psoriasisis a hereditary chronic skin disorder, usually characterized by scaly plaques or papules, and often distributed on areas exposed to frequent minor trauma

1. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
PSORIASIS
PREPARED BY: MESHACK J. MASOMHE
Intern Pharmacist
1/30/2019
1

2. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
INTRODUCTION
Psoriasis
is a hereditary chronic skin disorder, usually
characterized by scaly plaques or papules, and
often distributed on areas exposed to frequent
minor trauma.
• The skin lesions are characterized by
epidermal thickening and scaling due to
increased epidermal undifferentiated cell
proliferation with abnormal keratin.
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3. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Clinical types of psoriasis1/7
Psoriasis vulgaris (chronic plaque
psoriasis)
 Is the most common form of psoriasis
 Affects 80 to 90% of people with psoriasis
 It can occur at any age
 The typical psoriatic lesion is a red,sharply
demarcated plaque with overlying silvery
scale.
 The distribution is usually symmetrical
And involves extensor sites such as
the elbows and knees.
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4. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Clinical types of psoriasis 2/7
Guttate psoriasis
• Is more commonly in children and young adults
• Is characterised by a widespread scaly eruption of small
‘tear drop-like’ scaly plaques
• The presentation is often acute and can appear 10–14
days after a streptococcal upper respiratory tract
infection.
Commonly found on trunk and proximal limbs
• Tropical treatments are usually effective.
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5. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Clinical types of psoriasis 3/7
Scalp psoriasis
• Appears as scaly demarcated plaques
Extending to the hairline and around
The ears.
• Hair loss is rare.
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6. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Flexural psoriasis (inverse
psoriasis)
• Can occur at axillae, groin, submammary
areas and genitalia.
• Tend to be red and glazed rather than
scaly.
• Affected areas tend to be clearly
demarcated.
• Secondary infections, particularly with
candida are common.
• It is aggravated by friction and sweat
• Potent steroids are not advised at these
sites due to the high risk of skin atrophy.
Clinical types of psoriasis 4/7
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7. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Psoriatic nail
May be present in patients with any type of
psoriasis
– Can take several forms:
• Pitting: discrete, well-circumscribed depressions
on nail surface
• 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
surface
• Systemic treatments such as methotrexate,
improve nail disease.
Clinical types of psoriasis 5/7
1/30/2019
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8. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Palmoplantar psoriasis
• sites on the palms and soles, where
there is sharp demarcation
take two forms
hyperkeratotic- fissured skin which
can be very painful
pustular
pustules on an erythematous base which dry
to leave small brown macules
Clinical types of psoriasis 6/7
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9. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Clinical types of psoriasis 7/7
Erythrodermic psoriasis (exfoliativedermatitis)
• is a severe, potentially life-threatening
condition in which more than 90% of the
body surface is red and scaly.
• Skin function is impaired
patients suffer dehydration,
electrolyte imbalance,
temperature dysregulation and
serious secondary infection.
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10. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Pathology 1/2
• Psoriasis is characterized by increased
turnover of the basal skin cells.
• Their doubling time is reduced from some
20–30 days to about 2–3 days,
• there is an increased growth fraction the
three lowest layers of the epidermis are
involved in cell germination instead of the
normal, single basal layer.
• the resultant cell production considerably
exceeds the rate of cell differentiation, the
epidermis is thickened
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11. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Pathology 2/2
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12. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Aetiology 1/3
• The aetiology of psoriasis is a combination of genetic
and environmental factors.
• In most cases, there is a genetic predisposition and up to
70% of patients report a family history of psoriasis.
Non-inherited factors
Trauma
• skin laceration, pressure from belts, brassieres, etc.
Infections
• streptococcal tonsillitis, especially in children; HIV.
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13. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Aetiology 1/3
Drugs
• lithium, ß-blockers (most frequently atenolol,
oxprenolol and propranolol), anti-malarials, non-
steroidal anti-inflammatory drugs (NSAIDs),
tetracyclines and rapid withdrawal of systemic
corticosteroids.
Alcohol and smoking
• Excess alcohol consumption may exacerbate
established psoriasis. Additionally, psoriasis is
associated with high rates of alcoholism due to the
psychological stresses of the disease.
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14. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Aetiology 1/3
Stress
e.g. marital, bereavement.
Hormone status
there is an increased incidence in pregnancy
and at puberty and the menopause.
Sunburn or excessive
exposure to the sun is harmful in 10% of
patients, although sunshine may benefit others,
and its lack predisposes to attacks.
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15. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Epidemiology
• occurs in approximately 2% of the population.
• The incidence is similar in both sexes.
• About 75% of cases occur between the ages of
15 and 25 years, but it is unusual for lesions to
appear before the age of 10.
• The condition tends to appear earlier in females
than in males
• The disease is less common among
Asians,Blacks and Eskimos
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16. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Clinical features and diagnosis
• A diagnosis of psoriasis is usually based on the
appearance of the skin. There are no special
blood tests or diagnostic procedures for
psoriasis. Sometimes a skin biopsy, or scraping,
may be needed to rule out other disorders and
to confirm the diagnosis. Skin from a biopsy will
show clubbed pegs if positive for psoriasis.
• Another sign of psoriasis is that when the
plaques are scraped, one can see pinpoint
bleeding from the skin below (Auspitz's sign).
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17. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
treatment
The specific treatment aims are to
• Promote normal maturation of epidermal cells, with vitamin D derivatives
and retinoids.
• Reduce epidermal cell turnover, using cytotoxic or cytostatic agents, e.g.
dithranol, corticosteroids, methotrexate, phototherapy and retinoids.
• Reduce inflammation, with corticosteroids and immunosuppressants.
• Remove scale using keratolytics, e.g. salicylic acid, coal tar.
• Hydrate the skin and reduce itch, with emollients.
Factors influencing treatment selection are:
• Age.
• Form of psoriasis, i.e. plaque, guttate, pustular or erythrodermic.
• Site and extent (localized or generalized) of skin involvement
• Prior successful and unsuccessful treatment.
• Concurrent disease, e.g. HIV.
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18. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
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Vitamin D analogues
• Eg Calcipotriol (calcipotriene) and tacalcitol
• they reduce excessive epidermal cell proliferation,
improve cellular differentiation and strongly inhibit
T cell activation by interleukin-1.
Retinoids
• Eg Tazarotene is used for the topical treatment of
mild to moderate plaque psoriasis affecting up t
10% of the skin surface
Topical pharmacotherapy
Promotion of normal cell maturation

19. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Keratolytics, antipruritics and skin hydration
Salicylic acid
• Creams and ointments containing 2% of
salicylic acid are used primarily as mild
keratolytic agents to remove excessive skin
scales.
• It also helps to stabilize dithranol and can be
used to remove dithranol staining
• It can be mixed with coal tar,steroid or urea.
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20. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Coal tar
• This has mild keratolytic, antimitotic and
antipruritic actions
• is effective only Psoriasis in mild cases.
• Although tar is a recognized carcinogen,
there are no reports of associated skin
tumours over more than 40 years of
pharmaceutical use.
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21. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
• The crude forms of tar are more effective
than refined ones, especially as antipruritics,
• refined ones are more acceptable
cosmetically and cause less staining.
• Coal tar is used in the form of creams,
ointments, pastes, lotions and bath emollients
in a range of concentrations, often prepared
from coal tar solutions.
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22. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
• Dithranol
• is a synthetic anthracene derivative which has an anti-
proliferative and anti-inflammatory effect on the skin.
• inhibits thymidine incorporation into DNA, mitochondrial DNA
replication and repair,and ATP supply in epidermal cells.
• used for stable, chronic plaque psoriasis.
• Side effect; include burning and irritation of normal skin,
staining of clothes as well as a strong odour
• Dithranol has often been used as a first choice,with excellent
results, especially if the condition is mild to moderate. It is
also used if coal tar treatment has not been successful.
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23. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
• Scale removal
• If the scaling is very thick, e.g. on the
elbows and knees, it will hinder the
penetration of drugs, so it may be helpful
initially to remove excess scale
by using 2% salicylic acid ointment on its
own for a week or so. Propylene glycol is
also used.
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24. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
• Phototherapies
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Both natural (sunlight) and artificial UV radiation
may be beneficial and are often used after tar
orpsoralen baths.
UVB, i.e. short wavelength, 290–320 nm radiation,
responsible for sunburn, is used either alone or with
emollients as required.
Alternatively UVA, i.e. longer wavelength,
320–365 nm, is used with a psoralen: this is
photochemotherapy (PUVA).

25. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Anti-inflammatory treatment
• Corticosteroids are potent anti-inflammatory
agents and have cytostatic effects that reduce cell
proliferation in the basal layer,
they have only a limited role in the treatment of
psoriasis.
Although there is an inflammatory element in
psoriasis, and potent steroids may produce a
dramatically rapid symptomatic improvement,
there may be a substantial rebound effect on
withdrawal and subsequent difficulties in treatment
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26. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Systemic pharmacotherapy
• Systemic therapy is indicated in severe
widespread psoriasis, intolerant of or
rapidly relapsing after topical therapy
and phototherapy
• Systemic treatments commonly prescribed
include methotrexate, acitretin and
ciclosporin
.
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27. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Methotrexate
• is a folic acid antagonist used in moderate to severe
psoriasis.
• In males and females of non-childbearing potential,
this tends to be the first-line systemic agent.
• Methotrexate is given as a once weekly oral low dose
regimen, with an initial test dose of 5 mg increasing
up to 30 mg weekly
• Acute toxicity occurs due to the effect of methotrexate
on folic acid metabolism of rapidly dividing cells in the
bone marrow and gastro-intestinal tract
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28. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Acitretin
•Is a vitamin A derivative that inhibits epidermal
proliferation,
• Is effective for disorders of keratinization including
chronic plaque psoriasis.
• The starting dose is usually 25–30 mg daily for 2–
4 weeks increasing to 75 mg Daily for short
periods and according to clinical response.
• Mucocutaneous side effects, hair loss and lethargy
are common
• Should be avoided in women of childbearing
potential because of the teratogenic risk.
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29. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Ciclosporin
• is an effective treatment for all variants of
psoriasis with a fairly rapid mode of action.
• The dose is 2–5 mg/kg.
• Adverse events include hypertension,
hypertrichosis, paraesthesia, tremor and
increased risk of infections
• Other systemic
Hydroxyurea/hydroxycarbamide, Fumaric
acid esters
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30. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Biologic therapy
• Biologic therapies or ‘biologics’ are drugs designed to block
• specific molecular steps important in immune-mediated disease.
• They have been used successfully in rheumatoid arthritis,
inflammatory bowel disease and are now licensed for use in chronic
plaque psoriasis.
TNFα antagonists
• TNFα is a pro-inflammatory cytokine that plays a central role
• in the pathogenesis of psoriasis.
The tumour necrosis factor antagonists: infliximab, adalimumab and
etanercept all have potent immunosuppressant action and have proven
efficacy in severe psoriasis.
• Ustekinumab Efaluzimab,
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31. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
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32. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
STG 2013
• Treatment
• Sun exposure to the lesions for half an hour or one hour daily may
be of benefit
• Crude Coal tar 5% in Vaseline in the morning
Plus
• Salicylic acid 5% in Vaseline to descale
Plus
• Betamethasone ointment 0.025% in the evening.
• Alternatively:
• Dithranol 0.1% once a day
OR
Calcipotriol 0.05% ointment OD (vitamin D derivative, azathioprine etc.
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33. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Refferences
• Roger-Walker-Clinical-Pharmacy-and-
Therapeutics-5th-Ed.
• CLINICAL
PHARMACOLGY&THERAPEUTICS
• Pathology and Therapeutics for
Pharmacists
• STANDARD TREATMENT GUIDELINES
AND ESSENTIAL MEDICINES LIST 2013
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34. Department Pharmacy –Bugando Medical center (bmc)
M ESHACK . MASOMHE
Thank you for Listening
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