disease

4. GROUP MEMBERS
 AIMAN KHAILD
 FAKIHA BAIG
 KHADIJA ZAMAN
 MARIHA MUNEEB
 SIDRA WAQAS KHAN
 SNOBIA MALIK
 SUMBUL SOOMRO
 USHBA JAMAL
 ZAINAB ASGHAR ALI
 FATIMA JOHAR
 ZAINAB ALI

5. INTRODUCTION
 Psoriasis is a common chronic
inflammation disease chaeacterized
byrecurrent exacerbation and remissions of
thickend , erythematous, and scaling
plaques.

6. ETIOLOGY
It is basically the study of cause, set of
causes, or manner of causation of a disease.

7. ETIOLOGY OF PSORIASIS
The cause of psoriasis is related to an immune system problem with T
cells and other white blood cells, called neutrophils.
Skin cells build up in thick, scaly patches on the skin's surface.
80% reports are due to sunlight and 90% reports documented in cold
weather.
Psoriasis is often associated with infections of group A-BETA
HEMOLYTIC streptococci.
It can be develop at the injury site on normal skin by rubbing, bites,
surgery or any mechanical pressure. This phenomena is known as
Koebner response.

8. The antigens involved in this disease development are not
completely known or understood.
Lithium carbonate, beta-adrenergic blocking agents,
tetracyclin, nonsteroidal anti-inflammatory drugs,
angiotensin converting enzyme inhibitors, these
are the commonly reported drugs which trigger
psoriasis effect.

9. PATHOPHYSIOLOGY
 T cell mediated auto immune disease
 Stress, genetic ,autoimmune reaction causes activation of
T cell
 Migration of T cell from lymph node to skin
 Release of cytokines
 Keratinocytes and neutrophils are induced
 Epidermal cells proliferate at faster rate than normal
 Formation of thick patches or plaques or red sores and
scales

10. PATHOGENESIS
 Epidermis is thickened
 Granular layer is absent
 Epidermal cell nuclie are persisting in the horny
layer
 Dermal cappilaries become dilated and closer to
the surface of skin
 Langerhans cells and lymphocytes increased

11. CLINICAL MANIFESTATION
 A typical psoriatic lesion.
 Most common sites.
 Initial lesions and plaques.
 The silver scales.
 Tend to appear for the first time in young
adults.
 Runs a chronic relapsing course.
 Treatment is aimed at controlling the current
attack.
 A number of different patterns of psoriasis
occur which are classified into
 different types.

12. TYPES OF PSORIASIS
There are several types of psoriasis are as under:
1. PLAQUE PSORIASIS:
•It is the most common type of
psoriasis
•PSORIASIS VULGARIS
•It is characterized by the erythematous
plaques covered by silvery
micaceous scales
•It is appeared as inflamed red skin
covered by
silvery patches
•SITES: elbows, knee, scalp, hands and feet,
lower back.

13. 2. GUTTATE PSORIASIS:
■ LATIN ( GUTTA = Drop like )
■ Manifests at early age ( children )
■ It is characterized by eruption of small
papules over the trunk and proximal extremities
■ Seen in association with streptococcal
pharyngitis
3. PUSTULAR PSORIASIS:
■ It is usually uncommon but mostly appear in
adults
■ It appear as pus filled lesion surrounded by
red skin
■ It mostly appear at hand and feet

14. 4. INVERSE PSORIASIS:
■ Localized in the major skin folds, such as the
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.
5. 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

15. 6. NAIL PSORIASIS:
■ It appear as a pitting –small bit nail, yellow-brown
nail, tender and painful nail with chalk like debris build
up under nails.
■ Treated by steroid injected into nail or light therapy
7. PSORIATIC ARTHROPATHY :
■ This is the condition which involve both psoriasis
and joint inflammation.
■ The most distinctive features of psoriatic arthritis
are
•Distal arthritis ( Involves the terminal interphalangeal
joints of the fingers and toes)
• Dactylitis (result in sausage shape swelling
of toes and fingers)

16. DIAGNOSIS
 Diagnosis of psoriasis may include physical
examination of lesion.
 Medical history includes the duration and onset of
lesion.
 Family history includes the presence of
exacerbating factors.
 Skin biopsy is also the diagnostic tool to confirms
the disease.

18. FIRST-LINE TOPICAL
PHARMACOTHERAPY
■ SALICYLIC ACID:
 Most commonly used keratolytics.
 MOA: It causes disruption in corneocyte-to-corneocyte
cohesion in the abnormal horny layer of psoriatic skin.
 Uses:
 Removes scales and smoothes the skin
 Decreases hyperkeratosis.
 Enhances penetration and efficacy of other topical agents
such as corticosteroids,dithranol,coal tar,etc.

19. APPLICATIONS:
 Applied as 2% and 10% gel or lotion ( 2-3 times a day)
 Causes local irritation.
 It may cause nausea , vomiting, tinnitus or
hyperventilation (salicylism)

20. CORTICOSTEROIDS:
MOA:
It stops the synthesis and mitosis of DNA in epidermal cells
and inhibits phospholipase A causing decrease levels of
arachiodonic acid, prostaglandins and leukotrienes.
PRODUCTS A/C TO THE POTENCY
 Low potency products safest for long term, weak
inflammatory effect, used in infants & children, to be
applied on face and intertiginous areas.
 Moderate potency moderate effect, limited
application time on face & intertiginous areas
 High potency as alternatives to systemic
corticosteroids.
 Very high potency for short periods of time,
applied on small surface area, use for thick and chronic
lesions

21. OINTMENTS VS CREAMS:
 Ointments are suitable for psoriasis because of their
hydrating effect due to their oily composition whereas
creams are drying than ointments .
 Creams are cosmetically more desirable than ointments
due to ease of washing.
 Creams may be used for intertiginous areas while
ointments are not suitable for it.

22. VITAMIN D ANALOGS
They inhibit keratinocyte differentiation & proliferations
causing anti-inflammatory effects by reducing IL-8, IL-2 &
other cytokines.
Limited use due to tendency to cause hypercalcemia.
EXAMPLES:
1. Calcipotriene
2. Tazarotene

23. CALCIPOTRIENE:
 For mild to moderate plaque psoriasis
 Within 2 weeks improvements can be observed and after
8 weeks prominent effects can be seen.
 Adverse effects includes stinging and burning in lesions.
 Application: 0.005% creams , ointments or solutions 1-2
times a day(NMT 100G/week).
Examples:
Calcitriol
Tacalcitol

24. TAZAROTENE:
 It is a synthetic retinoid.
 Hydrolyzes to its active metabolite tazarotenic acid and
modulates keratinocyte differentiation and proliferation.
Application:
■ 0.005%-0.1% gel or cream applied once a day.
■ Not recommended to use gel on eczematous skin or more
than 20% of body surface area( leads to extensive systemic
absorption)
Adverse effects:
Stinging , erythema , burning , mild to moderate psoriasis,

25. Non pharmacological treatment
■ Emollient : act as moisturizer minimizes the water evaporation it
decreases pruritus and is used in mild cases Emollient give
soothing effect when applied up to 4 times a day to achieve
expected therapeutic effect it Helps in enhancing skin peeling and
reduces scaling . Adverse effect may include folliculitis and allergic
or irritant contact dermatitis.
■ Balneotherapy : it is a clinically effective approach to treat
psoriasis it involves immersion in mineral medicated water it is
also a type of hydrotherapy balneotherapy works when salt in
certain water reduces the activated T cells in skin
2nd line topical pharmacotherapy
■ Coal tar : is a thick dark liquid which a by product of production
of coke and coal gas from coal. It is applied to affected area to
treat psoriasis to make it cosmetically more acceptable coal tar is
purified but it ultimately losses its potency coal tar is used to treat
guttate, scalp psoriasis and localized psoriasis of palm and sole.

26. ■ ANTHRALIN OR DITHRANOL : works by inhibiting DNA synthesis,
stopping the skin to grow. Dithranol works at very low concentrations
initially start from (0.1% - 0.25%) then gradually increased to (0.5%-1%)
anthralin work by entering antipoliferative effect on keratinocytes
■ INGRAM REGIMEN : a standard treatment used in UK for psoriasis
patient . Dithranol is applied via lassar paste a vehicle designed to
prevent the paste from spreading onto normal healthy skin if it comes
in contact with normal healthy skin it may cause burning sensation
initial concentration starts from 0.1% if no burning occur then gradually
increase dose
• When used with UVB it is observed that efficacy of coal tar is not
recommended because of the theoretical risk of patients developed to
coal tar and UV light rigorously have chances to develop nonmyeloma
skin cancer. 2% - 5% coal tar are available in lotion cream ointment
shampoo gel and solution it can also be used as bath additive it is
applied on lesion in evening and remain in skin contact till night side
effect of using coal tar is that it has an unpleasant odor causes local
irritation staining of skin cloth and increased sensitivity to UV light (sun)

27. ■ The paste is covered with stockinette tubular dressing wash off
after 24 hr in a bath with coal tar additive the treatment is followed
by short wave UV light UVB before application of dithranol. Daily
application of paste can treat psoriasis
■ SHORT CONTACT ANTHRALIN TREAT: at higher
concentration dithranol is applied onto the effected area it causes
less burning and staining the paste penetrates in skin for 20 -30
min and have similar effect as 24 hr application initially start at
0.5% increased every day and tolerated to 3%.

29. FIRST LINE SYSTEMATIC
PHARMACOTHERAPY
 Biologic therapies – primarily immunomodulating
agents designed to alter immune responses-
comprise first line systematic therapy.

30. INFLIXIMAB
(Remicade) is a chimeric monoclonal antibody directed against TNF-
alpha.
Dosage
5mg/kg as an IV infusion at weeks 0, 2, and 6, then every 8 weeks
Adverse effects
headaches, fever, chills, fatigue, diarrhea, pharyngitis, upper respiratory
and urinal tract infections..

31. Etanercept (Enbrel)
It’s binds TNF-alpha, competitively interfering with its
interaction with cell-bound receptors.
Dosage
50mg subcutaneously once per week.
For plaque psoriasis, the dose is 50mg subcutaneously twice
weekly (administered for 3 or 4 days apart) for three
months followed by a maintenance dose of 50mg per
week.
Adverse effects
It includes local reactions at the injection site (20% of
patients), respiratory tract and GI infections, abdominal
pain, nausea and vomiting

32. Adalimumab
(Humaira)is a human immunoglobulin G1 monoclonal TNF- alpha
antibody..
Dosage
40 mg subcutaneously every other week. psoriasis is initial dose of 80mg,
followed by 40mg every other week starting 1 week after the initial
dose.
Adverse effects
The most common adverse reactions are infections (e.g., upper
respiratory, sinusits), injection site reactions, headache and rash.

33. Alefacept
(Amevive) is a dimeric fusion protein that binds to CD2 on Tcells to inhibit
cutaneous T-cell activation and proliferation.
Dosage
The recommended dose is 15mg intramuscularly once weekly for 12
weeks.
Adverse effects
Its adverse effects are mild and include pharyngitis, flu-like symptoms,
chills, dizziness, nausea, and non-specific infection

34. Efalizumab
(Raptiva) is a humanized monoclonal antibody that inhibits CD11-alpha integrin, which is
involved in T-cell activation, migration into skin, and cytotoxic function.
Dosage
The recommended dose is a single 0.7mg/kg subcutaneous conditioning dose followed by
weekly subcutaneous doses of 1mg/kg (200mg maximum single dose).
Adverse effects
The most frequent adverse effects are mild to moderate flu-like complaints such as headache,
nausea, chills, nonspecific infection, pain, fever and asthenia.
Precaution
Cases of exacerbation of psoriasis on discontinuation have been reported, leading to the
suggestion that continuous treatment may be required to maintain disease suppression.

35. SECOND LINE SYSTEMIC
PHARMACOTHERAPY
1. ACITRETIN (SORIATANE):
 It is a retinoic acid derivative
 Active metabolite of etretinate
 Indicated for severe psoriasis and useful in the treatment of
 plaque psoriasis
 Shows good result with combined therapies ( UVA combine
 with oral methoxsalen (PUVA) and UVB and topical calcipotriol)
Contraindicated in pregnancy
DOSE: 25 – 50 mg
ADVERSE EFFECTS: Hypervitaminosis A, hepatotoxicity,
hypercholesterolemia and hypertriglyceridemia.

36. 2. CYCLOSPORINE:
■ Immunosuppressive activity by inhibiting the first phase of T cells
activation
■ Inhibits the release of inflammatory mediators from mast cells,
basophills, polymorphonuclear cells.
■ Used in the treatment of cutaneous and arthritis psoriasis
DOSE: 2.5 and 5 mg/kg/day in two divided doses
ADVERSE EFFECTS: Hypertension, hypomagnesemia, hyperkalemia,
nephrotoxicity

37. 3. TACROLIMUS:
■ Immunosuppressant that inhibits T cell activation
■ Useful in severe psoriasis
DOSE: 0.05 mg/kg daily
ADVERSE EFFECTS: diarrhea, nausea, insomnia, hypertension
4. METHOTREXATE:
■ It is an Antimetabolite
■ Indicated for moderate to severe psoriasis
■ Indicates for patients refractory to topical or UV therapy
■ Contraindicated in pregnancy
DOSE: 7.5 – 15 mg per week ( can be adm orally, I/M, S/C )
ADVERSE EFFECTS: nausea, vomiting, malaise, headache

38. 5. MYCOPHENOLATE MOFETIL:
■ Inhibits DNA and RNA synthesis
■ Useful in the treatment of moderate to severe plaque
psoriasis
DOSE: 500 mg orally four times a day upto max 4 g/day
ADVERSE EFFECTS: GI toxicity, hematologic effects, viral and
bacterial
infections

39. SULFASALAZINE
Contain anti inflammatory property and produces this effect by
inhibiting 5 lipoxygenase it is not effective when used alone as a
single agent as compare to arthritis.
oral dose is 3-4 g/day for 8 weeks sulfasalazine produces
adverse effect similar to sulfonamide antibiotic
6-thioguanine is prescribed when conventional method fail it
is a purine analog a normal dose start with 80 mg twice weekly
gradually increasing the dose by 20mg every 2-4 week the dose
can be increased to 160 mg three times a week.
Hydroxyurea
is preferred for patient suffering from psoriasis as well are
hepatically compromised they act by inhibiting cell synthesis in S
phase of DNA cycle typical dose is 1g/day which can increase up
to 2g/day ADR associated to hydroxyurea are bone marrow
toxicity with leukopenia, leg ulcer, megaloblastic anemia

40. Phototherapy and
phytochemotherapy:
■ 1.UVB light:
it is an imp phototherapeutic intervention
for psoriasis.
■ wavelength: 310 t0 315 nm.
■ uses: used adjunctively to hasten
response to UVB phototherapy.

41. ■ 2.PUVA:
■ photo chemotherapeutic approach for selected
patients.
■ These ptients are unresponsive to topical and
systemic therapies
■ other methods which have less carcinogenic
potential are:
■ a)bath PUVA
■ b)PUVa cream

42. 3)COMBINATIONAL THERAPY:
It include
a)Acitretin+UVB light
b)PUVA+UVB light and further more.
4) ROTATIONAL THERAPY:
Involves using a biological regimen for a limited
period.
5) sequential therapy:
■ involves rapid clearing of psoriasis.

43. PATIENT COUNSELING
Psoriasis is a immune mediated disease it causes red scaly patches appear on skin
Psoriasis can be mild moderated severe the severity of psoriasis can be measured
by how it affects ones quality of life it can also be distressing for the person suffering
from this chronic illness it can also affect the persons confidence and social life.
Mild psoriasis covers less than 3 percent of the body.
Moderate psoriasis covers between 3 and 10 percent of the body.
If psoriasis covers more than 10 percent of your body, it is severe.
When psoriasis is associated joints it causes pain and to some extent joint
deformity
Psoriasis of hand and feet can also cause fissuring which ultimately causes pain
and infection and makes impossible for the person to manage daily routine task
Doctors nurses and pharmacist can help the patient to have a better
understanding of their condition and best ways to treat their condition so that the
patient can live a normal life. There is no cure the disease can be controlled by
daily treatment. The responsibility lies with the patient to apply or take treatment
on regular basis to ensure maximum benefit. A follow up and monitoring of
systemic treatment is necessary if patient is treated in psoriasis in summer time
he / she can take advantage of natural sunshine

44. CASE STUDY
■ A 3 yr old child was brought to the hospital dermatology clinic with
widespread, dry atopic eczema, from which she had suffered from the age
of 6 month. She always had been a poor eater and restless sleeper due to
the itch of her eczema she has also been repotedly treated for bacterial
infection of her skin her normal skin treatment was 1%hydrocortisone
cream her parents had been advised by their health visitor and other
health professional to keep were very keen to have test performed to
identify the cause of the eczema and to decide on a cure.