Download Psoriasis

Psoriasis
Psoriasis
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Definition and causes
Types
GP management
Pitfalls
Hospital treatments
Psoriasis
• Definition
A chronic, non-infectious,
inflammatory skin disorder, with well
defined, erythematous plaques &
large adherent silvery scales
• Prevalence 1.5-3%
• Age onset 20-30y or 50-60y
Psoriasis
• Epidermal
hyperproliferation
• Vascular dilatation
• Inflammatory infiltrate
What causes psoriasis ?
• T cell mediated autoimmune disease
→ increased keratinocyte
proliferation
• Environmental and genetic factors
Psoriasis
Genetics
• 40% have FHx
• 73% monozygotic twins concordant
v 20% dizygotic twins
• 1st degree relatives have 4-6 fold
increased risk
• Environmental triggers
GP Management
• Time (for proper examination and to
communicate with the patient)
• Explanation
• Information and support sources
(patient.co.uk, psoriasisassociation.org.uk)
• Follow-up
GP Management
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Emollients
Bath oils
Site-specific topical treatments
Topical treatments
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Vitamin D analogues
Dovonex (calcipotriol) oint
Dovobet (calcipotriol &
betamethasone) oint or gel
Silkis (calcitriol) oint
Curatorderm (tacalcitol) oint & lotion
Zorac (tazarotene) gel (retinoid)
Dovonex cream and scalp application
no longer available
Topical treatments
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Tar
Carbo-dome
Exorex
Psoriderm
Alphosyl HC
Sebco
Cocois
Tar-based bath oils & shampoos
Topical Treatments
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Steroids
Often in conjunction with Vit D
analogue as Dovobet or separate
steroid
Eumovate (only oint available)
Trimovate
Scalp preparations (eumovate to
dermovate strength)
BE CAREFUL (but not mean)
Topical Treatments
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Dithranol
Dithrocream
Micanol
Psorin
Stains skin
Has to be washed off
Start and low strength and build up
Topical treatments
• Nails
difficult
potent topical steroids
dovonex
tazarotene
systemic therapy
Topical Treatments
Scalp
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Remove scale first
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Sebco messy but effective
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Tar or salicylic acid shampoo
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Topical steroids if necessary for
short periods
Types of psoriasis
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Plaque
Guttate
Rupioid
Unstable
Pustular
Erythrodermic
?palmo-plantar pustulosis
Guttate psoriasis
Pustular psoriasis
Erythrodermic psoriasis
Plantar pustulosis
Acrodermatitis continua of Hallopeau
Pitfalls
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'It's not working Doc'
It did work, but then he stopped
using it and the psoriasis returned
It was too greasy/timeconsuming/smelly so he stopped
using it
He wasn't applying it properly
It really didn't work
Hospital Treatment
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Out-patient advice and support
UVB
PUVA
Acitretin
Methotrexate
Ciclosporin
Biologics
Admission (tar, other topicals)
UVB phototherapy
• Suitability – age, PH skin cancer,
medication, radiotherapy,
photosensitive disease
• X3 / week for ~6 weeks
• Shield genitalia, uninvolved sites
• SE burning (30%)
• ↑ risk skin cancer (screen yearly if
>150 treatments)
PUVA
• Suitability – as for UVB + CI in renal/hepatic
disease, cataracts, pregnancy, children
• X2 / week for ~6-8 weeks
• Need eye protection for 24 h after psoralen
• SE burning, nausea, itch
↑ risk skin cancer (screen yearly if >150
treatments)
Systemic therapy
acitretin
methotrexate
ciclosporin
7-20% of patients with psoriasis have arthritis
Acitretin
mec: affects keratinocyte differentiation
CI: ? fertile women (as must avoid
pregnancy for 2 years)
SE: dry lips, teratogenicity, abnormal
LFT, lipids, DISH
Methotrexate
mec: inhibits DNA synthesis by inhibiting dihydrofolate
reductase → reduces proliferation of lymphocytes +
keratinocytes
CI: pregnancy, lactation, infection, liver/renal disease,
peptic ulcers
SE: anorexia, nausea, myelosuppression, hepatotoxicity,
mouth ulcers, pulmonary toxicity, oligospermia, skin
cancer
Interactions: NSAIDs, septrin, trimethoprim, penicillin,
phenytoin
Given once a WEEK
Ciclosporin
Mec Inhibits T cell activation
CI uncontrolled HBP, malignancy, infection
SE HBP, nephrotoxicity, skin cancer, other
malignancy, gum hypertrophy
Not recommended for long term treatment
New Biologicals
Anti TNF drugs
Infliximab, etanercept, adalimumab
Targeted T - cell therapy
alefacept (binds CD2 & blocks LFA3)
efalizumab (binds to LFA-1 & blocks ICAM-1)
Anti-IL 17 receptor antibodies
Brodalumab
Ixekizumab
GP Issues
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Know what your patient is on
(?record as outside script on EMIS)
Know what monitoring you are
responsible for
Keep a look out for myelosuppression
Don't be afraid of your local Derm
department!
SIGN 121
Patients with psoriasis or psoriatic arthritis
should have an annual review with their
GP involving the following:
documentation of severity using DLQI
ƒscreening for depression
assessment of vascular risk (in patients
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with severe disease)
ƒassessment of articular symptoms
ƒoptimisation of topical therapy
ƒconsideration for referral to secondary care