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Psoriasis
DR YAZAN ALRASHDAN
DEPARTMENT OF BIOPHARMACEUTICS AND CLINICAL PHARMACY
FACULTY OF PHARMACY
UNIVERSITY OF JORDAN
[email protected]
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Definition and facts
Epidemiology
Classification
Signs and symptoms
Etiology
Diagnosis
Management
Prognosis
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University of Jordan/Faculty of Pharmacy
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• A a common chronic inflammatory skin disorder characterized by
recurrent exacerbations and remissions of thickened, erythematous,
and scaling plaques.
• Occurs when the immune system sends out faulty signals that speed
up the growth cycle of skin cells.
• Is NOT contagious.
• Occurs on the skin of the elbows and knees, scalp, palms of hands and
soles of feet, and genitals.
• Fingernails and toenails are frequently affected.
• Can also cause inflammation of the joints (psoriatic arthritis; 10-40%).
• The cause not fully understood, however, genetics plus local psoriatic
changes are the favorable perpetrators.
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University of Jordan/Faculty of Pharmacy
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Epidemiology
• Psoriasis affects both sexes equally.
• Can occur at any age (most commonly appears for the first
time between the ages of 15 and 25 years).
• The prevalence of psoriasis in Western populations is
estimated to be around 2-3%.
• Around one-third of people with psoriasis report a family
history of the disease.
• Onset before age 40 usually indicates a greater genetic
susceptibility and a more severe or recurrent course of
psoriasis.
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University of Jordan/Faculty of Pharmacy
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Classification
• Non-pustular:
- Psoriasis vulgaris: the most common (80-90)%
- Psoriatic erythroderma: often results from exacerbation of
vulgaris particularly following the abrupt withdrawal of systemic
treatment.
• Pustular:
- Appears as raised bumps that are filled with pus.
- The skin under and surrounding the pustules is red and
tender.
- Can be localized to the hands and feet or generalized with
widespread patches occurring randomly on any part of the body.
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University of Jordan/Faculty of Pharmacy
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Signs
• The typical lesion is a well-demarcated, pink to salmon-colored
plaque covered by loosely adherent scale that is
characteristically silver-white in color.
• Nail changes occur in 30% of cases of psoriasis and consist of
yellow-brown discoloration, with pitting, dimpling, separation of
the nail plate from the underlying bed, thickening, and
crumbling.
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University of Jordan/Faculty of Pharmacy
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Symptoms
• Relatively asymptomatic.
• Pruritus is a complaint in about 25% of patients.
• Severe, widespread psoriasis can involve fever and chills.
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University of Jordan/Faculty of Pharmacy
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• Severity:
- Mild
- Moderate
- Severe
• The Psoriasis Area Severity Index (PASI):
- The most widely used measurement tool for psoriasis.
- Combines the assessment of the severity of lesions and
the area affected into a single score in the range 0 (no
disease) to 72 (maximal disease).
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Etiology
• There are two main hypotheses:
1. Considers it as a disorder of excessive growth and
reproduction of skin cells (the problem is simply seen as a fault
of the epidermis and its keratinocytes).
2. Considers it as being an immune-mediated disorder in
which the excessive reproduction of skin cells is secondary to
factors produced by the immune system.
- T cells become active, migrate to the dermis and trigger
the release of cytokines (TNFα) which cause inflammation and
the rapid production of skin cells.
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University of Jordan/Faculty of Pharmacy
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University of Jordan/Faculty of Pharmacy
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• Triggering/Aggravating factors:
- Stress (physical and mental)
- Skin injury (Koebner phenomenon)
- Streptococcal infection
- Changes in season and climate
- Certain medicines (lithium salt, β-blockers & chloroquine)
- Excessive alcohol consumption, smoking and obesity
- Hairspray, some face creams and hand lotions
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University of Jordan/Faculty of Pharmacy
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Genetics
• Psoriasis has a large hereditary component.
• The MHC and T cells play pivotal role.
• PSORS1 through PSORS9.
• The major determinant is PSORS1 (accounts for 35-50%). It
controls genes that affect the immune system or encode
proteins that are found in the skin in greater amounts in
psoriasis:
- HLA (MHC-1)
- IL12B
- IL23R (interleukin-23 receptor)
upregulating TNFα and NFκB
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University of Jordan/Faculty of Pharmacy
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Chemical Mediators of Inflammation in Psoriasis (CMI)
CMI
Cell Type
Outcome
GM-CSF
T cells
mononuclear cells, neutrophils
INF- γ
T cells
E selectin, ICAM, IL4, keratinocytes, MHC I and II,
VCAM, TH2
IL-2
T cells
macrophages, TH1 cells
IL-3
T cells
dendritic cells, macrophages
IL-8
Keratinocytes, neutrophils
vascular response
IL-12
APC
TH1 cells
IP-10
Keratinocytes
leukocyte adhesion
MIG
Keratinocytes
leukocyte adhesion
RANTES
Keratinocytes
IL-12
TNF- α
Keratinocytes, macrophages,
E selectin, ICAM
T cells
TH1 cells, VCAM
Keratinocytes, T cells
angiogenesis
VEGF
APC, antigen-presenting cell; GM-CSF, granulocyte-macrophage colony-stimulating factor; ICAM, intercellular adhesion
molecule; INF, interferon; IL, interleukin; IP, inflammatory protein; MHC, major histocompatibility complex; MIG, monokine
induced by interferon-; RANTES, regulated on activation, normal T-cell expressed and secreted; TNF, tumor necrosis factor;
TH1, T-helper cell type 1; TH2, T-helped cell type 2; VCAM, vascular cell adhesion molecule; VEGF, vascular endothelial growth
factor.
Data from Mehlis S, Gordon KB. From laboratory to clinic: Rationale for biologic therapy. Dermatol Clin 2004;22(4):371–377, vii–
viii.
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• Diagnosis:
- Based on the appearance of the skin.
- There are no special blood tests or diagnostic procedures.
- A skin biopsy (or scraping) may be needed to rule out other
disorders and to confirm the diagnosis.
- When the plaques are scraped, one can see pinpoint
bleeding from the skin below (Auspitz's sign)
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University of Jordan/Faculty of Pharmacy
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Management/Treatment
• Topical agents:
1. Moisturizers, mineral oil, and petroleum jelly may help
soothe affected skin and reduce the dryness which accompanies
the build-up of skin on psoriatic plaques.
2. Ointment and creams containing:
- coal tar
- dithranol (anthralin)
- corticosteroids (desoximetasone & fluocinonide)
- vitamin D3 analogues
- retinoids
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University of Jordan/Faculty of Pharmacy
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• Phototherapy:
- Wavelengths of 311–313 nm are most effective.
- The amount of light used is determined by a persons skin
type.
- Increased rates of cancer from treatment appear to be small.
- Psoralen and ultraviolet A phototherapy (PUVA).
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University of Jordan/Faculty of Pharmacy
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• Systemic agents:
- Patients are required to have regular blood and liver function
tests because of the toxicity of the medication.
- Pregnancy must be avoided for the majority of these
treatments.
- Most people experience a recurrence of psoriasis after
systemic treatment is discontinued.
- Three main traditional systemic treatments are
methotrexate, cyclosporine and retinoids.
- Two drugs that target T cells are efalizumab and alefacept.
- MAbs (infliximab, adalimumab, golimumab and certolizumab
pegol).
- Recombinant TNF-α decoy receptor (etanercept).
- Antibodies have been developed against pro-inflammatory
cytokines IL-12/IL-23 and IL-17.
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• Alternative therapy:
- Fasting periods, low energy diets and vegetarian diets have
improved psoriasis symptoms in some studies, and diets
supplemented with fish oil.
- Ichthyotherapy, which is practised at some spas in Turkey,
Iran, Iraq, Croatia, Ireland, Hungary and Serbia.
- Hypnotherapy.
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University of Jordan/Faculty of Pharmacy
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University of Jordan/Faculty of Pharmacy
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