clinical manifestations and treatment of Psoriasis

1. Prepared By,
Dr.A.Infant Smily Pharm-D.,
Asst.Professor,
Dpt. of Pharmacy Practice,
RVSCOPS, Coimbatore.

2. INTRODUCTION
Psoriasis is a complex, chronic, multifactorial,
inflammatory disease that involves hyperproliferation
of the keratinocytes in the epidermis, with an increase
in the epidermal cell turnover rate.
A problem with the immune system causes
psoriasis. In a process called cell turnover, skin cells
that grow deep in skin rise to the surface.

3.  Environmental, genetic, and immunologic factors
appear to play a role. The disease most commonly
manifests on the skin of the elbows, knees, scalp,
lumbosacral areas, intergluteal clefts, and glans penis.
 Some people who have psoriasis also get a form of
arthritis called psoriatic arthritis.

4. DEFINITION
Psoriasis is defined as a persistent skin
disease causes cell to build rapidly on the surface of
the skin, forming thick silvery”scales, itchy,dry and
red patches

5. EPIDEMIOLOGY
• Although psoriasis occurs worldwide, its prevalence varies
considerably.
• In the USA, approximately 2% of the population is affected. High
rates of psoriasis have been reported in people of the Faroe islands,
where one study found 2.8% of the population to be affected.
• The prevalence of psoriasis is low in certain ethnic groups such as
the Japanese, and may be absent in aboriginal Australians and
Indians from South America

6. ETIOLOGY
Idiopathic cause. It can last a long time, even a lifetime. Symptoms
come and go. Some of the factors that may trigger psoriasis are:
Genetic
Infection
Autoimmune reaction Infection
Injury to skin, Dry skin.
Medication:lithium, antimalarial medications, inderal,
indomethacin
Stress
Obesity
smoking

7. CLASSIFICATION
There are several types of psoriasis include
Plaque psoriasis
Guttate psoriasis
Inverse psoriasis
Pustular psoriasis
Erythrodermic psoriasis
Nail psoriasis
Psoriatic arthritis

8. PLAQUE PSORIASIS
 It is the most common type
of psoriasis
 It is also known as psoriasis-
vulgaris
 It is appear as raised,
inflammed,- red skin covered
by silvery patches or scales
 Sites :Elbows, Knees,
sacrum,- Scalp, lower back,
Hands andFeet

9. GUTTATE PSORIASIS
 Characterized by eruption of
small (0.5 to 1.5 cm in diameter)
papules over the upper trunk and
proximal extremities
 Streptococcal throat infection
frequently precedes or is
concomitant with the onset or
flare

10. INVERSE PSORIASIS
 Localized in the major skin
folds, such as the axilla, the
inguinal and inflammatory
areas and sweating areas
 Scaling is usually minimal
or absent, and the lesions
appear glossy, smooth and
bright red.
 Its is commonly seen
in obese client.

11. PUSTULAR PSORIASIS
 It is usually uncommon but
mostly appear in adult.
 It appear as pus filled
lesion surrounded by red
skin.
 It appear mostly at hands
and feet.
 It is the serious condition
so immediate medical
attention is required.

12. ERYTHRODERMIC PSORIASIS
 The disease affects all
body sites
 Erythema is the most
prominent feature with
superficial scaling /
peeling that may appear
like burning
 Causes: sun burn, allergic
reaction, strong coal
product use

13. NAIL PSORIASIS PSORIATIC ARTHRITIS
 Commonly seen along with-
psoriatic arthritis
 It appear as a pitting –small-
bit nail, yellow-brown nail,
tender and painful nail with
chalk like debris build up
under nails
 This is the condition which
involve both psoriasis and joint
Inflammation
 The most distinctive features of
psoriatic arthritis are
 Distal interphalangeal joint
arthritis
 Dactylitis

14. CLINICAL MANIFESTATIONS
Red patches of skin covered with thick, silvery scales.
Small scaling spots (commonly seen in children)
Dry, cracked skin that may bleed.
Itching, burning or soreness.
Thickened, pitted or ridged nails.
Swollen and stiff joints.

15. PATHOPHYSIOLOGY

16. DIAGNOSIS
Psoriasis can be hard to diagnose because it can look
like other skin diseases.
Collect history
Physical examinations
Skin biopsy : under local- anesthesia
Blood and radiography- test was done to rule out psoriatic
arthritis

17. Lifestyle and home remedies
 Take daily baths
 Use moisturizer
 Expose your skin to small amounts of sunlight.
 Avoid drinking alcohol.
 Avoid psoriasis triggers eg: Infections, injuries to your
skin, stress, smoking and intense sun exposure can all
worsen psoriasis.

18. TREATMENT
 Treatment is based on surface areas of involvement, body
site(s) affected, the presence or absence of arthritis, and the
thickness of the plaques and scale.
 Psoriasis treatments reduce inflammation and clear the skin.
Psoriasis treatment is divided into three main type
 Topical treatment
 Light therapy
 systemic medications

19. 1. TOPICAL AGENTS

20. Drugs Indication
Topical corticosteroids
(triamcinolone
acetonide aqueous
suspension 10 mg/mL
diluted with normal
saline is injected into
the lesion)
To treat mild to moderate psoriasis. It reduce
inflammation and relieve itching and may be
used with other treatments.
Long-term use or overuse of strong
corticosteroids can cause thinning of the skin.
Improvement is usually achieved within 2 to 4
weeks.
Vitamin D analogues.
Calcipotriene
(calcipotriol)
These synthetic forms of vitamin D slow skin
cell growth.
Anthralin (Dritho-
Scalp)
This medication helps slow skin cell growth. It
removes scales and make skin smoother
Topical retinoids
Tazarotene(zar, Zarotex)
These are vitamin A derivatives that may
decrease inflammation. The most common side
effect is skin irritation. These medications may
also increase sensitivity to sunlight

21. Calcineurin inhibitors
Tacrolimus
Pimecrolimus
They inhibit activation of T- cells which
inturn reduces inflammation and plaque
build up. treatment of inverse and facial
psoriasis
Salicylic acid promotes sloughing of dead skin cells and
reduces scaling.
Coal tar coal tar reduces scaling, itching and
inflammation. Coal tar can irritate the skin.
Moisturizers Moisturizing creams alone won't heal psoriasis,
but they can reduce itching, scaling and dryness.
Moisturizers in an ointment base are usually
more effective than are lighter creams and
lotions.
Apply immediately after a bath or shower to
lock in moisture.

22. 2. Light therapy (phototherapy)
 This treatment uses natural or artificial ultraviolet light.
 The simplest and easiest form of phototherapy involves
exposing your skin to controlled amounts of natural
sunlight.
 Other forms of light therapy include the use of artificial
ultraviolet A (UVA) or ultraviolet B (UVB) light, either
alone or in combination with medications.

23. THERAPY INDICATION
Sunlight Exposure to ultraviolet (UV) rays in sunlight or
artificial light slows skin cell turnover and reduces
scaling and inflammation.
UVB phototherapy Controlled doses of UVB light from an artificial light
source may improve mild to moderate psoriasis
symptoms. Short-term side effects may include
redness, itching and dry skin. Using a moisturizer may
help decrease these side effects.
Narrow band UVB
phototherapy
administered two or three times a week until the skin
improves, and then maintenance may require only
weekly sessions.
Goeckerman therapy Combination of UVB treatment and coal tar treatment,
which is known as Goeckerman treatment. The two
therapies together are more effective than either alone
because coal tar makes skin more receptive to UVB
light.

24. Psoralen plus ultraviolet
A (PUVA)
This form of photochemotherapy involves
taking a light-sensitizing medication
(psoralen) before exposure to UVA light.
UVA light penetrates deeper into the skin
than does UVB light, and psoralen makes the
skin more responsive to UVA exposure. side
effects include nausea, headache, burning and
itching.
Excimer laser used for mild to moderate psoriasis, treats
only the involved skin without harming
healthy skin. A controlled beam of UVB light
is directed to the psoriasis plaques to control
scaling and inflammation. Side effects can
include redness and blistering.

25. 3. SYSTEMIC THERAPY
Retinoids
 Related to vitamin A, this group of drugs may help if you
have severe psoriasis that doesn't respond to other
therapies.
 Side effects may include lip inflammation and hair loss.
And because retinoids such as acitretin (Soriatane) can
cause severe birth defects, women must avoid pregnancy
for at least three years after taking the medication.

26. Cyclosporin A
100mg/ml Suspension & 100 mg capsules
M.O.A: Binds cyclo-philin producing a complex that blocks calci-
neurin, reducing the effect of the NF-AT in T cells, resulting in
inhibition of interleukin 2
Dosage: High-dose method: 5 mg/kg daily, then tapered
Low-dose method: 2.5 mg/kg daily, increased every 2-4 wk up to 5
mg/kg daily, then tapered
Side Effects : Nephrotoxicity Hypertension Immuno-suppression
Neurotoxicity, Increased risk of malignancy
Contraindication: Prior bone marrow depression Pregnancy,
Lactation, Renal abnormalities.

27. METHOTREXATE
Dose: 2.5 mg tab & 50 mg/lm vial
Action: Blocks dihydrofolate reductase leading to inhibition of
purine and pyrimidine synthesis Leading to accumulation of anti-
inflammatory adenosine
Dosage: Start with a test dose of 2.5 mg and then gradually increase
dose until a therapeutic level is achieved (average range, 10-15 mg
weekly; maximum, 25- 30 mg weekly
Side effect: Chronic use may lead to hepatic fibrosis, Fetal
abnormalities or death Pulmonary fibrosis
Contraindication : Liver toxicity Pregnancy

28. ACITRETIN
Dose: Acitretin 25 mg cap
Action: Binds to retinoic acid receptors. May contribute to
improvement by normalizing keratinization and proliferation of the
epidermis
Dosage: Initiate at 25-50 mg daily
Side effect : Hepatotoxicity, Lipid abnormalities, Fetal abnormalities
or death, Alopecia
Contraindication Severe infections Malignancy

29. Drugs that alter the immune system (biologics)
 etanercept (Enbrel),
 infliximab (Remicade),
 adalimumab (Humira),
 ustekinumab (Stelara),
 golimumab (Simponi),
 apremilast (Otezla),
 secukinumab (Cosentyx) and
 ixekizumab (Taltz).
Most of these drugs are given by injection (apremilast is oral) and
are usually used for people who have failed to respond to traditional
therapy or who have associated psoriatic arthritis.

30. Alternative Medicine
 Aloe vera. Taken from the leaves of the aloe vera plant, aloe
extract cream may reduce redness, scaling, itching and
inflammation.
 Fish oil. Omega-3 fatty acids found in fish oil supplements
may reduce inflammation associated with psoriasis, although
results from studies are mixed. Taking 3 grams or less of fish
oil daily is generally recognized as safe.
 Oregon grape. Also known as barberry, topical applications of
Oregon grape may reduce inflammation and ease psoriasis
symptoms.

31. COMPLICATIONS
Psoriatic arthritis: This complication of psoriasis can cause
joint damage and a loss of function in some joints, which can
be debilitating.
Eye conditions.
Obesity.
Type 2 diabetes.
High blood pressure.
Cardiovascular disease.
Metabolic syndrome.
Other autoimmune diseases.