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IPT 3 Lectures > Module 3.1.2 (Therapeutic Management of Psoariasis) > Flashcards

Module 3.1.2 (Therapeutic Management of Psoariasis) Flashcards

1
Q

What is the most common type of psoriasis? Where is it found on the body?

A

Different type of psoriasis – most common is plaque psoriasis

  • Well-defined, inflamed plaques with adherent silvery scale
  • Lesion normally found on extremities (elbows and knees) and sacrum (lower back)
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2
Q

What are the signs and symptoms of psoriasis?

A
  • Thick, silvery scales plaques „
  • Small scaling spots (commonly seen in children) „
  • Dry, cracked skin that may bleed „
  • Itching, burning or soreness „
  • Thickened, pitted or ridged nails „
  • Swollen and stiff joints
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3
Q

What are some trigger factors for psoriasis?

A
  • Infection (e.g. HIV, streptococcal infection) „
  • Trauma to the skin „
  • Sunburn „
  • Climate „
  • Emotional stress „
  • Pregnancy „
  • Smoking „
  • Excessive alcohol intake (> 2 standard drinks per day) „
  • Medications (ace inhibitors, CCBs, beta-blockers, systemic corticosteroids, NSAIDs, lithium, chloroquine, terbinafine)
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4
Q

Psoriasis is associated with an increased risk of?

A
  • Hypertension „
  • Obesity „
  • Dyslipidaemia „
  • Heart disease „
  • Diabetes „
  • IBD „
  • Lymphoma „
  • Depression
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5
Q

What are the aims of treatment?

fyi PSORIASIS CANT BE CURED

A
  • Symptoms control
  • Induce remission

> Minimise episodes of intermittent disease exacerbations

  • Manage comorbidities
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6
Q

What are some non-pharmacological treatment options for psoriasis?

A
  • Moisturise as frequently as possible „
  • Use soap substitute „
  • Quit smoking if applicable „
  • Stress management „
  • Diet and alcohol intake „
  • Quick shower with warm water
  • Review use of medications that could potentially aggravate psoriasis
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7
Q

Psoriasis treatment is stepped up from topical to phototherapy to systemic medications. Give examples of each of these classes.

A
  1. topical: corticosteroids, calcipotriol, anthralin, coal tar
  2. photo: PUVA, UVB
  3. systemic: biologics, ciclosporin, methotrexate, retinoids
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8
Q

When is topical treatment indicated for psoriasis?

A
  • Mainstay treatment for psoriasis

Indicated in:

  • mild to moderate psoriasis
  • Adjunct tx to phototherapy or systemic therapy in severe psoriasis
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9
Q

What are the examples of topical treatments? What are some of the combination products available?

A

​Topical monotherapy: tar, corticosteroids, calcipotriol

Topical combination therapy: tar/corticosteroids or corticosteroids/calcipotriol

for tar/corticosteroid combination, apply tar at night, and corticosteroid in the morning.

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10
Q

Why are emollients and moisturisers used? What are some examples?

A

A must for patient with psoriasis!

  • Hydrate, soften plaques, reduce itching and irritation
  • Example: Sorbolene cream with 10% glycerol; creams with urea/oatmeal/lipid-enriched
  • Ointment more effective than cream or lotion
  • Best to apply after shower
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11
Q

What is a keratolytic? Why is it used? How often to use it? When to not use it?

A
  • 2-10% salicylic acid in sorbolene cream or emulsifying ointment or WSP (white soft paraffin)
  • Reduce scaling and soften plaque –> allow better penetration of other topical treatment
  • Apply bd to tds –> apply under occlusion to maximise effect
  • DO NOT apply to broken skin or use in combination with calcipotriol
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12
Q

For topical corticosteroids;

A) What are its properties?

B) Why is propylene glycol an ingredient in it?

C) When to use ointment instead of cream? Why so?

D) How often to apply? What are the exceptions?

E) How much to apply?

F) How long can it be used for?

G) Which areas of the body NOT to use it on?

A

A)

  • Anti-inflammatory, anti proliferative, immunosuppressive and vasoconstrictive actions

B)

  • Absorption enhancing ingredient
  • Also, application under occlusion increases potency

C)

  • Use in palms and sole of feet for better absorption –> ointment is more potent than cream

D)

  • Apply twice a day, except for clobetasol, mometasone and methylprednisolone (once a day)

E)

  • Finger Tip Unit (FTU) rule
  • One FTU should cover the equivalent of TWO palmar surfaces on the patient’s body
  • One FTU= 0.5g

> 30 to 40 g of product for the whole body for a single application

> No more than 45 g/week of potent or 100 g/week of a moderately potent topical steroid to avoid systemic absorption\

F)

  • Potent corticosteroids should generally be limited to < 4 weeks
  • Once symptoms are controlled, reduce the potency of the topical corticosteroid gradually, and withdraw if possible

G)

  • Avoid high potency topical corticosteroids on areas of thin skin (face, flexural sites, genitalia, eyelids)
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13
Q

What are the local and systemic adverse effects of topical corticosteroids?

A

Local adverse effects

  • Loss of dermal collagen leading to skin atrophy, formation of striae (stretching of skin), fragility and easy bruising
  • Telangiectasia (increase in the size of tiny blood vessels)
  • Tachyphylaxis (adding a tar or calcipotriol can extend disease control)
  • Increase risk of infection
  • Allergic contact dermatitis

Systemic side effects are rare

  • Associated with the use of high potency topical steroids in large or broken areas or under occlusion
  • Include HPA axis suppression, glucose intolerance, Cushing’s syndrome
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14
Q

For Dithranol;

A) When is it used?

B) How often to apply? Which formulation to start with?

C) Strength?

D) Bad property?

E) Where to avoid use?

F) What are common AE?

A

A)

  • Rarely used
  • Reserved for when plaquie is large and limited

B)

​Apply daily

  • Contact with skin is progressively increased according to tolerance –> start with 0.1% formulation to be applied for a few hours then wash off

C)

  • 0.1-2% dithranol with 0.5% salicylic acid ointment

D)

  • Stains skin, clothing, hair

E)

  • Avoid use in face, flexure and genital area

F)

  • Skin irritation, burning in surrounding skin (use ointment to minimise spreading)
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15
Q

For Coal Tar;

A) Properties?

B) Indicated for?

C) Avaliable as?

D) How often to apply

E) Bad property?

F) Avoid what for at least 24 hours?

G) Used in combination with?

A

A)

  • Anti-inflammatory and antipruritic

B)

  • Indicated mainly for psoriasis of the scalp, hands and feet

C)

  • Available as 2-10% LPC (coal tar soln) in aqueous cream, ointment, shampoo, lotion, gel, foam

D)

  • Apply od to qid

> Scalp psoriasis (apply od to once a week)

E)

  • Stains skin, clothing, hair

F)

  • Avoid sunlight exposure for at least 24 hours

G)

  • Can be used in combination with dithranol +/- UVB phototherapy
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16
Q

For calcipotriol;

A) Can be used alone or in combination with? (main combination)

B) Also some other combinations such as?

C) Dose and dosage frequency?

D) Avoid use with?

E) What areas of body to avoid?

F) What protection is required?

G) Common AE?

A

A)

  • or in combination with topical corticosteroid –> more effective in combo form
  • combination product with betamethasone dipropionate 0.05% ointment/ gel - apply od (up to 100 g each week) up to 4 weeks)

B)

  • Maybe used in combination with UVB, PUVA, and sparing agent for acitretin and ciclosporin
  • Space out from UVA therapy —> apply after UVA treatment

C)

  • Apply bd (up to 100 g each week) till sign of improvement. Then taper or cease treatment

D)

  • Avoid use with salicylic acid cream

E)

  • Avoid on flexure and face

F)

  • Sun protection –> inactivated by UVA

G)

  • Skin irritation, itching, redness
17
Q

For Tazarotene;

A) When is it used in psoriasis?

B) Available as? When to use?

C) Improvement within?

D) Can be used with?

E) Cant use in patients who are?

F) Common adverse effects?

A

A)

  • Limited role – associated with paradoxical worsening of psoriasis

B)

  • Available as 0.05%% and 0.1% cream – apply od in the evening

C)

  • Within 2 weeks

D)

  • Can be used with a mid to high potency corticosteroid

E)

  • avoid in women of childbearing age

F)

  • Dry skin, burning, itching, phototoxicity
18
Q

For phototherapy;

A) Which patients is it used for?

B) What is it?

C) How often is it applied to the entire skin or restricted area? What is the total amount of treatments?

D) Common AE?

A

A)

  • Failed to respond to aggressive topical therapy „
  • Widespread disease

B)

  • Controlled exposure to artificial UV radiation

C)

  • 2-3 times weekly at first then reduce to once every 2-4 weeks once remission achieved
  • Total of 20 to 25 treatments

D)

  • Itching, burning, and stinging
19
Q

What are the types of phototherapy (artificial sources)?

A
  • UVB narrowband 311nm
  • UVB broadband 290-320nm
  • UVA 320-400nm –> takes a longer time to clear psoriasis. PUVA more effective
  • PUVA – chemophototherapy –> administration of a photosensitization agent (methoxsalen) 2 hrs before UVA exposure
20
Q

Which is better, UVB narrowband (311 nm) or UVB broadband (290-320 nm)? Discuss.

A

Narrow Band (311 nm)

  • Particularly effective for guttae psoriasis when used alone
  • Requires longer exposure times
  • More effective than broadband UVB but less effective than PUVA

Broad band (290-32nm)

  • May be used alone or in combination with tar
  • Monotherapy effective in mild psoriasis (<10% body affected) resistant to topical therapy
  • Clears 60-80% of lesions, remission ~ 6mo
21
Q

PUVA combines UVA phototherapy (wavelength 320-400nm) with psoralen.

How is psoralen given? When is PUVA used? What are some AE of PUVA (short term and long-term)?

A
  • Oral dose of psoralen – 2 hours before UVA exposure
  • Topical psoralen 30 mins before UVA exposure

> Used for extensive disease irresponsive to topical and UVB therapy –> clears lesions in 85% of patients –> lasts for 1 year

  • Short term adverse effect – nausea from oral psoralen (15% of patients)
  • Long-term adverse effect - malignancies, especially SCC
22
Q

PUVA and UVB can be enhanced by combination therapy with?

A
  • Tar baths (20-40mL LPC in a standard bath 1-2 hours before treatment)
  • Oral retinoid – acitretin (RePUVA) –> used for patients who are resistant to standard PUVA treatment.
23
Q

What are the examples of systemic treatment? Who are they reserved for?

A
  • acitretin
  • immunosuppressants (methotrexate, cyclosporin, hydroxyurea)
  • Cytokine modulators (adalimumab, etanercept, infliximab, apremilast, ixekizumab, secukinumab, ustekinumab)

Reserved for patients with

  • Moderate to severe psoriasis
  • Psoriasis refractive to topical therapy and phototherapy
24
Q

When using cytokine modulators (CM);

A) What baseline tests are required before treatment?

B) What is it associated with the reactivation of?

A

A)

  • LFTs, full blood count including platelet count, hepatitis test, TB test, creatinine, skin cancer

B)

  • Associated with reactivation of latent infections e.g. TB, Hep B
25
Q

What are the properties of acitretin?

A
  • teratogenic –> C/I in pregnancy
  • used for palmoplantar, pustular, erythrodermic psoriasis
  • may be combined with phototherapy or calcipotriol
26
Q

What are the properties of methotrexate? What are some toxicities?

A
  • Most commonly used
  • Take at least three months of treatment to induce remission
  • Folate supplementation
  • Major toxicities: myelosuppression, hepatotoxicity, pulmonary fibrosis
  • Monitoring requirements
27
Q

What are the properties of ciclosporin? How long to do treatment for?

A
  • Very effective, rapidly acting (6 to 12 weeks) but does not produce long remissions –> recurrence follows discontinuation
  • Limit tx to 12 to 16 weeks –> due to AE such as gingival hyperplasia, hirsutism, and neoplasia
  • Monitor BP, Cr
28
Q

Is hydroxyurea used?

A

Not really because less effective than methotrexate and ciclosporin

29
Q

What are the properties of TNF-alpha inhibitors (adalimumab, etanercept, infliximab) –> cytokine modulators

A
  • Improvement within two to four weeks

Adverse effects: Painful injection sites, Exacerbation or change in type of psoriasis, Malignancies

30
Q

What are the properties of ixekizumab (new drug) –> cytokine modulator

A
  • Alternative for patient who cannot tolerate TNF-alpha inhibitors
  • Improvement in two weeks

Adverse effects: • Nausea • Injection site reaction • URTI, candidiasis • Neutropenia • Thrombocytopenia • Development of antibodies

31
Q

What are the properties of apremilast (new drug) –> cytokine modulator

A
  • Avoid in individual with depression
  • Improvement in two weeks
  • Less effective than TNF alpha antagonist

Common adverse effects: • N, V, D • GORD • Dyspepsia • URTI

32
Q

What is the PASI score?

A

PASI= Psoriasis Area and Severity Index

  • Quantitative rating score for measuring the severity of psoriatic lesions based on area coverage and plaque appearance
  • Body divided in 4 areas: head, arms, trunk, legs
  • Each region is given a score to show how much of the region is affected by psoriasis (area) and a score on severity
  • area score from 0 to 6
  • severity score from 0 to 4 (bases on redness, thickness and scale)

> Score rating from 0-72 (rare for score > 40)

33
Q

What is the DLQI score?

A

Ten-question questionnaire used to measure the impact of skin disease on the quality of life –> each question is scored from 0 to 3

Interpretation of score

  • 0-1 = No effect on patient’s life
  • 21-30 = Extremely large effect
34
Q

Algorithm of treatment in psoriasis (ACD)

A

non-biologic therapies: methotrexate, cyclosporin and acitretin

35
Q

Summary for psoriasis

A
  • Identifying and managing trigger factors is important in the management of psoriasis
  • Treatment for psoriasis include topical, phototherapy and systemic treatment
  • Topical treatment is indicated for mild to moderate psoriasis and can be used in combination to increase efficacy
  • Phototherapy is indicated in individual who does not respond to topical tx or has widespread disease
  • Systemic therapy with acitretin, immunosuppressants and cytokine modulators are reserved for patients with severe psoriasis and psoriasis refractive to topical therapy and phototherapy
  • Use of systemic therapy are associated with serious adverse effects and require ongoing monitoring

Cytokine modulator (biological therapy) reserved for patients who have tried 2 out of 4 treatments (non-biological therapy + phototherapy) based on ACD guidelines or 3 out of 4 treatments based on PBS.

IPT 3 Lectures (26 decks)

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