Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Psoriasi dalla diagnosi agli approcci clinici

934 views

Published on

  • I Cured My Yeast Infection. Top ranked Candida plan for download Unique holistic System. ●●● http://ishbv.com/index7/pdf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Psoriasi dalla diagnosi agli approcci clinici

  1. 1. PSORIASISDiagnosis and management
  2. 2. OVERVIEW 2 1. Epidemiology and pathophysiology 2. Clinical presentation 3. Diagnosing psoriasis 4. Managing psoriasis 5. Case studies
  3. 3. WHAT IS PSORIASIS? 3– Inflammatory and hyperplastic disease of skin1– Characterised by erythema and elevated scaly plaques1– Chronic, relapsing condition– Course of disease often unpredictable1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  4. 4. SYMPTOMS OF PSORIASIS 4 Most frequentlyexperienced symptoms Scaling 94 Itching 79 Skin redness 71 Tightness of skin 31 Bleeding 29 Burning sensation 21 Fatigue 19 Other 5 0 20 40 60 80 100 Percentage of respondents (n = 17,425) Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.
  5. 5. SOCIAL IMPACT OF PSORIASIS 5 Psoriasis mistaken as contagious 57 Psoriasis mistaken for other disease 48 Trouble receiving equal treatment inservice establishments 40 (e.g. hair salons, public pools) 0 10 20 30 40 50 60 Percentage of respondents with severe psoriasis (n = 502)Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.
  6. 6. PSORIASIS AFFECTS 6EMOTIONAL STATEConcern that disease would worsen 88 Feelings of embarrassment 81 Feelings of unattractiveness 75 Depression 54 0 20 40 60 80 100 Percentage of 18-to-34-year-old respondents with severe psoriasis (n not reported)Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.
  7. 7. EPIDEMIOLOGY 7• Common skin disorder• Prevalence variable: ~ 0.3–2.5%1• Prevalence equal in males and females2• Estimated incidence: ~ 60 per 100,000 per year31. Plunkett A et al. Australas J Dermatol 1998; 39: 225–232. 2. Griffiths CEM et al. In: Burns T et al., eds. Rook’s textbook of dermatology.8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Bell LM et al. Arch Dermatol 1991; 127: 1184–7.
  8. 8. AGE OF ONSET 8• Mean age: ~ 23–37 years1• Current theory: 2 distinct peaks with possible genetic associations1 – Early onset (16–22 years)2 • More severe and extensive • More likely to have affected first-degree family member – Late onset (57–60 years)2 • Milder form • Affected first-degree family members nearly absent1. Plunkett A et al. Australas J Dermatol 1998; 39: 225-232. 2. Henseler T et al. J Am Acad Dermatol 1985; 13:450-6.
  9. 9. GENETIC INFLUENCE 9• Evidence suggests strong genetic association – Studies of monozygotic twins show concordance for psoriasis (e.g. 64% in a Danish Study)1 – Multiple susceptibility loci have been identified2• Disease expression – likely result of genetic and environmental factors21.Brandup F et al. Acta Dermato-Vernerol 1982; 62L: 229–36. 2. Barker J. Clin Exp Dermatol 2001; 26(4): 321–5.
  10. 10. COMMON TRIGGER FACTORS 10FOR PSORIASIS1• Infections (e.g. streptococcal, viral)• Skin trauma (Koebner phenomenon)• Psychological stress• Drugs (e.g. lithium, beta blockers)• Sunburn• Metabolic factors (e.g. calcium deficiency)• Hormonal factors (e.g. pregnancy)1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  11. 11. PSORIASIS IS A T-CELL MEDIATED, 11AUTOIMMUNE DISEASE1• Current hypothesis: – Unknown skin antigens stimulate immune response • Antigen-specific memory T-cells are primary mediators – Leads to impaired differentiation and hyperproliferation of keratinocytes1. Lee M et al. Australas J Dermatol 2006; 47: 151–9.
  12. 12. CLINICAL PRESENTATION: 12CLASSIC PSORIASIS– Well-defined and sharply demarcated1,2– Round/oval-shaped lesions1,3– Usually symmetrical1,3– Erythematous, raised plaques1–3– Covered by white, silvery scales1–31. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology.2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  13. 13. COMMON SITES 13AFFECTED BY PSORIASIS• Can affect any part of the body – typically scalp, elbow, knees and sacrum1• Extent of disease varies1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  14. 14. TYPES OF PSORIASIS 14• Chronic plaque • Pustular• Guttate – Localised and generalised• Flexural • Local forms – Palmoplantar• Erythrodermic – Scalp – Nail (psoriatic onychodystrophy)1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed. Australian medicineshandbook. Adelaide: AMH, 2010.
  15. 15. CHRONIC PLAQUE PSORIASIS 15– Most common type – affects approximately 85%1– Features pink, well-defined plaques with silvery scale2– Lesions may be single or numerous2– Plaques may involve large areas of skin2– Classically affects elbows, knees, buttocks and scalp31. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
  16. 16. CHRONIC PLAQUE PSORIASIS 16
  17. 17. CHRONIC PLAQUE PSORIASIS 17
  18. 18. CHRONIC PLAQUE PSORIASIS 18
  19. 19. CHRONIC PLAQUE PSORIASIS 19
  20. 20. GUTTATE PSORIASIS 20– Numerous and small lesions – ~ 1 cm diameter1,2,3– Pink with less scale than plaque psoriasis1– Commonly found on trunk and proximal limbs1,3– Typically seen in individuals < 30 years4– Often preceded by an upper respiratory tract streptococcal infection1,21. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter Aet al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
  21. 21. FLEXURAL PSORIASIS 21– Lesions in skin folds1– Particularly groin, gluteal cleft, axillae and submammary regions– Often minimal or absent scaling1,2– May cause diagnostic difficulty when genital or perianal region is affected in isolation1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. SchonMP et al. N Engl J Med 2005; 352(18): 1899–912.
  22. 22. ERYTHRODERMIC PSORIASIS 22– Generalised erythema covering entire skin surface1,2– May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon1,3– Patients may become febrile, hypo/hyperthermic and dehydrated3– Complications include cardiac failure, infections, malabsorption and anaemia1– Relatively uncommon1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. WellerPA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
  23. 23. PUSTULAR PSORIASIS 23– Two forms:• Localised form• More common1,2• Presents as deep-seated lesions with multiple small pustules on palms and soles1,2• Generalised form• Uncommon3• Associated with fever and widespread pustules across inflamed body surface31. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds. Rook’stextbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
  24. 24. PALMOPLANTAR PSORIASIS1 24– Can be hyperkeratotic or pustular– May mimic dermatitis – look for psoriatic manifestations elsewhere to aid diagnosis– Possibly aggravated by trauma1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  25. 25. SCALP PSORIASIS 25– Varies from minor scaling with erythema to thick hyperkeratotic plaques1,2– May extend beyond hairline1,2– Patient scratching may produce asymmetric plaques21. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter Aet al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  26. 26. NAIL PSORIASIS1 26– May be present in patients with any type of psoriasis– Can take several forms:• Pitting: discrete, well- circumscribed depressions on nail surface• Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate• Onycholysis: nail separates from nail bed at free edge• ‘Oil-drop sign’: pink/red colour change on nail surface1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  27. 27. NAIL PSORIASIS 27
  28. 28. NAIL PSORIASIS 28
  29. 29. NAIL PSORIASIS 29
  30. 30. PSORIATIC ARTHRITIS 30– Approximately 5–20% have associated arthritis1– Five major patterns of psoriatic arthritis:2• Distal interphalangeal involvement• Symmetrical polyarthritis• Psoriatic spondylarthropathy• Arthritis mutilans• Oligoarticular, asymmetrical arthritis– Clinical expressions often overlap21. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  31. 31. DIAGNOSING PSORIASIS 31• Other dermatological disorders can resemble psoriasis• Diagnosed clinically according to appearance, distribution, history of lesions and family history• Important to consider non-cutaneous complications11. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney:Australasian Medical Publishing Company, 2005.
  32. 32. DIFFERENTIAL DIAGNOSIS1,2 32• Localised • Flexural patches/plaques – Tinea – Eczema – Tinea – Candidiasis – Eczema – Seborrhoeic dermatitis – Superficial basal cell carcinoma and Bowen’s disease • Erythrodermic – Seborrhoeic dermatitis – Eczema – Cutaneous T-cell lymphoma – Cutaneous T-cell lymphoma (mycosis fungoides) – Pityriasis rubra pilaris – Lichen planus• Guttate – Drug – Pityriasis rosea – Drug eruption • Palmoplantar – Secondary syphilis – Tinea1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd ed.Oxford: Health Press, 2004.
  33. 33. LOCALISED PATCHES/PLAQUES 33– Tinea corporis1• Affects body• Lacks symmetrical lesions• Presence of peripheral scale and central clearing Tinea coporis Psoriasis1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  34. 34. LOCALISED PATCHES/PLAQUES 34– Discoid eczema1• Individualised patches more pruritic than psoriasis• Lack silvery scale• Less vivid colour than psoriasis Discoid eczema Psoriasis1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  35. 35. LOCALISED PATCHES/PLAQUES 35– Superficial basal cell carcinoma/Bowen’s disease1,2• Asymmetrical lesions, either single or few in number• Perform biopsy if lesions resistant to topical psoriasis treatment, or to confirm diagnosis Bowen’s disease Psoriasis1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nded. Oxford: Health Press, 2004.
  36. 36. LOCALISED PATCHES/PLAQUES 36– Seborrhoeic dermatitis• Characterised by yellowish scaling and erythema1– Localised to many of the same areas as psoriasis• Diffuse scaling differs from sharply defined psoriasis plaques2• Affects furrows of face (facial psoriasis is generally restricted to hairline)1 Dermatitis Psoriasis1. Marks R et al. Dermatology within the pharmacy. Australia: Department of Dermatology, StVincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press,2004.
  37. 37. LOCALISED PATCHES/PLAQUES 37– Cutaneous T-cell lymphoma (mycosis fungoides)• Red, discoid lesions1• Asymmetrical and less scaly than psoriasis1• Lesions may present with fine atrophy and be resistant to antipsoriatic therapy2• Biopsy to confirm diagnosis Mycosis fungoides Psoriasis 1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  38. 38. GUTTATE PSORIASIS 38– Pityriasis rosea1• Difficult to distinguish from acute guttate psoriasis• Presents first as single large patch, progresses to a truncal rash of multiple red scaly plaques (‘Christmas tree’ distribution)• Resolves over 8–12 weeks < Psoriasis ^ Pityriasis rosea 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  39. 39. GUTTATE PSORIASIS 39– Secondary syphilis• Search for characteristic primary syphilitic lesion, lymphadenopathy, and lesions of face, palm and soles1• Conduct serology and skin biopsies to confirm1,2 < Psoriasis ^ Secondary syphilis 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003.
  40. 40. FLEXURAL PSORIASIS 40– Tinea cruris1• Affects groin area• Characterised by central clearing with advancing edge• Non-silvery lesion with fine scale, particularly at periphery• Lesion frequently extends more on left side < Psoriasis ^ Tinea cruris 1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  41. 41. FLEXURAL PSORIASIS 41– Atopic eczema1,2• Often associated with asthma and hay fever• Lacks classic psoriatic nail involvement and sharply demarcated scaly plaques < Psoriasis ^ Atopic eczema1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor. 16 April 2010: 29–36.
  42. 42. FLEXURAL PSORIASIS 42– Candidiasis1,2• Characteristic peripheral pustules and scaling differ to psoriasis• Yeast cultures are diagnostic– Seborrhoeic dermatitis2 Flexural psoriasis1. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003.2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  43. 43. PALMOPLANTAR PSORIASIS 43– Tinea manum1• Ringworm of hands• Fine powdery scale, particularly involving palms and palmar creases• Usually asymmetrical Tinea corporis Psoriasis1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  44. 44. PALMOPLANTAR PSORIASIS 44– Hand and foot eczema• Hyperkeratotic forms difficult to distinguish from psoriasis1,2• Biopsies can assist diagnosis1• Look for history of atopy, a lack of psoriasis elsewhere on body, and evidence of eczema elsewhere on skin1 Eczema Psoriasis1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.2. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne:Blackwell Publishing, 2003.
  45. 45. PALMOPLANTAR PSORIASIS 45– Pompholyx of palms and soles (dishydrotic eczema)1• Presents as clear vesicles – contrast to white/yellow pustules in pustular psoriasis• Accompanied by intense pruritus Eczema Psoriasis1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  46. 46. DETERMINING PSORIASIS SEVERITY 46• Psoriasis Area and Severity Index (PASI)1 – Score indicates severity of disease at a given time – Single number that considers severity of lesions and extent of disease across four major body sites (head, trunk, upper limbs and lower limbs) – Score ranges from 0 (no disease) to 72 (maximal disease)1. Dubertret L. Psoriasis from clinic to therapy. France: Med’com, 2005.
  47. 47. MANAGING PSORIASIS 47• Before starting treatment – Establish relationship of trust with patient1 – Provide patient with information • Emphasise benign nature of disease2,3 • Explain that psoriasis tends to be chronic and recurrent2,31. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  48. 48. MANAGING PSORIASIS 48• Determine clinical setting before selecting treatment, considering – Disease pattern, severity and extent1,2 – Sites of disease2 – Coexistent medical conditions1 – Patient’s perception of disease severity1 – Time commitments and treatment expense1,2 – Previous treatments for psoriasis11. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  49. 49. MANAGING PSORIASIS 49• Goals of management – Tailor management to individual and address both medical and psychological aspects1–3 – Improve quality of life3 – Achieve long-term remission and disease control3 – Minimise drug toxicity3 – Evaluate and monitor efficacy and suitability of individual treatments3 – Remain flexible and respond to changing needs1–31.Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3.Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
  50. 50. TREATMENT OPTIONS FOR PSORIASIS 50• Stepwise approach is advised1• Treatments include:1,2,3 – General measures and topical therapy – Phototherapy – Systemic and biological therapies• Combination therapies may reduce toxicity and improve outcomes21. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,2005. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  51. 51. TREATING PSORIASIS: 51GENERAL MEASURES1,2• Reduce/eliminate potential trigger factors: – Stress – Smoking – Alcohol – Trauma – Drugs – Infections1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  52. 52. TOPICAL THERAPIES 52• Approximately 70% of patients with mild-to-moderate psoriasis can be managed with topical therapies alone1• Tailor to needs of patient2• Potency, delivery vehicle and patient motivation may affect compliance1• Application may be time-consuming for patients11. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  53. 53. TOPICAL THERAPIES: 53EMOLLIENTS• Include aqueous cream, sorbolene cream, white soft paraffin and wool fats1• Regular use can: – alleviate pruritus2 – reduce scale2 – enhance penetration of concomitant topical therapy2 – hydrate dry and cracked skin3• Soap should be avoided41. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A etal. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Rossi S, ed. Australian medicines handbook. Adelaide: AMH, 2010. 4. WellerPA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
  54. 54. TOPICAL THERAPIES: 54KERATOLYTICS• Over-the-counter products include:1 – Salicylic acid – Urea• Help dissolve keratin to soften and lift psoriasis scales1,2• May enhance penetration of other actives11. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  55. 55. TOPICAL THERAPIES: 55COAL TAR• Help reduce inflammation and pruritus1• May induce longer remissions2• Use limited by distinctive smell and ability to stain clothing and skin1,2• May cause local skin irritation21. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. WellerPA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
  56. 56. TOPICAL THERAPIES: 56DITHRANOL• Anti-proliferative properties1• Particularly effective in thick plaque psoriasis1• Initiate therapy at very low concentrations – can burn skin2• Not suitable for face, flexures or genitals1,3• Stains clothes permanently and skin temporarily1,2,31. Dermatology Expert Group. Therapeutic Guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A etal. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R,ed. MJA practice essentials – dermatology. 2nded. Sydney: Australasian Medical Publishing Company, 2005.
  57. 57. TOPICAL THERAPIES: 57TAZAROTENE• Topical synthetic retinoid1,2• For treatment of chronic plaque psoriasis1,2• Applied once daily in evening1,2• Commonly causes local irritation1,21. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. ZoracProduct Information, 30 March 2007.
  58. 58. TOPICAL THERAPIES: 58CORTICOSTEROIDS• Possess anti-inflammatory, antiproliferative and immunomodulatory properties1,2• Reduce superficial inflammation within plaques3• Potency choice depends on disease severity, location and patient preference21. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter Aet al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009.
  59. 59. TOPICAL THERAPIES: 59CORTICOSTEROIDS• Adverse effects associated with long-term use include:1,2 – Skin atrophy and telangiectasia – Hypopigmentation – Striae – Rapid relapse or rebound on stopping therapy – Precipitation of pustular psoriasis – Pituitary-adrenal axis suppression through significant systemic absorption (rare)1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  60. 60. TOPICAL THERAPIES: 60CALCIPOTRIOL (DAIVONEX®)• Synthetic vitamin D analogue1• For chronic plaque-type psoriasis1• Reverses abnormal keratinocyte changes by:1 – Inducing differentiation – Suppressing proliferation of keratinocytes1. Daivonex Product Information, 23 September, 2006.
  61. 61. TOPICAL THERAPIES: 61CALCIPOTRIOL (DAIVONEX®)• Response may require 4–6 weeks1,2• Adverse effects include erythema and irritation31. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Weller PA. Psoriasis. In: Marks R, ed.MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. DaivonexProduct Information, 23 September, 2006.
  62. 62. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 62DIPROPIONATE OINTMENT (DAIVOBET®)• For plaque-type psoriasis1• Combination of calcipotriol and a potent topical corticosteroid (betamethasone dipropionate)1 – Stable formulation for both actives1• Provides rapid, effective psoriasis control1,21. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.
  63. 63. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 63DIPROPIONATE OINTMENT (DAIVOBET®)– Combination of calcipotriol and betamethasone dipropionate in Daivobet is more effective than either active constituent used alone• 39.2% mean reduction in PASI score after 1 weekAdapted from Kaufmann R et al. Dermatology 2002; 205(4): 389–93.
  64. 64. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 64DIPROPIONATE OINTMENT (DAIVOBET®)• Once-daily treatment with the potential to improve compliance1,2• Can be used intermittently in 4-weekly cycles with Daivonex® used in between for maintenance1• Most common adverse events include pruritus, rash and burning sensation11. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.
  65. 65. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE 65DIPROPIONATE GEL• Newly TGA approved product not yet available in Australia• Specially formulated for the scalp1• Provides rapid, effective control of scalp psoriasis1,2,3 – More effective than treatment with individual actives alone – 53.2% (more than half) of patients had absent or very mild disease after just two weeks of gel application1• Once-daily formulation may encourage compliance21. Daivobet ®Gel Product Information, 14 July 2010. 2. van de Kerkhof et al. BJD 2008; 160: 170–6.3. Jemec GBE et al. J Am Acad Dermatol 2008; 59:455-463.
  66. 66. OTHER THERAPIES 66• Phototherapy• Systemic therapies• Biological agents
  67. 67. PHOTOTHERAPY 67• For psoriasis resistant to topical therapy and covering > 10% of body surface area1• Immunomodulatory and anti-inflammatory effects2• Three main types of phototherapy:2 – Broadband UVB – Narrowband UVB – PUVA (administration of psoralen before UVA exposure)• Treatment usually administered 2–3 times/week1,21. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.2. Dermatology Expert Group. Therapeutic guidelines:dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
  68. 68. SYSTEMIC THERAPIES 68• Reserved for patients with widespread or severe psoriasis1• Potentially serious adverse effects and drug interactions2• Many require PBS authority prescription from dermatologist31. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter Aet al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Department of Health and Ageing. Schedule of Pharmaceutical Benefits.http://www.pbs.gov.au (accessed online 14 August 2010).
  69. 69. SYSTEMIC THERAPIES: 69METHOTREXATE• Most commonly used systemic treatment for psoriasis1• Slows epidermal cell proliferation and acts as immunosuppressant1• Closely monitor kidney, liver and bone-marrow function2• Perform PASI score before starting treatment1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.2. Methoblastin Product Information, 11 August 2004.
  70. 70. SYSTEMIC THERAPIES: 70CYCLOSPORIN• Immunosuppressive agent1• For patients with severe psoriasis that is refractory to other treatments2• Requires ongoing monitoring of blood elements, and renal and liver function21. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.2. Neoral Product Information, 22 October 2009.
  71. 71. SYSTEMIC THERAPIES: 71ACITRETIN1• Oral retinoid• For treatment of all forms of severe psoriasis• Once-daily oral therapy• Teratogenic – pregnancy must be avoided1. Neotigason Product Information, 18 March 2008.
  72. 72. BIOLOGICAL AGENTS 72• Proteins derived from living organisms that exert pharmacological actions1• For adults with moderate-to-severe chronic plaque-type psoriasis who are candidates for phototherapy or systemic therapy2–5• Most administered sub-cutaneously2–51. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Humira Product Information, 18 September 2009. 3. StelaraProduct Information, 15 July 2009. 4. Remicade Product Information, 17 September 2008. 5. Enbrel Product Information, 16 February 2010.
  73. 73. BIOLOGICAL AGENTS 73• Target key parts of immune system that drive psoriasis1• Biological agents include:2–5 – Tumour necrosis factor-alpha inhibitors • Etanercept • Adalimumab • Infliximab – Interleukin (IL-12 and IL-32) inhibitor • Ustekinumab1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009 2. HumiraProduct Information, 18 September 2009. 3. Stelara Product Information, 15 July 2009. 4. Remicade Product Information, 17 September 2008.5. Enbrel Product Information, 16 February 2010.
  74. 74. CASE STUDY 1 74• ((insert image of condition))• ((insert information under headings below))• Presentation• Clinical examination• Diagnosis• Management• ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred))
  75. 75. CASE STUDY 2 75• ((insert image of presenting condition))• ((insert information under headings below))• Presentation• Clinical examination• Diagnosis• Management• ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred))
  76. 76. DIAGNOSIS AND MANAGEMENT OF 76PSORIASIS: SUMMARY• Chronic, inflammatory disease of skin• T-cell mediated disorder• Classic presentation characterised by red, scaly plaques• Management should address both medical and psychological aspects• Treatments include topical therapy, phototherapy, systemic therapy and biological agents
  77. 77. MINIMUM PRODUCT INFORMATION 77Minimum Product Information: DAIVONEX® cream (50mcg/g calcipotriol), scalp solution (50mcg/mL calcipotriol). Indications: Topicaltreatment of chronic stable plaque type psoriasis vulgaris in adults (cream). Psoriasis of the scalp in adults (scalp solution). Contraindications:hypersensitivity; calcium metabolism disorders; ophthalmic use. Precautions: severe extensive psoriasis, generalised pustular psoriasis,guttate psoriasis, erythrodermic exfoliative psoriasis; facial use; skin fold use; occlusion; excessive, prolonged use; use in children. Monitorserum calcium and renal function prior to therapy and then three monthly; max weekly dose, see dosage. No experience with: continuous usefor greater than 1 year in adults, sunlight and UV light, impaired renal or hepatic function, pregnancy (category B1), lactation. Adverse Effects:Local irritation, photosensitivity, pigmentation changes, hypercalcaemia (excessive use). Dosage and Administration: In adults, twice daily onaffected areas, reduce frequency according to response; maximum dosage 100g/week of cream or 60mL of scalp solution; total calcipotriolshould not exceed 5mg/week; reinstate on recurrence. Minimum Product Information: DAIVONEX® cream (50mcg/g calcipotriol), scalpsolution (50mcg/mL calcipotriol). Indications: Topical treatment of chronic stable plaque type psoriasis vulgaris in adults (cream). Psoriasis ofthe scalp in adults (scalp solution). Contraindications: hypersensitivity; calcium metabolism disorders; ophthalmic use. Precautions: severeextensive psoriasis, generalised pustular psoriasis, guttate psoriasis, erythrodermic exfoliative psoriasis; facial use; skin fold use; occlusion;excessive, prolonged use; use in children. Monitor serum calcium and renal function prior to therapy and then three monthly; max weeklydose, see dosage. No experience with: continuous use for greater than 1 year in adults, sunlight and UV light, impaired renal or hepaticfunction, pregnancy (category B1), lactation. Adverse Effects: Local irritation, photosensitivity, pigmentation changes, hypercalcaemia(excessive use). Dosage and Administration: In adults, twice daily on affected areas, reduce frequency according to response; maximumdosage 100g/week of cream or 60mL of scalp solution; total calcipotriol should not exceed 5mg/week; reinstate on recurrence. Please review Product Information before prescribing. DAIVONEX® PBS Information: 30g cream and 30mL scalp solution. Restricted benefit. Treatment of chronic stable plaque-type psoriasis vulgaris. Refer to PBS Schedule for full information.
  78. 78. MINIMUM PRODUCT INFORMATION 78Minimum Product Information: DAIVOBET® 50/500 Ointment. 50mcg/g calcipotriol / 500mcg/g betamethasone dipropionate. Indication:Once daily topical treatment of plaque-type psoriasis vulgaris amenable to topical therapy. Contraindications: Allergic sensitisation to anyconstituent of DAIVOBET® ointment; disorders of calcium metabolism; viral skin lesions, fungal / bacterial skin infections, parasitic infections,skin manifestations related to tuberculosis or syphilis, perioral dermatitis, acne vulgaris, atrophic skin, striae atrophicae, fragile skin veins,ichthyosis, acne rosacea, ulceration, wounds, perianal / genital pruritus; erythrodermic, exfoliative and pustular psoriasis; severe renal orhepatic insufficiency; ophthalmic use. Precautions: For external use only; avoid application to scalp, face, mouth or eyes; treatment of >30% ofbody surface area; monitor serum calcium and renal function; concurrent treatment with other steroids; application to large areas of damagedskin, occlusive dressings, application to mucous membranes or in skin folds; avoid long term treatment of face and genitals; infected lesions;generalised pustular psoriasis; sunlight / UV exposure; pregnancy category B1; lactation; children below 18 years of age; renal or hepaticimpairment; HPA axis suppression with excessive prolonged use of topical corticosteroids; risk of rebound when discontinuing long-termcorticosteroids. Recommended treatment period is 4 weeks under medical supervision, for up to 52 weeks. There is clinical trial experiencewith intermittent 4 weekly cycles of DAIVOBET® ointment and calcipotriol alone used between treatment cycles. Adverse Effects: Pruritus,rash, burning sensation, skin pain or irritation, dermatitis, erythema, exacerbation of psoriasis, folliculitis, application site pigment changes,hypercalcaemia, hypercalciuria, photosensitivity, allergic and hypersensitivity reactions including very rare cases of angioedema and facialoedema. Local reactions, especially during prolonged application include skin atroph elangiectasia, folliculitis, hypertrichosis, perioraldermatitis, allergic contact dermatitis, depigmentation, colloid milia and generalised pustular psoriasis. Adrenocorticol suppression,hypercalcaemia, cataract, infections and increase in intra-ocular pressure can occur, especially after long term treatment. Risk of reboundwhen discontinuing long term treatment with corticosteroids. Dosage and Administration: Apply topically to the affected area once daily.Maximum 15g ointment per day. Maximum 100g of ointment per week. Treated area should be no more than 30% body surface. Treatmentshould be intermittent for up to 1 year; treatment should be limited to 4 week periods with calcipotriol used alone for 1 month between periodsof DAIVOBET® use as needed. Please review Product Information before prescribing. DAIVOBET® PBS Information: Restricted benefit. Treatment of chronic stable plaque-typepsoriasis vulgaris in a patient who is not adequately controlled with either calcipotriol or potent topical corticosteroid monotherapy.
  79. 79. 79 Thank youProduct Information is available from CSL Biotherapies Pty Ltd ABN 66 120 398 067, 45 Poplar Road, Parkville, 3052. DAIVOBET ® andDAIVONEX® are registered trademarks of licensor, LEO Pharma, Ballerup, Denmark. DAIVOBET® and DAIVONEX® are distributed byCSL Biotherapies Pty Ltd under licence from LEO Pharma. ® Thinking Australia is a registered trademark of CSL Limited, Australia. 8713.

×