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Block 18 Week 7: Psoriasis
1
CalumLyons
Psoriasis
Chronic T-cell-mediated autoimmune disease
Histology
 Inflammatory T-ce...
Block 18 Week 7: Psoriasis
2
CalumLyons
o In all cases,except one patient with Crohn’s disease,onset of psoriasis preceded...
Block 18 Week 7: Psoriasis
3
CalumLyons
Psoriasis (flexural)
 Commoner in adults
 Partof psoriasisvulgarisor isolated (i...
Block 18 Week 7: Psoriasis
4
CalumLyons
Unstable Psoriasis
Previously stablepsoriasisthathas become erythrodermic or gener...
Block 18 Week 7: Psoriasis
5
CalumLyons
Management
Patient Advice
 Incurable
 Chronic/recurrent
 Not an infection
 Not...
Block 18 Week 7: Psoriasis
6
CalumLyons
Tazarotene
 Retinoid
 Very irritantin somepeople
 Useful in hand psoriasis
Vita...
Block 18 Week 7: Psoriasis
7
CalumLyons
Methotrexate
 Antimetabolite. Inhibits dihydrofolatereductase
 Anti-inflammatory...
Block 18 Week 7: Psoriasis
8
CalumLyons
Nails
 Very difficultto treat
 Can be socially and practically disablingtherefor...
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Psoriasis

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Psoriasis

  1. 1. Block 18 Week 7: Psoriasis 1 CalumLyons Psoriasis Chronic T-cell-mediated autoimmune disease Histology  Inflammatory T-cell infiltratedirected againstoneor more antigens  Abnormal proliferation and differentiation  Vascular proliferation Epidemiology  Psoriasisiscommon o prevalence 1-3% (Faroes 5%)  Polygenic with different genes important in different individuals (monozygotic twin concordance~74%)  Association with IBD  May demonstrate Koebner (isomorphic) phenomenon (>40% of cases) Age of onset has 2 peaks  5-10 years females;15-19years males o Genetic influence  6th-7th decade (male=female) o No genetic influence Association between IBD and Psoriasis  Clinical Studies (Yates, VM et al 1982,Keohane, S et al 1998) o most refer to Crohn’s o psoriasisin Crohn’s ranges from4-12% (1.1-3% in controls)  Genetic studies o HLA - Cw6, DR7 o genome scans - 16q  Antigen persistence
  2. 2. Block 18 Week 7: Psoriasis 2 CalumLyons o In all cases,except one patient with Crohn’s disease,onset of psoriasis preceded onset of abdominal diseaseby at least1 year  Genetic o FH of psoriasisin 1stdegree relatives o 5/84 IBD patients; 2/110 non-IBD patients  Emotional stress of severe IBD Triggers  Trauma (Koebner) - In 38-76% of patients  Infection o Throat infection (guttate) (tonsillectomy usually makes no difference) o HIV o Eg HHV?  Hormone o Puberty o pregnancy  UV light o Sunburn o iatrogenic  Emotional stress  Alcohol  Drugs o Li+ o Beta blockers o Antimalarials o Can usevibramycin and minocin less effective o Tetracyclines o Terbinafine o NSAIDS o 187 more including CORTICOSTEROIDS Types of Psoriasis  Flexural  Guttate  Localised pustular (PPP)  Unstable- Generalised pustular,Erthyrodermic  Nail  Hand  Joint  acral Psoriasis Vulgaris Well demarcated salmon-pink plaques with silvery whitescale - Auspitz sign  Elbows  Knees & shins  Scalp  Buttocks  Umbilicus  Nails (50%)  genitals
  3. 3. Block 18 Week 7: Psoriasis 3 CalumLyons Psoriasis (flexural)  Commoner in adults  Partof psoriasisvulgarisor isolated (inverse) psoriasis  ?Koebner to infection or seborrhoeic dermatitis  Therefore need to excludeinfection  Colour is typical  Scalingmay be absent Flexural and Extensor Psoriasis  Flexural psoriasis often occurs in association with extensor psoriasis  May fissure  Secondary infection is COMMON and hard to spot Treatment  Consider,exclude or treat infection, especially C.albicans  Topical steroids (includingcombinations) aremainstay  Eosin & Brilliantgreen  Systemics may be needed Guttate Psoriasis  Children and young adults  Infection related o Especially streptococcal sorethroat o ?tonsillectomy of littlevalue  50% clear and 50% are recurrent or progress to chronic Psoriasis vulgaris Localised Pustular Psoriasis  Palmoplantar pustulosis  Pink & scaly areas studded with pustules  In all stages o Yellow o Brown & flat o detaching  Itchy and/or sore  Chronic and resistantto treatment o Best evidence for RE-PUVA  Adults female>male  Especially smokers
  4. 4. Block 18 Week 7: Psoriasis 4 CalumLyons Unstable Psoriasis Previously stablepsoriasisthathas become erythrodermic or generalised pustular (GPP) as a resultof: - Irritanttreatments - Corticosteroids or other drugs - Infection - Pregnancy - UV - Unknown factors in many cases especially of GPP GPP can occur in patients with no previous history of psoriasis  Adults  Erythema  Pustules  Systemic symptoms  Relapses occur Management  Admission  Supportive therapy and remove trigger factors  Emollients  Retinoid  Methotrexate iv Complications  Hypothermia  Malabsorption  Protein and iron loss  Oedema  Heart failure Nail Psoriasis  Partof all types in up to 50% or more  May be isolated finding  Often associated with PsA and dactylitis  Always check mycology before givingoral terbinafineas itexacerbates psoriasisaswell as causingTEN Hyperkeratotic hand & foot Psoriasis  Thick, fissuringhyperkeratotic plaques on palms and sole o Thenar and hypothenar o Possibly no psoriasiselsewhere  Can be hard to treat o Fissures  Lassar’s pasteor superglue o Emollient o May be responseto topical tar,retinoid or dithranol aloneor in combination (steroids) o Topical PUVA +/- retinoid Psoriatic arthropathy Deforming inflammatory arthropathy develops in up to 23% of psoriasis patients  May predate psoriasis  Not related to skin severity  NSAIDS and corticosteroidscan exacerbatethe skin disease
  5. 5. Block 18 Week 7: Psoriasis 5 CalumLyons Management Patient Advice  Incurable  Chronic/recurrent  Not an infection  Not contagious  Not a genetic defect  Drugs and other trigger factors What do patients want to achieve from treatment  Do they wish systemic  Will they put creams on Topical  Emollients  Occlusion  Tar  Dithranol  Retinoids  Steroids  Vitamin D Topical: choice drug(s) and vehicle  Child or adult  Body site  Tolerability to the patient  Likelihood of compliance Corticosteroids  Block the effect of T-cell mediators of inflammation atthe receptor level o Therefore there may be a rebound inflammation when they are withdrawn o Most other therapies down regulate T-cells and induceapoptosis so that remission is longer lasting  Useful atflexures, scalp and ?nails?  Useful in combination  Some dermatologists never use any corticosteroids Tar  “complex mixtures” o Crude------highly refined o Cruder the better  Availablein creams and ointments as well as solution for bathing  Combinations with corticosteroid and or salicylic acid available o Alphosyl o CTS10% in Eumovate o Betnovate 25% in CTP  Anti-inflammatory,antipruritic and antiseptic  Complications o Contact dermatitis o Folliculitis o No clear evidence of carcinogenicity buttheoretically possible Dithranol  Synthetic anthralin  Ideal vehicleis Lassar’s paste o Short contact creams and micronised preparationsarefar easier to use at home but less effective  Complications o Irritancy.Unsuitablefor multiplesmall plaques. o Stains everything in sightincludingbath enamel
  6. 6. Block 18 Week 7: Psoriasis 6 CalumLyons Tazarotene  Retinoid  Very irritantin somepeople  Useful in hand psoriasis Vitamin D analogues  Effects on cell division and differentiation.Therefore antiproliferativein psoriasis.  Mild-moderate psoriasis  Safe and well tolerated. Little stainingetc  Calcipotriol  Tacalcitol  Calcitriol  Used alone or in combination with emollientor corticosteroid o Eg Calcipotriol o.n.Eumovate o.m. o Dovobet  Better compliancethan separate preparations  Especially importantas patients can overusesteroids in psoriasis  Alternating Vit D analogues as for emollients,appears to maintain efficacy. Light therapy UVB TL01  8-12 week courses 3 times per week  Complications includeburning  The long term skin cancer risk is notknown o Effective as is PUVA which is associated with BCC,SCC, MM  Dead sea PUVA  Topical;hands and feet especially  Systemic o 8-MOP, 5-MOP (can causenausea) o Tablets are unlicensed  Cancer risk increases remarkably after upper level Complications Pigmentation, burning, itch,lentigines,malignancies Contraindications  Photoaggravated diseases or drugs  Skin cancers and previous radiotherapy  Immunosuppression eg posttransplant  Severe renal,cardiac or liver disease  Pregnancy  children Systemic drugs Indications  Psoriasisnotrespondingto other treatment  Other treatments not tolerated  Special sites
  7. 7. Block 18 Week 7: Psoriasis 7 CalumLyons Methotrexate  Antimetabolite. Inhibits dihydrofolatereductase  Anti-inflammatory  Once WEEKLY treatment  Test dose 2.5mg  Maximal benefit begins at 4-8 weeks Monitor  initially weekly then 2-3 monthly  U+E  LFT  FBC  PIIIP  Maintenance dose 5- 25mg Contraindications  BM suppression  Infection  UC  Alcoholism  Pregnancy, lactation  Diabetes mellitus and cirrhosis risk Side effects  Nausea  Cheilitis  Pulmonary/hepatic fibrosis  Skin necrosis  Drug interactions (especially thosewith renal effects) Ciclosporin • 3.5-5mg/Kg/day • Not for long term use becauseof renal damage and hypertension. Contraindications  Renal dysfunction  Uncontrolled hypertension  Malignancy  Infection  Pregnancy and lactation Interactions  NSAIDS  Erythromycin  Grapefruitjuice  anticonvulsants Side effects  Tremor  Headache  Hypertrichosis  Gum hypertrophy  Hypertension  Nephrotoxicity  malignancy Hydroxyurea  500-1500mgdaily  Start dose 500mg  Slow clinical response Side effects  Bone marrow suppression  Photosensitiveexacerbation.Dermatomyositis-like Acitretin • Useful in Ps vulgarisand pustular/ generalised • Combination with UV • Similar sideeffects to roaccutanebut desquammation more sever. Also persists in fatfor 2 years therefore contraception for 2 years Side effects  Bone marrow suppression  Photosensitiveexacerbation.Dermatomyositis-like Infliximab Anti-TNF monclonal antibodies
  8. 8. Block 18 Week 7: Psoriasis 8 CalumLyons Nails  Very difficultto treat  Can be socially and practically disablingtherefore ?systemics?  Topical treatments littleuse.  Intralesional steroid?  Keep nails SHORT  Nail varnish ( even for men) Scalp There is no pointin putting an activetreatment onto thick scale.Therefore:  SA 10% in EO for 1 month  Ung cocois co  Dovonex  Combinations  Coal tar pomade  Dithranol0.25%pomade Guttate  May be self-limitingand need no treatment in children  Outpatient tar treatments eg Alphosyl may be all thatis needed  UV is highly effective Children  Complianceis better and other factors eg alcohol arenot a problem  Avoid UV  Early inpatienttreatment o Providerapid treatment without hazardous therapies o Improve patient understanding for treatment of a lifelongdisease Seborrhoeic dermatitis  Scaly,red, non-itchy, greasy-lookingrash o Hairline o Glabella,eyebrows o Chin o Occasionally flexures  Secondary infection is common in flexures  Seems to be caused by yeasts (Malassezia furfur) in susceptibleindividuals  ?part of a psoriasisspectrumor not? Seborrhoeic Psoriasis or “Sebopsoriasis” Coincidence of 2 chronic diseases?  Both worsen with stress and illness  Both worsen in early HIV  Scalp psoriasiscan improvewith Nizoral  Both associated with IBD  Seb derm worse in PD General treatment  Suppression not cure  Medicated shampoo includingNizoral  Ketoconazole cream o Sulphur and salicylic acid  Topical steroid and combined  UV phototherapy  Check for and treat infection

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