Treatment incl Biologics, Systemic, Topicals, Phototherapy, Climatic Dead Sea Therapy et al, also encompassing Treatment issues and newer therapeutic scoring systems.

1. TREATMENT MODALITIES IN
PSORIASIS

2. PSORIASIS
Psoriasis is a Chronic, incurable, disfiguring,
inflammatory, progressive disorder
characterized by Erythematous, Scaly, Indurated
Plaques present predominantly over Extensor
Surfaces and Scalp, progressing to involve Nails /
Joints as the disease progresses

3. IMPLICATIONS
• PHYSICAL / PSYCHOLOGICAL BURDEN
• HAMPERS QoL / WORK / SOCIAL OUTLOOK /
PERCEPTION OF SELF
• CAFETERIA APPROACH TO TREATMENT
• NON-COMPLIANCE TO COMPLEX REGIMENS / NONADHERENCE TO TOPICALS / LONG-TERM
COMPLICATIONS OF SYTEMIC AGENTS / SEASONAL
EXACERBATIONS should be kept in mind

4. GOALS OF TREATMENT
• Reduce Extent of Disease so it doesn’t hamper
Daily Quality of Life.
• Pt education essential
• Discussion of treatment options so that patients
know what to expect from treatment in terms of
overall results, time scale of improvement and his
effort involved in the process.
• Consider psychological wellbeing of patient
• Salford Score (Severity / Psyhosocial /
Interventions) > PASI / SPASI / PGA / NPF-PS /
PQoLI

6. TOPICALS
• Stand-alone therapy > 80% Cases / Mainstay ; 1st
Line Therapy in Mild-Moderate Psoriasis
• Non-compliance = 40%
• Cosmetically Unacceptable
• Complex Regimens
• Time consuming
• Improved by Simple Regimens / Patient
Education

7. TOPICALS
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Corticosteroids
Vitamin D3 Analogues
Coal Tar
Anthralin
Retinoids
Calcineurin Inhibitors
Emollients

8. CORTICOSTEROIDS
Stabilize Glucocorticoid receptors by induction
of phospholipase A2 inhibitory proteins
LIPOCORTINS  control the biosynthesis of
potent mediators of inflammation such as PGs /
LTs by inhibiting the release of their common
precursor Arachidonic Acid
• Anti-inflammatory / Anti-pruritic

9. CORTICOSTEROIDS
• Superpotent / Potent – Scalp / Limb / Trunk
• Mild Potency – Face / Flexures
• Initial Clearance for 02 – 04 weeks 
Maintainence Doses / Weekend Application
OR Dilution / Combination

10. CORTICOSTEROIDS
PROS
• Non-irritant (Used on Face / Flexures)
• Non-staining (Clothes / Skin)
• Ease of L/A and Removal
CONS
• Folliculitis / Acne / Acneiform Eruptions
• May ppt Pustular Psoriasis
• Stria / Atrophy / Telangiectasis
• Dec Plasma Cortisol levels by Adrenal Suppression
• Tachyphylaxis
Pregnancy Cat
C

11. CORTICOSTEROIDS : Formulations
Ointments
Clobetasol Propionate 0.05%
Betamethasone Dipropionate 0.05%
(Combined with 3% SA)
Clob + Vit D3 analogues
CLOB
BETASALIC
SORVATE-C
Creams
Fluticasone Propionate 0.05%
Mometasone Furoate 0.1%
FLUTIVATE
MOMATE
Lotions
Clobetasol Propionate 0.05%
Clob + 3% SA
Clob + SA + Coal Tar
Desonide 0.05%
CLONATE
TOPISAL
ULTITAR-CS
DESOWEN

12. CORTICOSTEROIDS : Formulations
Shampoos
FLUOCINOLONE ACETATE 0.1%
SEBOWASH
Hydrocolloid / Occlusive Film Dressings
Foams
CLOBETASOL PROPIONATE 0.05 %
Oils / Sprays
Deptt)
-
OLUX-E
Trials (Being used by ENT

14. VITAMIN D3 ANALOGUES
MECHANISM OF ACTION
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Stabilize Vitamin D Receptors
Promote Epidermal Differentiation
Inhibit Keratinocyte Proliferation
Inhibit Pro-inflamm CK production viz IL-2 / IFN gamma

15. VITAMIN D3 ANALOGUES
• Combiation > Monotherapy
• Long-term Therapy safe & effective
ADRs
Local Irritation / Burning
Hypercalcemia
Hypervitaminosis D
Pregnancy Cat
C

16. VIT D3 FORMULATIONS
• CALCITRIOL 0.003% (SORVATE / SORVATE-C)
(1,25-dihydroxycholecalciferol) - Natural Active
VD3
Metabolite of
Synthetic Derivatives:• CALCIPOTRIENE (-OL) 0.005% (PACITREX)
• TACALCITOL (1,24-dihydroxycholecalciferol)
• MAXACALCITOL (1,25-Dihydroxyoxacalcitriol) 0.0025%
• Synergistic Combinations with Corticosteroids / Anthralin
• Ointment / Creams

17. TAZAROTENE
• 3rd Gen Topical Retinoid
• Metabolized into TAZAROTENIC ACID
• (RAR-binding ; affinity for Beta / Gamma)
• Normalizes Epidermal Differentiation
• Antiproliferative Action

18. TAZAROTENE
• Available as 0.05 / 0.1 % Gel / Cream

19. TAZAROTENE
• ADRs - Local Irritation / Erythema /
Photosensitivity / ‘Retinoid Dermatitis’
dosing
• Pregnancy Cat
X
• Combination with Corticosteroids
• Phototherapy - UV reduction by 33%
LAHS

20. CALCINEURIN INHIBITORS
• Macrolide Antibiotics that bind to FK506Binding Protein to inhibit Calcineurin via
Calcium-Calmodulin blockade  Inhibit NFactivated T-cell Proliferation / pro-inflamm IL2 inhibitor
• Pimecrolimus 1% / Tacrolimus 0.1% Oint

21. • aa

22. CALCINEURIN INHIBITORS
• Flexural / Inverse Psoriasis
• Local Burning
• ? Lymphoma / Neoplastic tendency
• ? Use in children < 02 yrs of age
• Pregnancy Cat
C

23. COAL TAR
• 2000 yrs old (Asphalt used in 20 AD)
• By-product of Anerobic, Dry Distillation of
Organic Matter
• Polyaromatic HCs / Phenol
• ‘Liquor Picis Carbonis / Liquor Carbonis
Detergens’ - medical prep

24. COAL TAR
• William H Goeckerman (1925)
2-6% Coal Tar in Petrolatum X 02-04 hrs
Wash  UV-B
Inhibits Epidermal Proliferation by Antimitotic
action at Stratum Basale

25. COAL TAR
ADRs
• Odour / Stain / Appearance
• Contact Derm / Follicultitis / Pruritis
• Carcinogenic (Benzapyrene / Anthracin
compounds)
• Systemic Toxicity (Phenol)

26. COAL TAR
Preparations
Baths (120 mL in 150 L Water)
Ung Psoriasis (SA 2% LPC 10% Vaseline 100%)
Ung LSU (SA 3% LPC 10% Urea 10% Emul 100%)
Salytar (SA 3% Tar 6%)
Ultitar-CS (Clob 0.05% SA 3% Tar 6%)
Foam 2%

27. COAL TAR

28. COAL TAR

29. ANTHRALIN (DITHRANOL)
• 1,8-dihydroxy 9-anthrone
• Synthesized from natural CHRYSAROBIN
(South American Araroba tree bark or
Anthrone)
• Antiproliferative / Anti-inflammatory

30. • John Ingram - UV-B therapy followed by

31. ANTHRALIN
• ICD / Folliculitis / Burning
• Stains Hair Purple / Green
• Stains Skin Brown (Oxidative Product –
Anthraquinone)
• Stains Clothes / Nails
• NO SYSTEMIC TOXICITY
• Available as 1% Cream / Shampoo / GC
combination
• Inconvenient

32. EMOLLIENTS
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•
•
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Avoid Dryness
Limit fissuring
Reduce Scaling / Desquamation
Controls Pruritis
• Increases absorption of Topical Agents by
maintaining Hydration

33. EMOLLIENTS
• Ung COCCUS CO (1% SA 1% SULPHUR 3% Coal
Tar 3% Camphorated Oil 12% Coconut Oil
100% Vaseline)
• COTARYL CREAM (12% Urea 6% Lactic Acid
3% Glycine)
• LIQUID PARAFFIN 10-50%
• AQUASOFT LOT (70% Aqua + Glycerine)

34. PHOTOTHERAPY
• Antiproliferative / Anti-inflammatory action by
Selective Depletion of Epidermal T Cells by
Apoptosis
• NB-UVB (311 nm)
• BB-UVB (290-320 nm)
• EXCIMER LASER (308 nm)
• Safe in Pregnancy

35. PHOTOCHEMOTHERAPY
• PSORALEN + UV A (320-400 nm)
• Photosensitizer Furocoumarin derived from
Psorela corylifolia followed by Phototherapy
for clearance of lesions
• Potent / Higher Side-Effect profile due to
Photo-Carcinogenesis

37. Other Phototherapy Modalities
PHOTODYNAMIC THERAPY
PHOTOSENSITIZER (Amino-Levulinic Acid)
+ Tissue 02 + Light Source  ROS
CLIMATOTHERAPY
EQUATORIAL (SUMMER REMISSION)
DEAD SEA THERAPY 400 mbsl ; Salt + Mineral
Aerosol ; UV-A Penetrance 02-04 wks

38. SYSTEMIC THERAPY
• Indicated for Severe Psoriasis (>30% BSA) or Recalcitrant
Psoriasis or PsA
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MTX
CsA
ACITRETIN
FUMARIC ACID ESTERS
HYDROXYUREA
6-THIOGUANINE
MMF
SULFASALAZINE
BIOLOGICS

40. • aa

41. • ss

42. NEWER AGENTS
• ANTI IL-12 / IL-23 (Ustekinumab / Guselkumab)
• ZIDOVUDINE (ZDV-AZT) for Retinoid-resistant
AIDS-associated Psoriasis
• Protein Kinase C-Inhibitor
• Gluten-free Diet (16% IgA/G to Gliadin)
• Liarozole (Retinoic Acid Metab Blocking Agents RAMBAs)
• Somatostatin
• Vidofludimus (Crohn’s / Psoriasis) DHODH-I
• Newer Biologics (Anti-IL 17)

43. IXEKIZUMAB
• Humanized MAB
• Selectively binds and neutralizes IL-17 proinflammatory Cytokines

44. SECUNIZUMAB
• Humanized MAB
• Selectively binds to IL-17a, reducing
inflammation
• 150 mg SC 02-weekly

45. BRODALUMAB
• Pure Human MAB
• Selective IL-17 blockade
• 140 mg SC 04-weekly
• ?? Neutropenia

46. ITOLIZUMAB
• ALZUMAB by Biocon
• ‘First in Class’
• Targets CD 6  downregulates T-cell Activation
and Maturation,
Reduces Pro- inflammatory Cytokines
25 mg / 5 mL @ Rs 7590/1.6 mg/kg SC every 02 weeks

47. MULTI-AGENT THERAPY
• COMBINATION : Low-dose of each agent to
prevent ADRs  Clearance  Less toxic
continued PUVA + Steroids / Re-PUVA /
Etanercept + CsA or MTX
• ROTATION : Rotation of multiple drugs to
avoid toxicity and resistance MTX  PUVA /
CsA  Re / MTX  Re
• SEQUENTIAL : Initial Clearance Transition
Maintenance (UV A/B)

48. PREVENTION OF RELAPSE
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PSYCHOLOGICAL – Stress / Depression
OBESITY – Linkage to Raeven’s Metabolic Syn
SMOKING?
SEASONAL (WINTER EXACERBATION)
Streptococcal Infection with Guttate Psoriasis
Trauma (Koebnerization)
DRUGS
– ANTIMALARIALS / LITHIUM / AEDs / ACE-I / B – BLOCKERS

49. THANK YOU