Psoriasis Flashcards
How is skin with psoriasis different than healthy normal skin?
Psoriasis skin is hyperkeratotic, which means that the skin cells turn over very frequently. Every 3 days
In psoriasis, the skin may form armour in the form of silvery plaques
Normal skin turns over every 30 days
What is psoriasis?
A skin disease that causes red/silver, itchy, scaly patches.
It is most commonly found on the knees, elbows, trunk, and scalp
May occur in cycles with itching, discomfort, and sometimes pain
Two peaks of onset 20-30 and 50-60
What is the most common presentation of psoriasis?
Plaque formation
90% are of this type
It shows silver scaling on skin level
What are the percentages of severity for psoriasis?
Mild - less than 3% of the body
isolated patches on the knees, elbows, scalp, hands and feet
Moderate 3-10% of the body
appears on the arms, torso, scalp and other regions
Severe - more than 10% of the body
affects large areas of the skin
face and palms/soles considered as severe
How does psoriasis look like on black skin?
White/ or silver patches
What is the clinical presentation of psoriasis on the scalp?
Generally the same
Dry scaly, can be red and inflammatory
What are some characteristics of psoriasis on the scalp?
Lesions linger longer in this area due to skin thickness
Most difficult to treat
50-80% of patients have some degree of scalp involvement
What is the clinical presentation of psoriasis on the nails?
You will see pitting/pits on the nails
Silvery lesions possible
What are the less common forms of psoriasis?
Guttate
Pustular
Palmo-plantar
erythrodermic
We don’t treat these, we are out, beyond our scope
What is guttate psoriasis?
Less common form of psoriasis
Looks like hives, not hives because it doesn’t move
What is pustular psoriasis?
You see pus filled stuff
MD territory
What helps with psoriasis? What makes psoriasis worse?
Sunlight -> UV light therapy
Worsened by cold weather, stress, trauma
Lesions resolve without scarring
What is healing process for psoriasis?
Initially crusty, dry, and white scaling
Then, flat red patches
Finally, clear skin no condition
What are the causes of psoriasis?
Autoimmune (T-cell and TNF dysfxn)
Genetic and environmental factors (infection, trauma, some drugs)
12X the normal rate of skin cell production
What are the impacts of psoriasis on patients?
Can be physically debilitating
Social aspects
Risk factor for other diseases
Affects 1M Canadians
What are the tx options for psoriasis?
Topicals: steroid crm, moisturizers, rx retinoids, SA, coal tar
Systemic drugs:
Non biologics - methotrexate and cyclosporine
Biologics - sterlara and enbrel
Phototherapy: Narrowband UVB therapy
Broad UVB therapy
Excimer laser therapy
Psoralen +UVA (PUVA)
Rank the psoriasis treatments based on toxicity and effectiveness
Least effective and least toxic: Topical
moderate toxicity and moderate effectiveness: Photo
Most toxic and most effective: systemic
What are emollients?
They are standard dry skin products that are used between flare ups
Also known as steroid saving products
Trial-and-error in finding the best one
Central/essential to routine skin care
Are emollients used alone or with other products?
With other products such as in a combination treatment option
What type of dry skin products do we look for for patients with psoriasis?
Use the eczema grade products
How do emoillents work?
They create a barrier on the skin’s surface and coat it with oils, allowing the skin to rehydrate
Reduced dryness and irritation
What are Keratolytics?
They are agents that help by softening scales
They are very mild agents
They won’t take care of plaque
ex) Salicylic acid (OTC)
What is the function of a combo product with SA and a steroid? Are they OTC or Rx? Examples?
The SA increases the penetration of the steroid
These products are Rx.
Diprosalic, Nerisalic
What is tar shampoo good for? What are some of the side effects?
Mild cases of psoriasis on the scalp can be treated with OTC shampoos
They have anti-proliferative/ antimitotic properties
S/e: irritating, smell, folliculitis
What is the difference between coal tar and LCD (liquor carbonis detergens)?
Coal tar is the OG, leave on scalp for several minutes and use 2X per week; 1%
LCS is a dilutant of coal tar; 10%
What are the number one treatments for psoriasis?
Topical steroids and Vit D derivatives?
Topical steroids:
Efficacy
benefit of 2 rx agents
combo with other agents
effect of dry skin lotions
Mainstay of therapy
only use it if the pt can afford it
Combined with dry skin lotions
Dry skin lotions decrease steroid use (steroid-sparring) and central to routine care - separate by 1 hour!
True or false: mild potency topical steroids work for psoriasis
False, we need mid-potency to treat (unless for sensitive areas like the face or skin folds)
What happens when we stop tx suddenly when using a topical steroid?
Pt might get a rebound flare up
there’s no evidence of tapering off, but should do it, lower or skip every second day
What is the agent used to treat psoriasis on the face?
HC 1%
True or false:
Medium and high-strength corticosteroids can be used long-term (for several months) on the face
False, avoid using for several months on the face
What are the side effects of topical steroids?
Skin atrophy, Striae, and Telangiectasia (spider veins)
Rebound flare-ups on d/c (for the potent and strong agents)
What are the guidelines for topical steroids?
No continuous use over 3 weeks
Apply thinly, don’t go crazy
When does skin atrophy occur from steroid use?
When topical steroids are continuously applied to the skin even after the skin has returned to normal or normal thickness
What additional risks are associated with using high potency agents?
Increased risk of cutaneous and systemic side effects
How much skin does 1 FTU cover?
One palm on both sides
How many FTU’s do you need to cover the entire chest + abdomen?
7 FTU’s
What can be said about patients with moderate/severe psoriasis?
They are candidates from phototherapy or systemic therapy because the application of topical agents to large areas are not practical for most ppl
What is the formulation preference for acute and chronic stage eczema? What about psoriasis?
Acute eczema - Lotion is better
Chronic eczema - ointments are better
Acute psoriasis - Lighter steroid (may seem like need stronger agent due to the silver and raised skin, but the skin barrier is weakened
Chronic psoriasis - stronger steroid as the skin is intact and need better penetration
What is calcipotriol/ene?
It is a vitamin D analogue that is very popular for psoriasis tx
Drug of choice
Decreases skin turnover rate
effective for mild-moderate cases
not recommended for the face
What are the max use guidelines for calcipotriol/ene?
100g crm
60ml scalp lotion
max weekly adult guidelines
What are some examples of calipotriol/ene?
Dovonex - pure vit D
Dovobet - contains betamethasone (steroid)
Xamiol scalp gel (off the market)
How many grams of topical medication is one FTU? Two FTUs?
1 FTU = 0.5 grams
2 FTUs = 1 gram
What is special about xamiol scalp gel?
The manufacturer claimed that the combo drug is less irritating with minimal s/eat 52 weeks
It is the same as dovobet, but just off the market now
What is said about using a vitamin D analogue such as dovonex and a vitamin supplement?
Some ppl say that you can’t use them together
ex) cholecalciferol and vitamin D - the drug interaction is that they may cause the blood calcium to increase; patient may feel dizzy, weakness, lethargy, muscle pain, headache, nausea, vomitting and seizures
How will a doctor choose to treat scalp psoriasis?
A potent or very potent steroid is better than a D analogue alone
A d analogue combo is a bit better than using a steroid alone
- The combo features very low to placebo-like side effects
What is special about clobetasol proprionate?
It is very expensive at 225$
How can dovobet be formulated?
As a gel or as a gel contained in an applicator device
The device likely to compete with the generic version of this formulation
What can we say about a patient using a vit d analogue with a steroid for a few months? Is this a concern?
This is a slight red flag, but really not because the manufacturer states that the product is safe for 1 year
However, the patient should d/c after the skin returns to normal (don’t use it permanently)
What are the tips for scalp medications?
Try not to scratch the scalp
Relieve the itch by treating the psoriasis
Shampoo gently
Remove scale with care
Derms recommend using a scale softener
Try not to stress out
How do retinoids work against psoriasis?
They utilize the retinoid receptor and decrease cell proliferation
What type of psoriasis is tazorac (tazarotene) used for? What are some tips with using it?
mild to moderate cases
indicated for the face (because it is an ance med)
Concurrent use with a steroid is recommended - to decrease irritation
There is a pregnancy concern
What is an example of a good tazarotene product?
Combo one
ex) Duobrii (halobetasol propionate + tazarotene)
What is the expectations for improvement for Calciotriol/betamethasone dipropionate combo, Vit D analogue monotherapy, and retinoid therapy?
Calciotriol combo: 1 week
Vit D analogue (mono): 2 weeks
Retinoid therapy: 1-4 weeks
What is anthralin?
It is a common medication for psoriasis in europe
Anti-mitotic
Not common in Canada
Quite ancient
Explain phototherapy for psoriasis
historically, sent pt to mineral spas
Now, Narrow band UVB and PUVA rapidly decreases cell proliferation (UVB and UVA at certain spectrums)
Explain narrow band UVB treatment
At a specific spectrum
Expose to UVB 2-3 times a week
More common over UVA due to less side effects
Can be done at home
Explain PUVA treatment
PUVA is UVA and psoralen
Pt needs to go to a clinic for treatment
Requires photoactive agent oral or topical psoralen (accelerator)
Tx is v itchy and eyes can be sensitive, avoid sunlight the day after
Is psoralen OTC or Rx in Canada?
Rx
What are biologic agents?
They are anti-inflammatories for severe cases of psoriasis
Mostly injections and they are expensive
Serious side effects such as infections or cancers (attenuate on part of the skin, a cancer part gets activated), but safety record is growing
What are two examples of biologic agents?
TNF-a and IL-23 antagonists
secukinumab (injectable), apremilast (pill)
What is psoriatic arthritis?
Psoriasis and arthritis in patients
Affects 20% of psoriasis patients
Fingernails are often involved
How do you treat psoriatic arthritis?
Methotrexate (anti-mitotic)
Cyclosporine (Anti-rejection med for transplants)
TNF-a blockers
What do all of the psoriatic arthritis treatments have in common?
They are all serious agents with bad side effects
Biologics:
prescribed with moderate treatment not effective
can prevent further joint damage
target the parts of immune sys linked to PsA
improves pain in 3 mo and mood quickly
