Psoriasis

Question 1

What are complications of psoriasis that pts need to be assessed for?

Answer 1

Psoriatic arthritis (Rheum referral if required)
CVS disease (treat modifiable RF)

Question 2

Basis of Psoriasis treatment?

Answer 2

Emollients to reduce scale
Topical treatments for acute flare-ups

Question 3

Topical treatment examples for psoriasis ?

Answer 3

Vit D analogues and steroids (Dovobet or Enstilar foam) for chronic plaque psoriasis for 8-12 weeks

Face/Flexural/Genitalia psoriasis: Mild moderate potent steroid e.g. Eumvate for 1-2 weeks

Question 4

Examples of Vit d analogues?

Answer 4

Calcipotriol
Tacalcitol
Calcitriol

Question 5

How do Vit D analogues work?

Answer 5

Help regulate the immune system, slow the overgrowth of skin psoriasis

Question 6

What are the benefits of Vit D analogues?

Answer 6

Safe, effective and popular
Don’t stain the skin, no strong odour and can be used long term

Question 7

What are side effects of Vit D analogues?

Answer 7

Can irritate sensitive areas
Can cause hypercalcaemia so do not exceed weekly limit

Question 8

When are Vit D analogues contraindicated?

Answer 8

Pregnancy and breast feeding

Question 9

What combinations can you prescribe Vit D analogues with?

Answer 9

Steroid in a gel/ointment for short term use (risk of skin atrophy)

Question 10

When do you refer to dermatology?

Answer 10

For 2nd line treatments:
Phototherapy
Acitretin
Methotrexate
Ciclosporin
PD4 inhibitor apremilast
Dimethyl fumarate

Question 11

How does phototherapy help in psoriasis?

Answer 11

Using UVA and UVB wavelengths to reduce inflammation

Question 12

What is the treatment regime for phototherapy for psoriasis

Answer 12

2x a week usually 15-30 treatments

Question 13

What are the types of phototherapy?

Answer 13

Narrow band UVB: severe psoriasis and eczema
PUVA: psoralen + UVA- Psoriasis (if UVB not effective), vitiligo, cutaneous T-cell lymphoma

UVB is more common

Question 14

What is psoralen?

Answer 14

A chemical that increases the effect of UVA on the skin
Available as a tablet or solution/lotion/gel

Question 15

Side effects of phototherapy?

Answer 15

Short term:
Redness and discomfort
Dry and itchy skin
Folliculitis
Polymorphic light eruption
Cold sores
worsening of skin disease
Psoralen: nausea

Long Term:
Premature skin ageing, skin cancer

Question 16

What is Apremilast?

Answer 16

Oral medication, inhibits an enzyme
(Phosphodiesterase Inhibitor, PDE4); responsible for
controlling the inflammatory process in the skin

Question 17

What are the contraindications of Apremilast?

Answer 17

Avoid live vaccines/getting pregnant whilst on it
Efficacy reduced by cytochrome P450 inducers

Question 18

Side effects of Apremilast

Answer 18

Gl upset (diarrhea,
nausea, reduced appetite)
Headache
Depression(rare)
Weight loss(rare)
Insomnia
Tiredness
Muscle pain
Respiratory infections

Question 19

When are biologic treatments used?

Answer 19

Both methotrexate and cyclosporin have failed/unable to be used
Psoriasis has a large impact on physical, psychological or social functioning
Psiriais is extensive or severely localised with functional impairment

Question 20

What do you need to do before prescribing biologics?

Answer 20

Screen for TB, Hep B and C, IV and ZV

Question 21

Names of first line biologics for Psoriasis?

Answer 21

Ustekinumab
Adalimumab
Secukinumab

Question 22

How to treat scalp psoriasis

Answer 22

1.Potent corticosteroid once daily scalp application up to
4 weeks (e.g. Betacap® scalp application)
2. Descaling prior to corticosteroid application with
Diprosalic® scalp application ( steroid and salicylic acid it softens and lifts scale allowing steroid to exert effect underneath )
3.Potent corticosteroid with calcipotriol up to 4
weeks e.g. Dovobet® gel - applicator
4.Very potent corticosteroid once daily up to 4 weeks
(Etrivex® shampoo) or coal tar applied OD/BD
(Sebco® scalp ointment)

Question 23

Pathophysiology of psoriasis

Answer 23

Genetic: associated HLA-B13, -B17, and -Cw6.
Immnunological: Th mediating keratinocyte proliferation
Environmental: may be worsened with stress/ skin trauma, triggered by strep infection or improved by sunlight

Question 24

Subtypes of psoriasis?

Answer 24

Plaque psoriasis
Flexural psoriasis
Guttate psoriasis
Pustular psoriasis

Question 25

Features of plaque psoriasis?

Answer 25

Most common subtype
Well-demarcated red, scaly patched affecting extensor surfaces, sacrum and scalp

Question 26

Features of Guttate psoriasis?

Answer 26

Transient psoriatic rash, frequently triggered by strep infection
Large numbers of red small plaques < 1cm appear on trunk and limbs. Often in young post acute strep infection.

Question 27

Features of pustular psoriasis?

Answer 27

Commonly occurs on the palms and soles

Question 28

Clinical features of psoriasis?

Answer 28

Itching
Irritation
Burning
Stinging
Nail changes: pitting and onycholysis
Psoriatic arthritis

Question 29

Complications of psoriasis?

Answer 29

psoriatic arthropathy (around 10%)
increased incidence of metabolic syndrome
increased incidence of cardiovascular disease
increased incidence of venous thromboembolism
psychological distress
Coeliacs disease (an association)

Question 30

Investigations for psoriasis?

Answer 30

None, clinical diagnosis