Psoriasis

Psoriasis

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

Psoriasis• Definition

a chronic relapsing and remitting scaling skin disease which may appear at any age and affect any part of the skin

• 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• GeneticsGenetics

73% monozygotic twins concordant 73% monozygotic twins concordant V 20% dizygotic twinsV 20% dizygotic twinsif 1 parent affected if 1 parent affected →→14/40% risk for 14/40% risk for offspringoffspring

• Environmental triggersEnvironmental triggers

Types of psoriasis

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

Guttate psoriasisGuttate psoriasis

Pustular psoriasisPustular psoriasis

Erythrodermic psoriasisErythrodermic psoriasis

Plantar pustulosisPlantar pustulosis

Acrodermatitis continua of HallopeauAcrodermatitis continua of Hallopeau

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

GP Management

• Emollients• Bath oils• Site-specific topical treatments

Topical treatments

• Vitamin D analoguesDovonex (calcipotriol)Dovobet (calcipotriol & betamethasone)Silkis (calcitriol)Curatorderm (tacalcitol)Zorac (tazarotene)

• Dovonex cream and scalp application no longer available

Topical treatments• Tar

Carbo-domeExorexPsoridermAlphosyl HCSebcoCocoisTar-based bath oils & shampoos

Topical Treatments

• SteroidsOften in conjunction with Vit D analogue as Dovobet or separate steroidEumovateTrimovateScalp 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• Nails

difficultpotent topical steroidsdovonextazarotenesystemic therapy

Topical Treatments• Scalp

Remove scale firstCocois or Sebco messy but effective

Tar or salicylic acid shampoo

Topical steroids if necessary for short periods

Pitfalls

• '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

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 arthritis7-20% 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 dihydrofolate

reductase → reduces proliferation of lymphocytes + keratinocytes

CI: pregnancy, lactation, infection, liver/renal disease, peptic ulcers

given once weekly

SE: anorexia, nausea, myelosuppression, hepatotoxicity, mouth ulcers, pulmonary toxicity, oligospermia, skin cancer

Interactions: NSAIDs, septrin, trimethoprim, penicillin, phenytoin

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)

GP Issues• 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!

Case Studies• Paul, age 45

• Carpet fitter

• Large plaque psoriasis knees, elbows, natal cleft. Hand and nail involvement

• Also has MS

Case studies

• Robert, age 35• Psoriasis since teens• Lives in a hostel, alcoholic

Case studies

• Anne, age 15• Recent onset guttate psoriasis• Wants skin to be clear for sister’s

wedding

Case studies• David, age 25

• Severe psoriasis

• Has had multiple admissions, MTX, Ciclosporin, acitretin, UVB

• Treatment so far has produced partial success only

• Very keen to improve his skin as finds holding down a job very difficult