Psoriasis (exam 1) Flashcards
Psoriasis presentation
sharp demacrated, erythematous papule and plaques with silver white fine scales
where is psoriasis typically found?
on the elbows, knees and scalp
can sometimes affect the nails
which is the most common type of psoriasis
chronic plaque psoriasis
what can cause psoriasis?
cell mediated immune mechanisms
autoimmune disease
genetics
polymorphisms of vitamin D receptor
medications that can exacerbate psoriasis
lithium carbonate
beta blockers
antimalarials
tetracyclines
what can exacerbate psoriasis?
smoking, alcohol, stress, infection
injury, trauma
medications
goals of therapy of psoriasis
decrease the size/thickness of plaques
improve quality of life
remission
chronic plaque psoriasis diagnosing criteria
mild - less than 5% BSA
moderate - 5-10% BSA
severe - more than 10% BSA
consideration for addition of agents in psoriasis is based on
disease severity
cost
convenience
mild to moderate psoriasis first line
topical agents
mild to moderate psoriasis second line
topical agents and phototherapy (if feasible)
mild to moderate psoriasis third line
topical agents and systemic therapy
what topical agents are typically given as first line for mild-moderate psoriasis
moisturizers (emollients)
intermittent topical corticosteroids
once mild-moderate psoriasis is controlled
step down to lower doses/potencies that maintain control of disease
for psoriasis, topical corticosteroids are generally continued
as long as the patient has thick active lesions
once clinical improvement of mild-moderate psoriasis occurs, application of topical corticosteroids should be
reduced as intermittent maintenance
what can be used to avoid long term intermittent topical corticosteroids?
topical immunosuppressives
salicylic acid
tazarotene
calciptriene (Dovonex)
calcitrol (Vectical)
synthetic vitamin D analogs reduce _______________ by binding to receptors in ______________________
cell proliferation
epidermal keratinocytes
coal tar (T gel) and anthralin (Zithranol or Dritho-creame) are used only in
adults
coal tar and anthralin MOA
inhibition of keratinocyte proliferation and anti-inflammatory
when coal tar or anthralin are used in combination with ultraviolet B light,
they inhibit epidermal DNA synthesis reducing plaque elevation
side effects of coal tar and anthralin
increases sensitivity to UV light and the sun
local irritation
unpleasant odor
stains skin and clothing
new alternative topical treatments for mild-moderate psoriasis
Vtama (tapinarof) cream
Zoryve (roflumilast) cream
chronic plaque psoriasis plaques typically ______________________ of treatment
recur after cessation
maintenance regimen for mild-moderate plaque psoriasis
intermittent treatment with previous topical corticosteroid
add a vitamin D analog
can do just vitamin D analog alone
severe psoriasis first line therapy
biologics
treatment for moderate to severe psoriasis
phototherapy
systemic non biologics
biologic agents
moderate to severe psoriasis first line therapy
systemic oral agent with topical agent or phototherapy
or
consider BRM if comorbidities
moderate to severe psoriasis second line therapy
more potent systemic oral agent
or
2 or more systemic agents in rotation with topical agent
moderate to severe psoriasis third line therapy
biologic response modifier with other agents
ultraviolet A vs B
A - penetrates deeper in the skin, takes 20 minutes per session
B - exposure times first few sessions 30-60 seconds
how many times is light therapy used per week?
what to do when there is a satisfactory response?
2-3 times per week
taper to lowest required to maintain improvement
PUVA
psoralens and ultra violet A
Uvadex (oral methoxsalen)
shorter photosensitization onset
produces a triplet electronic state
taken 1.5-2 hours before UVA light exposure
three common combination therapies of photochemotherapy
psoralen and UVA
Anthralin and UVB
coal tar products and UVB
acitretin
systemic retinoid
normalizes epidermal differentiation diminishes hyper proliferation and inflammation
acitretin is contraindicated in
pregnancy
program to monitor acitretin
Take Action to Prevent Pregnancy (TAPP)
program material for TAPP
patient agreement/informed consent form
authorization for use
voluntary patient survey and registration form
differences between TAPP and IPLEDGE
males have no limit on duration of treatment
females need a pregnancy test every 3 months for at least 3 years after stopping
no blood donation for 3 years after stopping (both males and females)
Otexzla (apremilast)
PDE4 inhibitor
stops inflammation
2nd line for mod-severe psoriasis
warnings/precautions for Otexzla
depression
weight decrease
GI symptoms
Important considerations for patients when taking Otexzla
titrate to recommended dose over 4-7 days to avoid risk of GI symptoms
Sotyktu (deuvravacitinib)
selective inhibitor of tyrosine kinase 2 (JAK family)
2nd line for mod-severe psoriasis
over immunosuppressive therapy for 2nd line treatment of moderate-severe psoriasis
cyclosporine (neoral, sandimmune)
methotrexate
biologic response modifiers for 3rd line treatment of moderate-severe psoriasis
entrercept (Enbrel)
adalimumab (Humira)
certolizumab (Cimzia)
Infliximab (Remicade)
biologic response modifiers (BRM)
binds to TNF cytokines
regulate the body’s immune response to infection and inflammation
for patients with failure to response to TNF inhibitors,
another agent in this class may be tried
anti-interleukin cytokine biologic agents for third line treatment of moderate-severe psoriasis
Stelara
Cosentyx
Taltz
Tremfya
Siliq
Ilumya
Skyrizi
are TNF inhibitors or anti-interleukin cytokine biologic agents preferred for moderate-severe psoriasis?
anti-interleukin cytokine biologic agents
warning/precautions for BRMs
formation of neutralizing anti-drug antibodies – loss of efficacy
hypersensitivity reactions within 2 hours of infusion
JAK inhibitor warnings
