Psoriasis

Question 1

Clinical Presentation

Answer 1

Plaques: patches of thick raised erythematous skin

Scales: dry think silver/white

Can have: pruritis, pain, bleeding

Scalp/elbows/knees/lower back

Question 2

Risk Factors & Triggers

Answer 2

− Stress
− Genetics
− Infection (streptococcal)
− Smoking/Alcohol
− Injury to the skin
− Obesity
− Weather (dry and cold)
− Medications
*BB, buproprion, CCB, captopril, fluoxetine, hydroxychloroquine, interferons, lithium

Question 3

Goals

Answer 3

• Minimize/eliminate existing skin lesions
• Reduce frequency of flare ups
• Improve quality of life (QoL)
• Avoid/manage adverse effects
• Minimize/manage exposure to environmental triggers

Question 4

Non-pharmacologic

Answer 4

• Moisturizing
• Mediating stress
• AvoidingTriggers
• Oatmeal baths
• Salt water baths
• Showering with luke warm water
• Non-irritating soaps/detergents
• Routine sunscreen (SPF30)

Question 5

Guidelines

Answer 5

Mild-Mod
*Topical Agents +/- Phototherapy +/- Systemic Agents

Severe
*Systemic Agents OR Biologic Therapy +/- Topical Agents

Question 6

Topical Corticosteroids (TCS) Considerations

Answer 6

Low: des, triam, hc
Med: flu, triam
High: flu, triam, des, beta
Super: aug beta, clob, flu
*increase conc as go up
*triam 0.25, 0.5
*flu 0.025, 0.05, 0.1

Question 7

Oral Systemic Agents: Acitretin and Apremilast

Answer 7

Acitretin:
-Hypertriglyceridemia, hepatoxicity
-NOT in pregnancy within 3 yr
HH3

Apremilast (Otezla):
-Depression/suicidal risk for depressive hx
-Weight loss
-Slow dose increase to 30 mg BID (less GI)
-Less AE in comparison
-Renal adj
DR. SW

Question 8

Oral Systemic Agents: Cyclosporine and Methotrexate

Answer 8

Cyclosporine:
-Risk of renal toxicity
-Hypertension
-Hypertriglyceridemia
-Caution in patients with cancer history

Methotrexate:
-Hepatotoxicity
-Requires lab monitoring
-CI in pregnancy/breast feeding
-Caution in patients with cancer history

Question 9

TNF Inhibitors: Severe TX Dosing
ADA, CERT, ETA, INFLIX

Answer 9

Adalimumab
-LD: 80 mg
-MD: 40 mg Q2W

Certolizumab
-LD: only if < 90 kg, 400 mg
-MD: > 90 = 400, < 90 = 200 q2w

Etanercept
-LD: 50 mg twice weekly X 3 mo
-MD: 50 mg Q1W

Infliximab
-LD: 5 mg/kg IV
-MD: 5 mg/kg IV q8w

Question 10

IL-12/23 Inhibition: Severe TX Dosing

Answer 10

Ustekinumab

> 90 kg
-LD: 90 mg Day 1, Day 29
-MD: 90 mg q12w

< 90 kg
-LD: 45 mg Day 1, Day 29
-MD: 45 mg q12w

WEIGHT BASED DOSING

Question 11

IL-17 Inhibitors: Severe TX Dosing
BRO IXE SECU

Answer 11

Brodalumab
-LD/MD: 210 mg wk 0, 1, 2 and then q2w

Ixekizumab
-LD/MD: 160 mg day 1, 80 mg q2w then q4w

Secukinumab
-LD/MD: 300 mg weekly X 5, then 300 mg q4w

IBS low to high 160, 210, 300

Question 12

IL-23 Inhibitors: Severe TX Dosing
RIS GUS TILD

Answer 12

Risankizumab
-For Crohn’s there is an On-Body Injector at a higher 360 mg dose:
-CANNOT USE FOR PSORIASIS
-Only 150 mg 1/29, q12w

Guselkumab
-LD/MD: 100 mg 1/29, q8w

Tildrakizumab
-LD/MD: 100 mg 1/29, q12w

Question 13

Considerations before starting biologics

Answer 13

-Current regimen (tried/failed first lines)
-Vaccinations (no lives)
-Infections (don’t start during active)
-Preg: Cimizia/CERT preferred
-Hold for surgery

Question 14

Comorbidities

Answer 14

NO TNFs (ACEI)
-CHF, MS

NO IL 17s (IBS)
-Crohn’s, depression for Brodalumab

NO FOR ALL IN ACTIVE INFECTIONS