The document discusses various challenges in treating psoriasis, including balancing treatment goals of reducing disease severity and burden while managing risks of long-term treatment and adverse effects. It presents 10 case studies highlighting issues such as treating psoriasis that presents or worsens with certain drugs, managing chronic or recurrent disease, and treating special populations like children and pregnant women. Treatment options and their risks/benefits are evaluated based on each patient's individual circumstances.

1. Psoriasis Treatment
By
Dr. Aliaa El-Husseiny M.Daifalla
Lecturer of Dermatology and Andrology
Benha University
2016

2. Psoriasis Treatment
Problems in Practice
CASES
YOUR
OPINIO
N

3.  As a result of therapy, lesions may
disappear.
 If the attack is completely
controlled, the relapse rate is low.
The aim of therapy is to reduce
extent of disease so it doesn't
hamper daily quality of life.
Psoriasis adversely affects
patients QoL causing physical /
psychological burden, impact
on work ability/ social outlook /
and patient perception of self
 No cure
 Treatment is only palliative
 Recurrences are almost
certain
 Burden of treatment: non-
compliance to complex
regimens / non-adherence to
topical / long-term
complications of systemic
agents
Why to treat? When to treat ?
When treatment is not recommended?

4.  Case (1): Guttate psoriasis
 Case (2): Psoriasis presenting for
first time after B-blockers
 Case (3): Male patient when
started NB-UVB, psoriasis
plaques increased in size and
number.
 Case (4): Male patient, his 2
daughters have psoriasis. He has
psoriasis plaques over both knees.
 Will guttate psoriasis
shift to chronic plaque
psoriasis or not? Will it
recur?
 Is it going to be chronic
even after stopping the
drug?
 What made him worse?
 When not to treat
psoriasis?
CASES
First: Aim (=Goals) of Psoriasis Therapy
YOUR
OPINION

5. Second: General Measures
 The existing provocative factors should be studied and
eliminated as far as possible.
 Also other possible factors should be avoided to prevent a
new episode of psoriasis or exacerbating pre-existing
disease.
1. Avoid trauma e.g: physical injury, wounds, sunburn
2. Control of streptococcal Infection
3. Relieving stress and depression
4. Weight reduction
5. Dietary supplementation
6. Cessation of smoking
Psoriasis Treatment ?

6. Third: Psoriasis Choice of Therapy ?
Quality of Life
(DLQI)
Surface Area
(BSA)
Severity
(PASI)
Site of lesions
-face
-flexures
-scalp
-palms+solesClinical
Type
Age of the
patient

7. Third: Psoriasis Choice of Therapy ?

8. Psoriasis Topical Treatment
Problems in Practice

9. Psoriasis Topical Treatment
Case (5): Female psoriasis patient, 48 years old,
have been using Dermovate ointment
For 10 years.
How to get the patient off steroids
without rebound ?
How to prevent steroids misuse ?

10. Fifth: Psoriasis Systemic
Treatment

11. Case (6)
 Female patient, 45 years
old suffering from GPP,
started at age of 30, did
not respond to NB-UVB
or acitretin.
 On Mxt for 3 years.
 Reached Mxt total
cumulative 150 two times
 Liver Biopsy done 2
times.

12. Case
(7)
 Male patient, 56 years old, HCV +ve, has GPP,
responded to Acitretin in initial course.
 Re-adminstration of retinoids in next attack did not
give response.

13. Psoriasis Treatment
Problems in Practice
In Children

14. Case (8)
 Female child, Rana,5 years old, presented with
erythrodermic psoriasis,
 She was given in a private clinic systemic steroids
 Initial improvement but then worsen.
 She was given Mxt but leukopenia developed after 2
weeks
 It was stopped and replaced with acetretin.
 Attempts to reduce retinoids dose resulted in
worsening of psoriasis.

16. Psoriasis Treatment
Problems in Practice
In Pregnancy

17. Moderate-Severe Psoriasis in Pregnancy
AcitretinMethotrexateCyclosporin A
X category
-The drug is
contraindicated in
women who are or
may become
pregnant
D category
-There is positive
evidence of human
fetal risk, but the
benefits from use in
pregnant women may
be acceptable despite
the risk (e.g., if the
drug is needed in a
life-threatening
situation)
C category
-Studies on animals
revealed teratogenic or
embryocidal effects
and there are no
controlled studies in
women
-It should be given
only if the potential
benefit justifies the
potential risk to the
fetus
Is topical treatment safe in pregnancy?

18.  A 27-year-old pregnant woman (G1P0 at 36 weeks gestation) presents
with erythema and pustular lesions in her flexures.
 She is diagnosed with impetigo herpetiformis.
 The condition generalizes rapidly.
Case
(9)
What is the most appropriate initial management for
this patient?

19. Case (10)
 Female patient, 23 years old, has generalized plaque psoriasis,
started 5 years ago
 She had winter exacerbation and was on Mxt therapy.
 She will marry and wish to get pregnant.
 Mxt was gradually tapered and stopped.
 Fatma had her first child safely.
 Psoriasis improved and the condition remitted for few months.
 Next winter she came with exacerbation, PUVA was started but
with moderate response.
 She was given Mxt with strict contraception.
 After 4 months, in monthly follow-up she was found to be
pregnant.