Psoriasis Flashcards
What is psoriasis characterized by?
I DAVES - Inflammation, Disease waxes and wanes, altered maturation of skin, vascular changes, epidermal hyperproliferation secondary to activation of immune system, Scaly, erythematous patches, papules and plaques that are itchy
What does psoriatic skin look like compared to regular skin on an epidemal cross sectional slide in a microscope
Psoriatic skin has proliferation of epitheliasl cells much deeper
What cell mediates the immue response for psoriasis
T-cells
What is the age of onset of psoriasis?
15-25 yrs old
What is psoriatic arthritis?
skin symptoms of psoriasis that precedes development of the joint symptoms of arthritis
What stimulates the keratinocyte huyperproliferation?
Interleukins (1,6,8,12,17,23), TNF
Where are the IL and TNF released from that cause the hyperproflieration of keratinocytes?
T-cells and keratinocytes
What kind of vascular changes happens during PsO
vasodilation, hyperpermeability, angiogenesis
with joint involvment, what invades the synovium and causes bone resorption and destruction?
The ILs(1,6,8,2,17,23) and TNF
Macrophages and T cells release ____ and it acts of 3 sites. What are the three sites and what is the outcome.
It releases TNF and IL 1, 6, 8, 12, 17, 23. They act on Endothelial cells, Keratinocytes and T-cells: which cause inc adhesion mol, VEGF; hyperproliferation and release of proinflammatory cytokines; induction of IL-1, il-6 and IL-8
What are some causes of PsO?
Genetic, stress, injury to skin, infections, medications, weather
What are the 9 different types of PsO
Plaque/Guttate/Pustular/inverse/erythrodermic/nail/palmar/plantar/scalp/psoriatic arthritis
What joints are usually affected in arthritic PsO?
DIP
What is affected more, finger or toe nails?
finger nails
What are some typical nail changes?
onycholysis (separation from the nail bed), pitting, oil-drops, hyperkeratosis (thickening), discoloration
What are some comorbidities with PsO?
arthritis, CD and UC, CV, metabolic syndrome
What are some assessment tools?
PASI, PGA, BSA, pt assessments of disease and QOL
What do you tx a pt with if they have Psoriasis with psoriatic arthritis?
Anti-TNF’s +/- MTX or just try MTX alone
What are some Anti-TNF’s
etanercept (Embrel), adailumumab (Humira), Infliximab (Remicade), Golimumab (Simponi but not for PsO)
If you have limited Psoriasis with no psoriatic arthritis what do you use first?
Tocials/targeted phototherapy (like Corticosteroid cream and Vit D)
If you dont have psoriatic arthritis but you have extensive disease, or there is no effect from topicals then what do you use?
systemic tx or biologics (anti-TNF or non anti-TNF)
What topicals do you use in mild (limited) disease for PsO?
Topical Corticosteroids, retinoids (vit A), vit D, anthralin, Tar, keratolytics, lubricants
Why are emollients or moisturizers used?
To moisturize, lubricate and soothes dry and flaky skin; retains moisture in the stratum corneum
How often are emollients and mositurizers uesed? contraindications?
1 - 3 times a day; no known ones
What is a common Keratolytic? What is the dose and the frequency? What does it do? What are some adverse effects?
Salicyclic acid (2-6%), apply 1-3 times a day. helps remove scales and reduce hyperkeratosis; can cause skin irritation and systemic absorption
What is a contraindication with salicylic acid topical for PsO?
UVB phototheray
How does Coal Tar work?
suppresses DNA, dec epidermal cell proliferation and scale development
What concentration of coal tar is the most effective?
5%
What are the 4 problems with coal tar?
SSSS: Smell, Sting, Stain, Sensitize
What are some adverse effects of coal tar?
Skin irriation, contact dermatitis, folliculitis, photosensitivity, staining
Can coal tar be used for scalp PsO? How?
yes, shampoo
What is Goekerman regimen?
Coal Tar + UV
What are the 4 properties of Corticosteroids?
Anti-inflammatory, dec in vascular permeablility, antiproliferative, immunosuppressive
What are the different levels of potency?
1-7 (1 is most potent, 7 is least potent) 1 is up to 92%, 7 is as low as 41%
what potency is hydrocortisone?
lowers potency (5,6,7)
What potency is clobetasol propionate?
highest potency (1)
what potency is Fluocinonide?
2 or 3,4
What potency is mometasone furoate?
2
What potency is diflorasone diacetate?
1
What usage restriction is on class 1 topical corticosteroids?
no more than twice daily for up to 2-4 weeks
What are some adverse effects of corticosteroids (topical)
burning, itching, skin atrophy, erythema, folliculities, excessive hair growth, acne, rebound PsO if abrubtly stopped
What are some rare systemic side effects?
hypothalamic-pituitary-adrenal axis suppression
What is calcipotriene? Brand name?
Vit D3 analogue; Dovonex
What is the MoA of Dovonex?
inhibits proliferation and inc differentiation of keratinocytes and decreases T-cell infiltration
What is Dovonex used to tx?
plaque PsO
What is the dose and dosage forms of calcipotriene?
0.005% cream, ointment and scalop solution applied QD or BID; often used in combination with corticosteroids
How long does it take the theraputic response to occur for Calcipotriene (Dovonex)
2 wk
Maximal effect of calcipotriene (dovonex) can take up to how long?
6-8 wk
Side effects from Dovonex?
burning, itching, skin irritation; redness, rash, dermatitits;
What are some serious but rare side effects of Calcipotriene (Dovonex)
inc Ca and dec parathyroid hormone
Can Vit A derivatives be used for PsO?
yes (topical Retinoids)
What is an example of a topical Retinoid?
Tazarotene (Tazorac)
How does Tazarotene work?
reduces keratinocyte proliferation, reducees inflammation and normalizes abnormal keratinocyte differenetatioan
What is Tazarotene indicated for?
plaque psoriasis
What is the dose and dosage form of Vit A Retinoids like Tazarotene
0.05% and 0.1% cream and gel applied QD
How long does it take to see the clinical efficacy of Tazarotene?
1-2 weeks
side effects of Tazarotene?
same as Vit D and cortico except for fissuring, inc sensitivity to sunlight
What pt population is Tazarotene contraindicated in?
Pregnancy (X)
Are there oral retinoids?
yes
What is the name of the two oral retinoids?
Etretinate & Acitretin
What is the brand name of Acitretin
Soriatane
What type of psoriasis is Acitretin for? WHy is it reserved for severe forms?
pustular and erythrodermic psoriasis; due to side effects
Etretinate was withdrawn from US market; but Acitretin is related to it how?
It is the active metabolite.
What is the MoA of Soriatane?
Unknown
What is the indication of Soriatane?
severe PsO
What is the dose of Acitretin?
25-50mg QD
What is the adverse effect profile of Acitretin (Soriatane)?
dryness and inflammation of the lips, alopecia, skin peeling, dry skin, rhinitis, nose bleeds, nail disorders, itching, thickening of the conjunctiva, joint pain, spinal hyperostosis, depression
What do I think are the important side effects of Soriatane?
depression, joint pain, alopecia, pregnacy X
Are the oral retinoids contraindicated in pregnanacy?
Yes
What are the two BBW to the oral retinoid, Soriatane?
Female pts should not injest ethanol during tx w/ or for 2 months after cessation of therapy; male pts should not d onate blood druing and for at least 3 yrs following Soratane therapy
What are some precautions associated with Soriatane (acitretin)?
teratogenic, BBWs, hepatotoxicity, lipid abnormalities, eye, bone, pancreatitis, benign intracranial hypertension
What should you monitor while on Soriatane?
glu, lipids, LFTs
What drugs should you avoid with Soriatane due to the inc risk of intracranial pressure?
Tetracyclines
What is the MoA of MTX
block folic acid synthesis by inhibiting dihydrofolic acid reductase; inhibits DNA synthesis
What is the dosing of MTX?
7.5mg QW; 2.5mg at 12hr intervals
preg category of MTX?
X
What are some contraindications of MTX?
avoid in oral antibiotcis, pts w/ alcoholism (liver damage), immunodeficient pts, pts with blood dyscrasias
Slide 33 Has a list of Warnings for MTX.
What are they?
What should you monitor when on MTX?
CBC and platelet counts; LFTs, RFTs, Chest X-ray (infection), liver biopsies with long term use
What are the serious adverse effects of MTX?
hepato and renal toxicity, bone marrow suppression, immunosuppression, malignant lympomas, D/N, abdominal distress, Ulcerative stomatitis, lung disease, skin reactions, alopecia, photosensitivity (burning of skin leasions)
How does Cyclosporine work?
It as an immunosuppressant that stops T-lymphocyte prolieration at the G0 or G1 phase of the cell cycle
What is cyclosporine used for?
recalcitrant, plaque psoriasis (non-immunocompramised) who have failed to other systemic therapy
Is there an oral for? what is the brand name?
Yes, Neoral
What is the dose for cyclosporine?
2.5mg/kg/day PO for 4 wks; if no improvment in 4 wks; inc by 0.5mg/kg/day q 2 wks to a max of 4mg/kg/day or until you see clinical benefit
What is the other brand name of cyclosporine?
Sandimmune
What brand has increased %F?
Neoral, so its not bioequivalent
What are the 5 black box warnings with cyclosporin (Sandimmune, Neoral)?
inc risk of infection, neoplasia, HTN, nephrotoxicity, previous tx with MTX, PUVA, immunosuppressive agents, coal tar, radiation therapy are at an inc risk of skin malignancies while taking cyclosporine
What are three things to monitor with cyclosporine?
RFTs, HTN, CBC
What are some adverse effects of Cyclosporine (HHHHIPMNR)
HA, HTN, hypertriglyceridemia, Hirsutism, influenza-like synmptoms, paresthesia, musculoskeletal or joint pain, N/V/D, renal dysfunction
What does PUVA stand for and how does it work?
Psoralen + UVA (320-400nm); psoralen binds to DNA and breaks it once light is shown on it
What nm range is the best for psoriasis?
313
What is narrowband? Which is more effective? how many txs?
311nm, narrowband, 2-5 tx
When is Psoralen given?
2 hr before UVA exposure 2-4/wk - 25 tx are required for clearance
What are some adverse effects of PUVA?
N/Pruritus/Erythema, skin burning, Carcinogenicity
What are some warnings with PUVA?
skin cancer, premature aging, skin burning,
What tx should you avoid for PsO in pts taking PUVA?
photosensitizing agents (coat tar, anthralin), cyclosporin, MTX and hepatic and cardiac disease
What are the three anti-TNFs for PsO?
Etanercept (Enbrel), Adalimumab(Humaira), Infliximab (Remicade)
What is the T-cell inhibitor for PsO?
Alefacept
What is the IL-12/23 inhibitor for PsO?
Ustekinumab
How does Enbrel work?
soluble Fc of human and IgG1 and binds TNF
What is the dose for psoriasis? psoriatic arthritis?
50mg BiWk for 3 months then 50mg QW; 50mg SQ QW
Boxed warnings for Enbrel?
serious infections (TB, sepsis, fungal infections); malignancies
Can Enbrel be used in pts with alcoholic hepatitis?
no
What is the MoA of remicade?
binds and blocks TNF receptor
BBW for remicade?
Infections (TB, Sepsis, fungal infections), cancer
What are some common side effects of remicade?
infections, HA, abdominal pain
MoA of Humira?
binds and blocks TNFalpha receptor
BBW for Humira?
serious infections (TB, fungal, sepsis), cancer
Can the three anti-TNF have hypersensitivity reactions?
yes
Can you used the Anti-TNF with anakinra or abatacept?
No
Can the three anti-TNF be used with heart failure?
No
What are some common side effects of Humira?
HA, rash, infection
common side effects of enbrel?
infection, infusion site reactions
brand name of alefacept? What is the MoA?
Amevive, stops T-cell lymphocyte activation
What are some warnings for Amevive?
lymphopenia, malignancies, infections, liver damage
What are some common side effects of Amevive?
pharyngitis, Dz, N, inc cough, pruritus, myalgia, chills, injection site pain
What is the brand name of ustekinumab?
Stelara
What is the MoA of Stelara?
antibody against IL-12 and IL-23 cytokines
What is the only disease that amevive (alefacept) and Stelara (ustekinumab) indicated for?
PsO
What are some warnings for Stelara?
infection, malignancies, hypersensitivity, RPLS, immunizations, use with immunosuppressive agents
Common adverse events of Stelara?
infections, HA, fatigue
What other pt population should u avoid stelara in?
CV pts
