learning objectives : Pathophysiology of Psoriasis Common sites with pictures Pharmacotherapy of Psoriasis Local Drug therapy Systemic Drug therapy Biological therapy Phototherapy

1. Dr.Uma Advani
Assistant Professor
Pharmacology,
SMS,MC Jaipur

2.  Introduction
 Pathophysiology of Psoriasis
 Common sites with pictures
 Pharmacotherapy of Psoriasis
 Local Drug therapy
 Systemic Drug therapy
 Biological therapy
 Phototherapy

3.  Chronic proliferative epidermal disease .
 Affects 1 to 3% of world’s population .
 Rapid increase in epidermal transit time.
 The time taken for a psoriatic epidermal cell
to travel from the basal layer to the surface
and be cast off is 3 to 4 days , in marked
contrast to the normal 26 to 28 days.
 In most cases the disease remains as discrete
localized plaques
 Stress and anxiety frequently precede flare
ups of the disease.

4.  Psoriatic lesions are usually erythematous
and sharply circumscribed plaques.
 The lesions are covered by silvery white
micaceous scales.
 Lesions occur most commonly on the
elbows , knees , scalp, genitalia ,
lumbosacral area and intergluteal cleft.

5.  50% of psoriatic patients will have some degree
of nail involvement
 Intense pruritus seen in 30 –40% of patients.
 Psoriatic arthritis.
 Reduction in the quality of life.

6. Topical agents (corticosteroids,tar,anthralin,calcipotriol,tazarotene)
Phototherapy
Immunosuppressive agents and retinoids
Biologic agents (Infliximab)
Mild Moderate Severe

7.  Topical therapy
1. Corticosteroids
2. Vitamin D analogues (calcipotriene and
calcitriol)
3. Coal tar
4. Anthralin

8.  Topical therapy
5. Tazarotene
6. Immunomodulators (tacrolimus and
pimecrolimus)
7. Keratolytics – salicylic acid
Drugs used in Psoriasis.

9.  Systemic therapy
1. Methotrexate
2. Acitretin
3. Cyclosporine
4. Mycophenolate mofetil
5. Sulfasalazine
6. 6-Thioguanine
7. Tacrolimus
8. Hydroxyurea
Drugs used in Psoriasis.

10. Biologic therapy
1. Infliximab
2. Etanercept
3. Alefacept
4. Efalizumab
Photochemotherapy
Drugs used in Psoriasis.

11.  Topical Corticosteroids.
 Classified according to their potency
(Stoughton Cornell classification) .
 High potency steroids like clobetasol,
halobetasol and betamethasone used in
chronic plaque psoriasis.
 Used for finite periods of time
 Should be used only for small body surface
areas.

12.  Low potency steroids like hydrocortisone
safer
 Can be used for long term and also in
infants and children.
 ADR: Local tissue atrophy, striae,
suppression of HPA axis, hyperglycemia,
cushingoid features.

14.  Do not abruptly cease topical steroids as
rebound flare is known to occur.
 Main role is as an adjunct.
 Ointment form considered the clinically
most effective .

15.  Vitamin D analogues
 Inhibits keratinocyte differentiation and
proliferation.
 Calcipotriene , calcitriol , tacalcitol
 Rapidly metabolized locally.
 Marked improvement seen after 8 weeks of
therapy.
 expensive.

16.  Tazarotene - synthetic retinoid.
 Prodrug , metabolized to active tazarotenic
acid.
 Modulates keratinocyte proliferation and
differentiation.
 Effective for mild to moderate plaque
psoriasis.
 Used in combination with steroids to
decrease ADR.

17.  Coal tar
 Down regulates epidermal
proliferation rate.
 Used in thick plaques and
in scalp psoriasis.
 Disadvantages:
 burdensome,time consuming, unpleasant
odour and staining of skin and clothing.
 Can be combined with UVB.

18.  Anthralin
 Inhibit DNA synthesis by
intercalating between DNA
strands
 Inflammation , irritation and
staining of skin and clothing.
 Staining of affected plaques is a
positive response.
 Dose to be gradually increased.

19.  Keratolytics - Salicylic acid
 Removes scales.
 Makes skin smooth .
 Decreases hyperkeratosis.
 Used in mild cases.
 Salicylism- nausea , vomiting, tinnitus and
hyperventilation.

20.  Synthetic analogue of folic acid.
 Competitive inhibitor of the enzyme
dihydrofolate reductase.
 Inhibits the replication and function of T and B
cells.
 Suppresses the secretion of cytokines such as
IL-1, IFN- g, TNF-a.
 Indicated in severe psoriasis

21.  Can be given as thrice weekly oral dose.
 Nausea , anorexia, headache and alopecia.
 Sign of MTX overdose- leukopenia and
thrombocytopenia.
 Hepatotoxicity , nephrotoxicity and
pneumonitis.
 Avoid all immunosuppressives in active
infection.

22.  Oral retinoid
 Active metabolite of etretinate.
 Indicated for the treatment of severe
psoriasis.
 Combination of acitretin and PUVA is
highly effective.

23.  ADR: hypervitaminoses A, hepatotoxicity,
skeletal changes, hypercholesterolemia and
hypertriglyceridemia.
 C/I in pregnancy and in women who are
planning pregnancy within 3 years following
drug discontinuation.

24.  Effective immunosuppressant.
 Inhibits the release of inflammatory mediators
from mast cells, basophils and PMN
leukocytes.
 Effective in both the cutaneous lesions and also
the arthritic symptoms.

25.  Effective in generalised pustular psoriasis
 Prolonged use causes nephrotoxicity and
hypertension.
 Use for more than two years leads to increased
risk of malignancy.

26.  UVA combined with oral / topical
methoxsalen on alternate days
 Immunomodulatory – induces Tcell apoptosis.
 Reserved for moderate to severe psoriasis.
 Short term adverse effect-mottling,
erythema,burns,blistering ,premature aging of
skin,nervousness and insomnia.
 Long term adverse effect- increased risk of skin
cancer.

30. Thank you.