Psoriasis

• Definition and causes• Types• GP management• Pitfalls• Hospital treatments

Psoriasis

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 keratinocyteproliferation

• Environmental and genetic factors

PsoriasisGenetics• 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, psoriasis-association.org.uk)• Follow-up

• Emollients• Bath oils• Site-specific topical treatments

GP Management

• Vitamin D analoguesDovonex (calcipotriol) ointDovobet (calcipotriol & betamethasone) oint or gelSilkis (calcitriol) ointCuratorderm (tacalcitol) oint & lotionZorac (tazarotene) gel (retinoid)

• Dovonex cream and scalp application no longer available

Topical treatments

• TarCarbo-domeExorexPsoridermAlphosyl HCSebcoCocoisTar-based bath oils & shampoos

Topical treatments

• SteroidsOften in conjunction with Vit D analogue as Dovobet or separate steroidEumovate (only oint available)TrimovateScalp preparations (eumovate to dermovate strength)

• BE CAREFUL (but not mean)

Topical Treatments

• DithranolDithrocreamMicanolPsorin

• Stains skinHas to be washed offStart and low strength and build up

Topical Treatments

Topical treatments• Nails

difficultpotent topical steroidsdovonextazarotenesystemic therapy

Scalp• Remove scale first• Sebco messy but effective• Tar or salicylic acid shampoo• Topical steroids if necessary for

short periods

Topical Treatments

Types of psoriasis

• Plaque• Guttate• Rupioid• Unstable• Pustular• Erythrodermic• ?palmo-plantar pustulosis

Guttate psoriasis

Pustular psoriasis

Erythrodermic psoriasis

Plantar pustulosis

Acrodermatitis continua of Hallopeau

• 'It's not working Doc'• It did work, but then he stopped

using it and the psoriasis returned• It was too greasy/time-

consuming/smelly so he stopped using it

• He wasn't applying it properly• It really didn't work

Pitfalls

Hospital Treatment• 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

Methotrexatemec: inhibits DNA synthesis by inhibiting

dihydrofolatereductase → 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

CiclosporinMec 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 drugsInfliximab, etanercept, adalimumab

Targeted T - cell therapyalefacept (binds CD2 & blocks LFA3)

efalizumab (binds to LFA-1 & blocks ICAM-1)

Anti-IL 17 receptor antibodies

Brodalumab Ixekizumab

• 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!

GP Issues

SIGN 121

Patients with psoriasis or psoriatic arthritis should have an annual review with their GP involving the following:documentation of severity using DLQIscreening for depression�assessment of vascular risk (in patients �with severe disease)assessment of articular symptoms�optimisation of topical therapy�consideration for referral to secondary care�