Psoriasis Therapeutics Flashcards
true or false
psoriasis is immune mediated
true
true or false
we can cure psoriasis
false - goal is just to control
normalize the skin and increase the pliability
true or false
psoriasis can be drug induced
true
important to ask what meds people are on
1st line for limited plaque psoriasis
1st line for moderate-severe plaque psoriasis
limited - topical corticosteroids + emollients (moisturizer)
(alternative is topical vitamin D, topical retinoids, coal tar and anthralin)
moderate-severe: phototherapy or systemic therapies (retinoids - not iso, methotrexate, cyclosporine, apremilast, biologics) ADJUNCTIVE WITH TOPICAL
alternative agents for limited plaque psoriasis (besides topical corticosteroid + emollient)
topical vitamin D
topical retinoids
coal tar preparations
anthralin
Topical calcineurin inhibitors
systemic agents for moderate-severe plaque psoriasis
retinoids
methotrexate
cyclosporine
apremilast
biologic immune modifying agents
true or false
isotretinoin is a systemic agent that can be used for psoriasi
FALSE - only acne
patient adherence may be the largest barrier to treatment success with ______ therapies for psoriasis
topical
true or false
in moderate-severe plaque psoriasis, the systemic therapies can also have topical therapies as adjunctive agent
TRUE
explain treatment algorithm for mild-moderate psoriasis
topical agents
if not working—
topical agents + phototherapy
if not working…
topical agents + systemic agent
ALL ARE USED WITH MOISTURIZERS
explain treatment algorithm for moderate-severe psoriasis
systemic agent with or without topical agent or phototherapy
if not working….
more potent systemiic agent and 2 or more systemic agents in rotation with or without topical
if not work
biologic with or without other agents(biologic can also be first line, but very costly)
ALL USED WITH MOISTURIZER
When using topical agents for mild-moderate plaque psoriasis, around how long does it take to see improvement
1-2 months
can combination regimens be used for mild-moderate plaque psoriasis
yes - localized phototherapy + topical
for moderate-severe plaque psoriasis, they are initially treated with _____ if possible
phototherapy, in combination with topical therapies
as mentioned, for mod-severe plaque psoriasis, first line is photherapy + topical if needed
if there is a contraindication to phototherapy, or they have PSORIATIC arthritis, what is used instead?
systemic agents like retinoids, methotrexate, cyclosporine, and biologic immine-modifiers
a BSA of how much is considered mild/moderate/severe?
mild is less than 3% BSA
moderate is 3-10% BSA
severe is greater than 10% BSA
what biologic therapies are used for plaque psoriasis? (general class)
TNFa blockers and IL17A blockers
name 3 TNFa blockers used in moderate-severe plaque psoriasis
adalimumab
infliximab
etanercept
name 3 IL-17A blockers used in plaque psoriasis
Brodalumab
Ixekizumab
Secukinumab
which vehicle is the BEST for psoriasis topical preparations and explain why
OINTMENTS
they’re hydrating, remove the scales and have the greatest bioavailability
disadvantage of using ointments and what is done to counteract this
very greasy - pt may not like
so, we typically use creams during the day and ointments at night if this is an issue
advantages/disadvantages of creams for psoriasis
advantage - high pt acceptance and less greasy than ointments
disadvantage - not as hydrating as ointments are
which 2 vehicles are drying and thus not preferred for psoriasis?
which of these is the MOST drying
gels and lotions
gels are the most drying
advantages and disadvantages of gels and lotions for psoriasis
gels - nongreasy and can be applied to hairy areas/ high pt acceptance
lotions - again, easy to apply to hairy area, including scalp. high pt acceptrance
disadvantage - both are drying. lotions have low bioavailability
where are lotions preferred to be applied
intertriginous (where the skin rubs together) and hair areas, face
can be applied to scalp
where are gels preferred to be applied
hairy areas (but still extremely drying - not preferred at all)
what areas are ointments applied
smooth skin with short or little hair
what areas are creams applied
smooth or hairy areas, and intertrignous areas (where skin rubs together)
the optimal vehicle choice is often the one that what?
the patient will use!!! if pt doesnt want ointment, dont give it to them. they will not use it
ADHERENCE IS THE BIGGEST THING
keep patient’s preferences in mind always
if you had to pick 2 things that are “first line” for psoriasis, what would they be
topical corticosteroids! and topical vitamin d analogs
topical retinoids and calcineurin inhibitors and PDE4 inhibitors are more 2nd line
how do topical CS work in psoriasis
ANTI INFLAMMATORY
what CS potencies are typically used in psoriasis?
explain
mid-high potencies
DO NOT START LOW. as the lesions get better. we can start to decrease the potency (usually at around 2 weeks) OR apply less frequently. the goal is to be able to control psoriasis and work our way down to the lowest possible potency to avoid ADRS
name a situation in which LESS potent CS’s would be used 1st for psoriasis instead of mid-high
for sensitive areas like the groin and face
explain how to apply topical CS for psoriasis
apply the drug, and then wrap in an occlusive dressing to increase penetration (typically for elbows and knees)
true or false
if a patient is using topical corticosteroids for psoriasis, they should NOT abruptly discontinue
TRUE
can lead to rebound flares
since the pt may have varying potencies of topical corticosteroids at different stages of psoriasis….
education is very important!!!
common side effects of TOPICAL corticosteroids
include some pt education
purpura (purple-red spots), striae, telangiectasias, skin ATROPHY
skin atrophy is actually desired at areas affected by psoriasis
however, we don’t want this on the healthy skin around it
to prevent this, educate pt to put a layer of emollient/vaseline on the normal skin to reduce the chance of AE on healthy skin
SYSTEMIC side effects of oral CS — not really topical
HPA suppression, glucose intolerance, cushing syndrome
how many groups of topical CS are there and which class is the most potent
1-7
class 1 is SUPERPOTENT
True or false
we typicall start with high doses of topical CS for psoriasis
TRUE
and then work our way down as lesions get better
TRUE OR FALSE
emollients should only be used if the psoriasis is severe
FALSE - should be used at every stage to moisturize the skin and minimize the symptoms of itching and tenderness
what are the 2 kinds of emollients and differentiate them
occlusive and humectant
occlusive works by keeping moisture IN and can’t leave the epidermis by forming an oily film on the skin.
humectant enhances the hydrating properties of emollients by pulling more water in
side effects of using emollients
can cause acne and exacerbate existing acne, dermatitis, but generally well tolerated
name 3 OCCLUSIVE emollients
petrolatum, lanolin, silicone
name 3 humectant emollients
glycerin
urea
pyrolidone carboxylic acid
-when are emollients typically applied?
are they used in combination with anything else?
which vehicles are preferred and why?
after a hydrating bath or shower, 2-3 times a day
can be used with other topical agents
creams and ointments preferred over lotions bc they’re thicker and more occludsive
how often are emollients typically applied in psoriasis
2-3 times a day
true or false
vitamin D analogs are 2nd line for psoriasis
false - also first line like topical CS
sometimes used in combo with them, but not often - usually 1 or other
are vitamin D analogs safe for pregnancy
questionable - they’re category C
name 2 topical vitamin D analogs used in psoriasis
calcipotriene
calcitriol
typicall ADRS of topical vitamin D analogs
mild irritant, contact derm, burning, pruritis, edema, peeling, erythema
SYSTEMIC side effect of topical vit d analogs
is it common
hypercalcemia
VERY RARE - only if using A LOT
how often are topical vitamin d analogs applied
how long does it take to start seeing improvement
2x a day
around 2 weeks and can take up to 8 to see the full effect
if there’s no improvement by 8 weeks, consider other therapy
if using a topical vitamin D analog AND phottherapy, when should each be done
apply the vitamin D AFTER UVA because it can be inactivated by it
