces desquamation, inflammation, thickness of scales
Dose: 10-75 mg/day,, Indication: moderate-severe
AE: arthralgia, myalgia, alopecia, dry lips and mucosa, hyperlipidemia, hepatotoxicity, pseudotumor cerebri
Monitor: lipid profile, liver and kidney fxn
Contra: alcohol can lead to teratogenicity due to conversion to etretinate and can remain in body for years
contra in child bearing pt, contraception before, during, and after for 3 years
Preview
Apremilast for tx of psoriasis (MOA, dose, indication, AE, contra)
MOA: blocks PDE4 = inhibit inflammation
Dose: 30 mg PO BID, titrate from 10 mg QD up to 30 mg BID over 5 days to minimize GI AEs
Indication: moderate-severe
AE: H/A, N/V, insomnia, increased or irregular HR, weight loss, mood changes
Contra: pregnancy, no live vaccines
can cost between 12-$13000 per year
Deucravacitinib (Sotktu) for tx of psoriasis (MOA, dose, indication, AE, contra)
MOA: oral Tyrosine-kinase 2 (TYK2) inhibitor = inhibits inflammation
Dose: 6 mg QD
Indication: moderate-severe, has shown superior efficacy compared with apremilast
AE: URTIs, herpes simplex infections, acneiform rash, folliculitis
need to prescreen for TB (CXR)
Contra: in pt with hepatic impairment, pregnancy
How should scalp psoriasis be managed?
wash hair at least 2-3 x per week with nonirritating fragrance free shampoo
this will hydrate plaques and reduce itching and desquamation
can apply medicated topical agents before moisturizers (moisturizers with ceramides are helpful)
