Psoriasis
Psoriasis
•
•
•
•
•
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
• Emollients
• Bath oils
• Site-specific topical treatments
Topical treatments
• Vitamin D analogues
Dovonex (calcipotriol)
Dovobet (calcipotriol &
betamethasone)
Silkis (calcitriol)
Curatorderm (tacalcitol)
Zorac (tazarotene)
• Dovonex cream and scalp application
no longer available
Topical treatments
• Tar
(Carbo-dome)
(Exorex)
Psoriderm
(Alphosyl HC)
Sebco
(Cocois)
Tar-based bath oils & shampoos
Topical Treatments
• Steroids
Often in conjunction with Vit D
analogue as Dovobet or separate
steroid
Eumovate
(Trimovate)
Scalp preparations (eumovate to
dermovate strength)
• BE CAREFUL (but not mean)
Topical Treatments
• 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
Remove scale first
Cocois or Sebco messy but effective
Tar or salicylic acid shampoo
Topical steroids if necessary for short
periods
Types of psoriasis
•
•
•
•
•
•
•
Plaque
Guttate
Rupioid
Unstable
Pustular
Erythrodermic
?palmo-plantar pustulosis
Guttate psoriasis
Pustular psoriasis
Erythrodermic psoriasis
Plantar pustulosis
Acrodermatitis continua of Hallopeau
Pitfalls
• '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
•
•
•
•
•
•
•
•
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
given once weekly
SE: anorexia, nausea, myelosuppression, hepatotoxicity,
mouth ulcers, pulmonary toxicity, oligospermia, skin
cancer
Interactions: NSAIDs, septrin, trimethoprim, penicillin,
phenytoin
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
• 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:
• ƒ
documentation of severity using DLQI
• ƒ
screening for depression
• ƒ
assessment of vascular risk (in patients with
severe disease)
• ƒ
assessment of articular symptoms
• ƒ
optimisation of topical therapy
• ƒ
consideration for referral to secondary care
Streptococcal theory
Streptococcal infection can:
 super-antigen immune stimulation
 very high cytokine excretion, especially
TNF-α
In guttate psoriasis, all strep isolates from
the throat stimulate this pathway. Once
activated, these T cells infiltrate the skin,
however the thereafter pathogenic
pathways diverge:
keratinocyte death & exfoliation in scarlet
fever
keratinocyte proliferation in guttate
psoriasis
Case Studies
• Paul, age 45
• Carpet fitter
• Large plaque psoriasis knees, elbows,
natal cleft. Hand and nail involvement
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