PSORIASIS VULGARIS

1. PSORIASIS
DR.ZEEL NAIK
Assistant Professor , Maliba Pharmacy College, UTU.

2. PSORIASIS
 Psoriasis is a common chronic inflammatory
skin disorder characterized by recurrent
exacerbations and remissions of thickened,
erythematous, and scaling plaques.

3. PSORIASIS
 The word psoriasis is derived from Greek word
‘psora’ means ‘itching’.
 Psoriasis is a chronic , non- infectious ,
inflammatory disease of the skin in which
epidermal cells are produced at a rate that is
about 6-9 times faster than normal.
 The cells in the basal layer of the skin divide
too quickly and the newly formed cells move
so rapidly to the skin surface that they become
evident as profuse scales or plaques of
epidermal tissue.

4. PSORIASIS
 The psoriatic epidermal cells may travel from
the basal cell layer of the epidermis to the
stratum corneum and with in 3-4 days, which is
in sharp contrast to the normal 26-28 days.

5. PSORIASIS
 It is a chronic inflammatory disorder of skin
that affects approximately 2%-3% of the
population.
 Common sites affected include the scalp,
buttocks, elbows, knees, hands , legs and
nails.
 Although it is often limited to skin, up to 25% of
patients also have am associated psoriatic
arthropathy and moderate to severe psoriasis
is associated with the risk of CVS disease and
death.

7. EPIDEMIOLOGY
 Psoriasis, a chronic proliferative skin disease is one of
the most common immune mediated disorders
occurring in 2- 3% of population world wide.
 Of patients, 75% present with symptoms of psoriasis
before age 45yrs.
 Although rarely life-threatening, psoriasis has an
adverse physical and emotional impact on quality of
life.
 It affects both sexes equally and can occur at any
age.
 Most commonly appears for the first time between the
ages of 15 and 35 years.
 The study found 35% of people with psoriasis could
be classified as having moderate to severe psoriasis.

8. Etiology
 Idiopathic Cause : It means disease or condition which
arises spontaneously or for which the cause is unknown.
 Some of the factor that may trigger psoriasis are :
 Genetic
 Autoimmune Reaction
 Infection
 Injury to Skin
 Change in climate.
 Medications.
 Stress(Physical and emotional).
 Obesity
 Smoking and Alcohol.

9. Etiology
 Bacteria or Viral infections including strep
throat and upper respiratory tract infection.
 Dry air and dry skin.
 Injury to the skin, including cuts, burns and
insect bites.
 Too little sunlight.
 Too much sunlight (sunburn).
 AIDs
 Rheumatoid Arthritis
 Cancer Chemotherapy.
 Koebner Phenomenon

10. ETIOLOGY
 Psoriasis is a complex and multifactorial
disease that is apparently associated with
interaction between environmental factors
(exogenous or endogenous antigens) and a
specific genetic background.
 It is not contagious and cannot be spread to
others.
 It occurs when body's immune system
mistakes healthy cells for dangerous
substance.

11. ETIOLOGY
 Usually, skin cells grow deep in the skin and
rise to the surface about once a month.
 In persons with psoriasis, this process is too
fast.
 Dead skin cells build up on the skin’s surface.

12. ENVIRONMENTAL FACTORS
 Factors such as climate, stress, alcohol, smoking,
infection, trauma, and drugs can aggravate psoriasis.
 Alcohol seems to have a greater influence on the
progression of psoriasis in men, and the association
between smoking and psoriasis seems to be stronger
in women.
 Psoriatic lesions can develop at the site of injury on
normal appearing skin. This response can be induced
by a variety of trauma that includes rubbing,
venipuncture, bites, surgery, and mechanical
pressure.
 Lithium carbonate, β-adrenergic blocking agents,
some antimalarial agents, NSAIDS, and tetracyclines
are among the most commonly reported drugs to

13. GENETIC FACTORS
 There is a significant genetic component in
psoriasis, but the exact mode of inheritance is
uncertain.
 Monozygotic twins or Identical twins have a
higher concordance for psoriasis than
dizygotic or fraternal twins.

14. Pathophysiology
 Etiologic Factors
 The skin in the patches of psoriasis is growing
much faster than normal skin
 Rapid production of cells which does not allow
the cells to manufacture a keratin that gives its
hard surface.
 Flaking and patches of skin.

15. Pathophysiology (2)
 Stress, Genetic, Autoimmune reaction and
Medication cause.
 Hyper activation of T-cells.
 Epidermis Infiltration and Keratinocyte
Proliferation
 Deregulated Inflammatory Process

16.  Large Production of various cytokines
(Interferon γ, IL-2,IL-12,IL-17,IL-23 TNF- α, IL-8
and others)
 Superficial Blood vessel dilated and vascular
engorgement.
 Epidermal hyperplasia and improper cell
maturation.

17. PATHOPHYSIOLOGY
 The three key steps involved in the pathogenesis of psoriasis
are
i. T-cell activation by antigen in the lymph nodes
ii. T-cell binding to the endothelium in the vasculature, with
subsequent migration into the dermis and epidermis
iii. T-cell reactivation by a second exposure to antigen, which
occurs in the dermis. Certain CD4+ and CD8+ T cells have
a marker on their cell surface known as cutaneous
lymphocyte antigen (CLA)
• These CLA-positive T cells are recruited from the
circulation and migrate to the skin during inflammatory
processes and have been implicated in the pathogenesis of
various skin diseases, including psoriasis
• For these T cells to become activated, an APC(antigen
presenting cell) presents antigen to the T-cell receptor.

19. Clinical Presentation and
Diagnosis
 Most patients with psoriasis have symptoms of the
disease throughout their lifetime.
 Patients who experience frequent relapses,
occurring within months or even weeks, tend to
develop more severe disease. The palm of one's
hand, from the wrist to the fingertips, represents
approximately 1% of the body surface area (BSA).
Disease affecting less than 2% of the BSA is
considered mild, moderate psoriasis involves 3%
to 10%, and severe psoriasis involves more than
10% of the BSA.

21. Classification

22. Classification
 Psoriasis Vulgaris or Plaque Psoriasis.
 Guttate Psoriasis.
 Inverse Psoriasis or Flexular Psoriasis.
 Pustular Psoriasis or palmoplantar
Psoriasis.
 Erythrodermic Psoriasis.
 Nail Psoriasis.
 Psoriatic Arthritis.

24. Psoriasis Vulgaris or Plaque
Psoriasis
 Psoriasis vulgaris or plaque psoriasis, the most
common form of the disease, affects
approximately 80% of psoriasis patients.
 Lesions are usually distributed in a symmetrical
pattern, typically located on the scalp, the lumbar
region of the back, and the extensor surfaces of
the elbows and knees. The well-demarcated
erythematous plaques covered with silvery scales
range in diameter from less than 1 cm to 10 cm.
The lesions are associated with pain and pruritus
(itching) and can occasionally crack and bleed.
Scale removal may result in punctate bleeding,
also called the Auspitz sign.

25. Psoriasis Vulgaris or Plaque
Psoriasis

26. Guttate Psoriasis
 Guttate psoriasis commonly affects children and
young adults and is often associated with recent
streptococcal infections. The lesions are usually
small, scaly, and teardrop-shaped and typically
are localized to the trunk, limbs, and scalp.
 Small , pink red spots appear on the skin.

27. Inverse Psoriasis
 Inverse psoriasis is a form of psoriasis that
often exclusively involves the body folds.
Lesions usually present in the axillae, groin,
inframammary folds, navel, intergluteal crease,
and glans penis areas. Inverse psoriasis
presents as a large, smooth, dry, and very
erythematous lesion. This type of psoriasis is
more common in obese patients.

28. Pustular Psoriasis
 Pustular psoriasis is distinguished by the development
of white pustules encircled by red skin.
 The pustules contain non-infectious pus and are usually
localized to the palms and soles. Generalized disease
affecting the entire body often requires hospitalization
and can be fatal.

29. Erythrodermic Psoriasis
 Erythrodermic psoriasis is an acute inflammatory, erythematous,
scaling disorder involving the entire skin surface
 Severe erythrodermic psoriasis and generalized pustular psoriasis
are associated with the loss of the protective functions of the skin.
These conditions are life-threatening because of the potential for
systemic infections, loss of thermoregulation, and cardiovascular or
pulmonary complications.

30. Psoriatic Arthritis
 Psoriatic arthritis is a chronic, progressive, inflammatory
arthritis that affects as many as about 30% of patients
with psoriasis.The arthritic symptoms are often
associated with the development of skin lesions and
include pain, swelling, and stiffness in the joints.
Furthermore, approximately 5% to 10% of those patients
may experience functional disability.

31. Nail Psoriasis
 Commonly seen along with psoriatic arthritis.
 It appears as a pitting , small bit nail, yellow
brown nail, tender and painful nail with chalk
like debris build up under nails
 Keep the nail short and trimmed

32. CLINICAL MANIFESTATION
 Irritated , red, flaky patches on the skin.
 Most often seen on elbows, knees and middle of the body.
 The skin is itchy, dry and covered with silver flaky
skin(scales).
 Skin pink-red in color, raised and thick.
 Genital lesions in male.
 Joint Pain or aching.
 Nail Changes.
 Severe dandruff on the scalp.
 Burning sensation on the skin.
 Cracked and bleeding skin
 Pus filled blisters.
 Pitting, small depression on the surface of the nail.

33. CLINICAL MANIFESTATION
 Restricted joint motion or pain.
 Bilateral symmetry is a feature of psoriasis.
 In approximately 25-50% of psoriasis patient,
nails are involved , with pitting , discoloration ,
crumbling beneath the free edges and
separation of the nail palate.

35. Psychosocial Aspects
 Physical and psychological disability produced by the disease may
range from minor to total. Severe psoriasis is associated with
substantial morbidity and can cause functional impairment, skin
disfigurement, and emotional distress.
 Approximately 30% of patients with psoriasis have moderate to
severe disease. The prevalence of depression and suicidal ideation
among patients with psoriasis is consistent with figures seen in
other populations with chronic illness.
 Psoriasis directly affects the quality of life and may cause difficulty
in work performance, problems with social rejection, sexual
dysfunction, and depression.

36. DIAGNOSTIC
INVESTIGATIONS
 COLLECT HISTORY(Onset and duration of
lesions, family history of psoriasis, presence of
exacerbating factors, exposure to chemicals
and toxins and allergies of food, drug and
environment).
 PHYSICAL EXAMINATION
 SKIN BIOPSY
 RADIOGRAPHY TEST TO RULE OUT
PSORIATIC ARTHRITIS.
 BLOOD TEST FOR PSORIATIC ARTHRITIS
(ESR, CRP)

37. GOALS OF MANAGEMENT
 TO SLOW THE RAPID TURNOVER OF EPIDERMIS.
 TO PROMOTE RESOLUTION OF THE PSORIATIC
LESIONS.
 TO CONTROL THE NATURAL CYCLES OF THE
DISEASE
 THERE IS NO KNOWN CURE OF THIS DISEASE OR
DISORDER.
 AVOID ANY PRECIPITATING OR AGGRAVATING
FACTORS.
 AN ASSESSMENT IS MADE OF LIFESTYLE ,
BECAUSE PSORIASIS IS SIGNIFICANTLY AFFECTED
BY STRESS.

38. TREATMENT
 Psoriasis treatment is divided into 4 main
types :
 1. Topical Therapy
e.g. Corticosteroids,Vitamin D analogues, Coal
Tar.
 2. Phototherapy
e.g. UVB, PUVA
 3. Systemic Therapy
e.g. Methotrexate,Azathioprine, Cyclosporin,
Acitretin,Hydroxyurea.

39. TREATMENT CHART

40. TREATMENT

41. Topical Therapy
 Topical therapy are first-line treatments for mild
to moderate psoriasis and can often be used in
combination with systemic treatments in more
severe psoriasis.
 Different formulations such as ointment,
creams and gels should be used.

42. 1st LINE TOPICAL
PHARMACOTHERAPY
 1. KERATOLYTICS
 Salicylic acid is most commonly used keratolytics.
 It causes a disruption in corneocyte to corneocyte
cohesion in the abnormal horny layer of psoriatic skin.
 This helps to remove scales, smooth the skin, and
decrease hyperkeratosis.
 The keratolytic effect enhances the penetration and
efficacy of some other topical agents such as
corticosteriods.
 It is applied as a 2% to 10% gel or lotion 2 – 3 times a
day.
 Salicylic acid produces local irritation.

44. 2. Topical Corticosteriod
 They halt synthesis and mitosis of DNA in
epidermal cells and appear to inhibit
phospholipase A, lowering the amount of
prostaglandins and leukotrienes in the skin.
 These causes vasoconstriction , reduce
erythema, pruritus and scaling.
 Improvement is usually achieved within 2-4
weeks.
 They slow the cells turnover by suppressing
the immune system which reduce
inflammation and relieves from associated
itching.

45. Topical Corticosteriods
 Low potency products (e.g. hydrocortisone 1%) have a weak
anti inflammatory effect and are safest for long term application
and are recommended for sensitive area.
 Medium Potency Products are used in moderate inflammatory
lesions.
 High Potency Preparations are used primarily as alternative to
systemic corticosteriods when local therapy is feasible.
 Very High Potency Products may be used for thick, chronic
psoriatic lesions but for only short periods of time and on
relatively small surface areas.
 Ointments are the most effective formulation for psoriasis
because they have an oily phase that conveys a hydrating effect
and enhances penetration of the corticosterioid.
 They are not suited for use in the axilla, groin or intertriginous
areas where maceration and folliculitis may develop.

46. Topical Corticosteriod
 Creams are more cosmetically desirable for
some patients.
 They may be used intertriginous areas even
though their lower oil content makes them
more drying than ointments.
 Topical corticosteroids can be applied 2-4
times a day daily.

47. Corticosteriod Brand Name Strength Relative Strength to
hydrocortisone
Hydrocortisone
(0.5-2.5%)
Hydrocortisone Mild 1
Fluocinolone Acetonide
(0.0025%)
Synalar 1:10 Mild 1
Betamethasone Valerate
(0.025%)
Betnovate RD Moderately Potent 2.5 times stronger
Clobetasone butyrate
(0.05%)
Eumovate Moderately Potent 2.5 times stronger
Fluocinolone Acetonide
(0.00625%)
Synalar 1:4 Moderately Potent 2.5 times stronger
Fludroxycortide Haelan Moderately Potent 2.5 times stronger
Betamethasone Valerate
(0.1%)
Betnovate Highly Potent 10 times stronger
Mometasone Furoate
(0.1%)
Elocon Highly Potent 10 times stronger
Clobetasol Propionate
(0.05%)
Dermovate Very Potent 50 times stronger

48. TOPICAL CORTICOSTEROIDS
 50 g of ointment or cream may be used per
week.
 Recommended amount of a topical
corticosteriod corresponding to one finger tip.
 The finger tip unit (FTU) is equivalent to
approximately 0.5 grams of cream/ointment
and should cover a skin area of about 2 %
body surface area.

50. ADRS of TOPICAL
CORTICOSTEROIDS
 Local tissue atrophy , skin degeneration and
striae.
 Thinning of the epidermis and purpura.
 The use of potent corticosteroids may cause
systemic absorption and include risk of
hyperglycemia and development of cushingoid
features.
 Tachyphylaxis(Drug Tolerance) and rebound
flare of psoriasis after abrupt cessation of
therapy can also occur.

51. 3. Vitamin D Analogues
 Vitamin D and its analogues inhibit keratinocyte
differentiation and proliferation and have anti
inflammatory effects by reducing IL-8, IL-2 and other
cytokines.
 Use of Vitamin-D itself is limited by its propensity to
cause hypercalcemia.
 Calcipotriene (Calcipotriol)
 Dovonex (Brand Name) is a synthetic Vitamin D
analog used for mild to moderate plaque psoriasis.
 Improvement is usually seen within 2 weeks of
treatment and approximately 70% of patients
demonstrate marked improvement after 8 weeks.
 Calcipotriene (0.005 %) cream, ointment or solution is
applied 1-2 times a day(no more than 100 g/week)

52. Vitamin D Analogues
 Calcitriol ,tacalcitol and maxacalcitol are other
vitamin D derivatives that have been studied for
treatment of psoriasis.
 Salicylic acid inactivates calcipotriene.
 It is often used in combination with or in rotation
with topical corticosteriods in an effort to maximize
therapeutic effectiveness while minimizing steroid
related skin atrophy.

53. 4.TOPICAL TAZAROTENE
 Tazarotene (Tazorac, Zarotex) is a synthetic
retinoid that is hydrolyzed to its active metabolite,
tazarotenic acid, which modulates keratinocyte
proliferation and differentiation.
 It is available as a 0.05% or 0.1% gel and cream
and is applied once daily(usually in the evening)
for mild to moderate plaque psoriasis.
 ADRS: Local irritation, pruritus, burning, stinging
and erythema.
 Tazarotene is often used with topical
corticosteroids to decrease local ADRs and
increase efficacy.

55. 2nd Line Topical Treatment
 1. Coal Tar
 Coal tar is one of the oldest(since 2000 years) topical treatments for
psoriasis and has anti-inflammatory , antibacterial , antipruritic and
antimitotic effects.
 A variety of preparations are available including bath preparations,
shampoos, creams and ointment.
 Coal tar preparations of 2%-5% tar are available.
 It is directly applied to the lesions in the evening and allowed to
remain in skin contact through night,
 It may also be used in bath water.
 Coal Tar can be used in combination with other products such as
topical corticosteroids or UVB phototherapy.
 The risk of carcinogenicity is low, but there may be a high rate of
non-myeloma skin cancers in patients chronically exposed to coal
tar and UV light.

57. 2. Anthralin (Dithranol)
 Anthralin possesses antiproliferative activity on keratinocytes, inhibiting
DNA synthesis.
 Anthralin is a man-made version of a natural substance found in goa
powder, which is from the araroba tree. It works by slowing down the
growth of skin cells.
 It also have anti-inflammatory effect.
 Therapy usually starts with low concentrations (0.1%-0.25%) with
gradual increases to higher concentrations (0.5%-1%).
 Creams and ointment formulations are applied in the evening and
allowed to remain overnight.
 It is an effective treatment for psoriasis and with coal tars, is one of the
oldest treatments used.
 Anthralin can irritate normal skin and stain clothing.
 Short contact Anthralin therapy (SCAT) with application for 10 to 20
minutes of higher concentrations( 1%-5%) in water soluble vehicle is
effective.

59. 2. PHOTOTHERAPY AND
PHOTOCHEMOTHERAPY
1. UVB
 Many patients with psoriasis will report an improvement in
their skin after sunny holidays, with only 10% of patient
reporting deterioration in symptoms on sun exposure.
 Phototherapy with either UVB or photochemotherapy with
UVA after psoralen exposure (PUVA) has an
immunosuprresive effects on the skin and has been used to
treat psoriasis.
 UVB light (290-320 nm) therapy is an important therapy for
psoriasis.
 The most effective wave length is 310-315 nm which is also
known as narrow-band UVB and most commonly used for
moderate-severe psoriasis.
 It is preferable to older UVB (290-320 nm) lamps, due to
increased safety and reduced risk of burning.
 Heat and humidity from sunlight provide additional positive
effects.

60. 2. PHOTOTHERAPY AND
PHOTOCHEMOTHERAPY
 Narrow-band UVB is an effective treatment for getting rapid
control of widespread disease, with 75% of patients being
clear or nearly clear of psoriasis after a course of treatment.
 Usually 2-3 treatments a week for 6 weeks.
 Topical and sometimes systemic psoriatic therapies are used
adjunctively to hasten and improve the response to UVB
phototherapy.
 Emollients enhance efficacy of UVB and can be applied just
before treatments.
 Combining short contact anthralin, Calcipotriene or
Tazarotene to UVB may also improve results.
 However, topical application should be done after or atleast 2
hours before UVB therapy because phototherapy can
inactivate the topical product.
 Risks: sunburn, photo aging, and skin cancer.

61. 2. PUVA (Photo
chemotherapy)
 It is photo chemotherapeutic approach for selected
psoriasis and mainly has a role in the treatment of
moderate to severe psoriasis.
 Psoralens (photo sensitizer) are drugs that are
activated by long wave UV light(320-400 nm) which
interact with DNA synthesis and reducing epidermal
turnover.
 Photo chemotherapy combines psoralens with UVA
light in the 320 to 400 nm spectrum.
 2 Psoralens are available : methoxsalen or 8-MOP(8-
methoxypsoralen) and 5-MOP.
 Psoralens are a group of photoactive compounds that
on absorption of UV light, are both antiproliferative
and immunomodulatory.

62. 2. PUVA (Photo
chemotherapy)
 Photo chemotherapy is used to control severe,
recalcitrant, disabling plaque psoriasis.
 After 10 to 25 treatments over 4 to 8 weeks(2-
3times a week), >80% of patients experience
clearing of symptoms, which can be maintained
with periodic (twice monthly) treatments.
 8-Methoxypsoralen (8-MOP) is the most widely
used agent, taken at an oral dosage of 0.6 to 0.8
mg/kg of body weight , 1.25 to 1.5 hours before
exposure to UVA light.
 ADR: Erythema, blistering, nausea, lethargy,
headache, pruritus, Skin Cancer(non-melanoma).

64. PHARMACOLOGIC THERAPY
 Topical treatments:
 Corticosteroids: beclomethasone, dexamethasone
 vitamin D analogues: calciprotriene
 Topical Retinoids: Tazarotene
 Coal tar
 Anthralin
 keratolytics
 Systemic treatments:
 Immunosuppressive agents: methotrexate, cyclosporin
 Immunomodulatory agents:
 Inhibitors of T-cell activation: alefacept, efalizumab
 TNF-alpha inhibitors: infliximab, etanercept, adalimumab
 Acitretin

65. Topical Therapy

66. 3.BIOLOGIC THERAPY
 Immunomodulatory agents:
 Inhibitors of T-cell activation: Alefacept, Efalizumab
 TNF-alpha inhibitors: Infliximab, Etanercept,
Adalimumab
 IL-12/IL- 23 antagonist : Ustekinumab
 IL-17 Antagonist : Secukinumab
1. Infliximab (Remicade)
2. Etanercept (Enbrel)
3. Adalimumab (Humira)
4. Alefacept (Amevive)
5. Efalizumab (Raptiva)

67. 1.INFLIXIMAB (Remicade)
 It is a chimeric monoclonal antibody directed against TNF-
alpha.
 Its used in the treatment of psoriatic arthritis and chronic
plaque psoriasis.
 An advantage over other sytemic psoriasis treatments is that
infliximab doesnot adversely affect the blood counts, hepatic
enzyme levels or kidney function.
 Dose: 5 mg/kg as an IV infusion at weeks 0,2 and 6, then
every 8 weeks thereafter.
 For psoriatic arthritis it may be used with methotrexate.
 ADRs: Headache, fever,chills, fatigue, diarrhea, pharyngitis,
URTI , urticaria, dyspnea and
 hypotension.

69. 2. Etanercept (Enbrel)
 It is a fusion protein that binds TNF-alpha, competitively
interfering with its interaction with cell bound receptors.
 Etanercept is fully humanized, thereby minimizing risk of
immunogenecity.
 It is indicated for patients with chronic moderate to severe
plaque psoriasis who are candidates for systemic therapy or
photo therapy.
 Dose : The dose for psoriatic arthritis is 50 mg SC twice
weekly (3-4 days apart) for 3 months followed by
maintenance dose of 50 mg per week.
 ADRs: Local reaction at site of injection(25% pateint),
Respiratory tract infection, GI infection, abdominal
pain,nausea and vomiting , headaches and rash. Serious
infections including TB and malignancies can occur

71. 3. Adalimumab (HUMIRA)
 It is a human immunoglobin G1 monoclonal TNF-
alpha antibody.
 The binding of Adalimumab results in inactivation
of the proinflammatory cytokine TNF-a.
 It is indicated for psoriatic arthritis and treatment
of moderate to severe plaque psoriasis.
 Dose: The dose for psoriatic arthritis is 40 mg SC
every other week. The dose for plaque psoriasis is
80 mg, followed by 40 mg every other week.
 ADRs: Infections(URTI, sinusitis), injection site
reactions, head ache and rash.

73. 4. ALEFACEPT(AMEVIVE)
 It is a dimeric fusion protein that binds to CD2
on T-cells to inhibit cutaneous T-cell activation
and proliferation.
 It is used for treatment of moderate to severe
plaque psoriasis and also effective for
treatment of psoriatic arthritis.
 Dose: 15 mg IM once weekly for 12 weeks.
 ADRs : Pharyngitis,chills, dizziness,nausea,
headache, injection site pain and
inflammation.

75. 5. Efalizumab(Raptiva)
 It is a humanized monoclonal antibody that
inhibits CD11-a integrin, which is involved in T-cell
activation, migration into skin and cytotoxic effect.
 Used for moderate to severe plaque psoriasis.
 DOSE: 1 mg/kg(200 mg maximum single dose)
 ADRs: Head ache, nausea, chills, pain, fever and
asthenia.
 Cases of exacerbation of psoriasis on
discontinuation have been reported, leading to the
suggestion that continous treatment may be
required to maintain disease suppression.

76. 6. Ustekinumab(IL-12/IL-23
antagonist)
 Ustekinumab is a fully human monoclonal
antibody used in the treatment of moderate to
severe psoriasis.
 It acts by binding to and blocking the cytokines
IL-12 and IL-23.
 Dose : It is administered as a SC injection at a
dose of 45 mg at baseline, week 4 and week
12.
 ADR: Head ache, confusion, seizures, sudden
vision changes, mental/mood disorders.
 Brand Name: Stelara

77. Secukinumab (IL-17 Antagonist)
 It is a fully human anti IL-17 antagonist
monoclonal antibody.
 Dose: It is administered as a SC injection at a
weekly dose of 300 mg monthly maintenance
dose.
 ADRs: Sore throat, diarrhea, URTI,
Sinusisitis,oral herpes, urticaria.
 Brand Name: Cosentyx

78. 4. Systemic Pharmacotherapy
Immunosuppressive agents
 Methotrexate
 Cyclosporin
 Tacrolimus
 Mycophenolate Mofetil (CellCept)
 6- Thioguanine
 Hydroxyurea/Hydroxycarbamide
 Acitretin [Soriatane] (It is not
immunosuppressant agent, it is a vitamin A
derivative)

79. Systemic therapy

81. 1.METHOTREXATE(GOLD
STANDARD)
 It is an antimetabolite and is indicated for moderate to severe psoriasis and
psoriatic arthritis.
 It inhibits purine and pyrimidine synthesis, which is required for DNA
synthesis.
 Methotrexate works by suppressing the overactive immune system that
causes psoriasis.
 It can be administered orally, SC or IM.
 DOSE : The starting dose is 7.5 to 15 mg per week,increased incrementally
by 2.5 mg every 2-4 weeks until response.(maximum 25 mg per week).
 50% improvement is seen after 4 months of starting of treatment.
 ADRs: Myelosuppression, Severe nausea and vomiting, mucosal
ulceration, stomatitis,malaise,headache, macrocytic anemia,
thrombocytopenia, leucopenia , hepatic and pulmonary toxicity.
 Contraindication: Active infections, liver disease and pregnancy
(teratogenic).
 Contraindicated in both males and females.

82. 2. Cyclosporine
 It inhibits the first phase of T-cell activation and also inhibits
the release of inflammatory mediators from mast cells,
basophils and polymorphonuclear cells.
 It is used in both severe form of psoriasis and arthritis.
 DOSE : The usual dose is between 2.5-5.0 mg/kg/day given
in 2 divided doses. 50 % improvement is seen after 16
weeks.
 ADRs: Nephrotoxicity, hypertension, hypomagnesemia,
hyperkalemia, alteration in LFTs, elevation in serum lipids. GI
intolerance, parasthesia and gingival hyperplasia.
 Cummulative treatment for 2 years may increase the risk of
kidney failure, skin cancer and lymphomas.
 Contraindications : A compromised immune
system;Abnormal kidney function;High blood
pressure;Cancer, or a history of cancer.

83. 3. ACITRETIN (RETINOID)
 It is a Vitamin A derivative that inhibits epidermal proliferation
and effective oral agent for psoriasis, an alternative to
immunosuppressive agents.
 It is used in severe plaque, Erythrodermic and Pustular types
of psoriasis.
 It shows good result when combined with PUVA and UVB and
topical calcipotriol.
 DOSE: The initial dose is 25-50 mg daily for 2-4 weeks.
 ADRs : Hypervitaminosis A, hepatotoxicity, skeletal changes,
hair loss, lethargy, Hyperlipidemia.
 Contraindication: Diabetes, high cholesterol, high amount of
triglyceride in the blood, mental problems, alcoholism,
depression.
 Brand Name: Soriatane

84. 4. TACROLIMUS
 It is an immunosuppressant that inhibits T-cell
activation and useful in severe chronic
psoriasis.
 It is not approved by FDA.
 DOSE : Oral doses of 0.05 mg/kg daily, with
increase upto 0.15 mg/kg daily.
 ADRs: Diarrhea, nausea, paresthesias(pins
and needles), hypertension, tremor and
insomnia.

85. 5. Mycophenolate Mofetil
(CELLCEPT)
 It inhibits DNA and RNA synthesis and have a
specific lymphocyte antiproliferative effect.
 Not approved by FDA.
 DOSE: 500 mg orally 4 times a day, up to
maximum 4 g/day.
 ADRs: GI toxicity, Myelosuppression, flushing,
Proteinuria , lymphoma and renal failure.

86. 6. Sulphasalazine
 It is an anti-inflammatory agent that inhibits 5-
lipoxygenase.
 Indicated for psoriatic arthritis.
 When used alone it is not as effective as
methotrexate , PUVA or acitretin.
 But it is highly safe.
 DOSE: Oral dose: 3-4 g/day for 8 weeks.
 ADRs : Gastric distress, nausea, vomiting and
anorexia.

87. 7. 6-THIOGUANINE
 It is a purine analog that has been used as an
alternative treatment for psoriasis when all
therapies have failed.
 Dose: 80 mg twice weekly , increased by 20 mg
every 2-4 weeks. The maximum dose is 160 mg
three times a week.
 ADRs: Bone marrow suppression, GI
complications and elevation in LFTs.
 It is less hepatotoxic compared to
methotrexate so can be used in hepatically
compromised patients with severe psoriasis.

88. 8.
Hydroxyurea/Hydroxycarbamide
 It inhibits cell synthesis in the S phase of the
DNA cycle.
 It is a cytotoxic immunosuppressant drug.
 It has similar mode of action to methotrexate.
However it is less effective than methotrexate.
 DOSE: 1g/day, with gradual increase to 2g/day
as needed.
 ADRs: Bone marrow toxicity , leg ulcers,
megaloblastic anemia, teratogenic, liver
toxicity.

89. NONPHARMACOLOGIC
THERAPY
 Emollients
 Emollients are frequently used during therapy-
free periods to minimize skin dryness that can
lead to early recurrence.
 As lotions, creams, or ointments, emollients
often need to be applied several times per day
(about four times per day) to achieve a
beneficial response. Adverse effects of
emollients include folliculitis and allergic or
irritant contact dermatitis.

90. NONPHARMACOLOGIC
THERAPY
 Balneotherapy
 Balneotherapy is a therapeutic approach that
consists of bathing in waters containing certain
salts, often combined with natural exposure to
the sun.
 Fangotherapy( MEDICINAL CLAY OR MUD
BATH).
 CLIMATOTHERAPY: It refers to temporary or
permanent reloaction of psoriasis patient to a
region with a climate more favorable to
recovery.
 Warm and moist climate is ideal for

91. FANGOTHERAPY
BALNEOTHERAPY