Pharmacotherapeutis of Psoriasis

1. Psoriasis
Dr. V. S. Swathi
Assistant Professor

2. Definition
 It is defined as chronic inflammatory disorder of skin and joints
characterised by well demarcated red papules with an overlying scale.

3. Epidemiology
 In the world, prevalence of
Psoriasis is approximately 2-3%.
 In India, prevalence of Psoriasis is
ranges from 0.44%-2.8%.

4. Types
 Psoriasis vulgaris
 Guttate Psoriasis
 Scalp Psoriasis
 Psoriatic nail disease
 Palmoplantar Psoriasis
 Flexural Psoriasis
 Erythrodermic Psoriasis
 Generalised Pustular Psoriasis
 Psoriatic Arthropathy

5. Psoriasis vulgaris
 Also called as Chronic Plaque Psoriasis
 Mostly begin in young adulthood
 Patients presented with well demarcated red, sharp plaque with overlying
silvery scale
 Symmetrical distribution of lesions at knees and elbows
 Sacrum, scalp and nails also affected

6. Guttate Psoriasis
 Commonly seen in children and young adults
 Patients presented with a widespread scaly eruption of small teardrop like
scaly plaques
 Presentation is acute or appears 10-14 days after a streptococcal upper
respiratory tract infection

7. Scalp Psoriasis
 In some patients scalp only involves
 Also occurs in Psoriasis vulgaris patients
 Patients presented with demarcated plaques extending to hairline and
around the ears
 Hair loss is rare

8. Psoriatic nail disease
 Nails are affected mostly
 Patients presented with nail pitting, nail ridging,
onycholysis, hyperkeratosis under the nail and
complete nail destruction
 It affects cosmetic appearance

9. Palmoplantar Psoriasis
 Palms and soles are affected
Two types:
 Painful inflamed hyperkerartotic fissured skin
 Sterile pustules on an erythematous base which dry
to leave small brown macules (Palmoplantar
Pustulosis) - Common in smokers

10. Flexural Psoriasis
 It affects axillae, groin, sub mammary areas and genitalia
 It occurs due to friction and moisture within skin folds
 Patients presented with well demarcated red glazy lesion at affected site
 Secondary infections may occur like Candida infection

11. Erythrodermic Psoriasis
 Also called as Exfoliative dermatitis
 It is severe potentially life threatening condition
 More than 90% of body appears as red and scaly
 Patients presented with dehydration, electrolyte
imbalance, temperature dysregulation and serious
secondary infection
 Patients require urgent hospital admission

12. Generalised Pustular Psoriasis
 It is acute and unstable form of Psoriasis
 Patients presented with wide spread sheets of tiny sterile
pustules on an erythematous base, fever and malaise

13. Psoriatic Arthropathy
 It affects 25% of patients with psoriasis
 Here Rheumatoid factor is negative
 Patients presented with pain, swelling, erythema at affected joints

14. Risk factors
 Infections- Streptococcal pharyngitis and HIV infection
 Drugs like:
 Lithium
 Beta blockers
 Anti malarial drugs
 Tetracyclines
 Rapid withdrawl of systemic steroids
 Alcohol
 Smoking
 Stress
 Cuts, burns, scratch or surgical scars- Koebner Phenomenon

15. Etiology
 Abnormal activation of
innate and adaptive
immunity

16. P
a
t
h
o
g
e
n
e
s
i
s

17. Clinical Presentation
 Red patches of skin covered with thick and silvery scales
 Small scaling spots in case of children
 Dry, cracked and bleedy skin
 Itching and burning skin
 Thickened, pitted and ridged nails- Nail Psoriasis
 Swollen and stiff joints- Psoriatic Arthropathy

18. Complications
 Psoriatic arthritis
 Conjunctivitis
 Uveitis
 Obesity
 Diabetes
 Hypertension
 Cardiovascular diseases
 Chronic renal disease
 Crohn’ s disease
 Parkinson’s disease
 Depression

20. Diagnosis
 Medical and medication history
 Clinical presentation
Type Body Surface Area
(BSA)
Psoriatic Area Severity Index
(PASI)
Dermatology Life Quality Index
(DLQI)
Mild Psoriasis ≤10 ≤10 ≤10
Moderate to Severe
Psoriasis
> 10 > 10 > 10

21. Non Pharmacological Treatment
 Stress reduction
 Avoid exposure to triggering factors
 Physical exercise
 Protect skin from sun by using sunscreen lotions
 Use moisturizers for dry skin

22. Treatment Algorithm for
Mild to Moderate Psoriasis

23. Treatment Algorithm for
Moderate to Severe Psoriasis

24. Drugs used in treatment of Psoriasis
Drug Category Mode of Action Dose Adverse effects
Betamethasone Topical corticosteroid Decreases release
of inflammatory
mediators
Decrease
proliferation of
keratinocytes
0.05% topical
formulations
 Local atrophy
 Itching
 Erythema
 Skin dryness
 Rebound effect on
withdrawl
Hydrocortisone Topical corticosteroid Decreases release
of inflammatory
mediators
Decrease
proliferation of
keratinocytes
0.5% topical
formulations
 Acne
 Skin redness
 Tingling and Prickling
feeling
 Skin dryness
 Hair bumps
Calcipotriol Vitamin D3 Analogue Inhibit
keratinocytes
differentiation and
proliferation
0.005% ointment  Burning
 Itching
 Dry skin
 Erythema
 Peeling of skin

25. Dithranol Synthetic
anthracene derivative
Decreases release of inflammatory mediators
Decrease proliferation of keratinocytes
0.5%-3% cream  Allergy
 Temporary
discoloration of skin
 Lesion soreness
 Staining of hair, nail
and skin
Salicyclic acid Keratinolytic agent Dissolves intracellular cement and makes
hyperkerartotic tissue to swell, macerate, soften and
desquamate
3% ointment
2.5% cream
3% shampoo
 Burning of skin
 Peeling of skin
 Scaling of skin
 Head ache
 Hyperventilation
Methotrexate Immunosuppressant Inhibit rapid proliferation of epithelial cells in skin 10-25mg/week
PO/IV/IM/SC
 Erythema
 Hyperurecemia
 Glossitis
 Leukopenia
 Renal failure
Cyclosporine Immunosuppressant Suppresses production of T cells 1.25mg/kg-PO-BID  Tremor
 Nephrotoxicity
 Hypertension
 Infection
 Hirsutism
Drugs used in treatment of Psoriasis

26. Drugs used in treatment of Psoriasis
Azathioprine Immunosuppressant Suppresses
production of T
cells
1mg/kg/day  Leukopenia
 Infection
 Alopecia
 Arthralgia
 Bone marrow
suppression
 Hepatotoxicity
Acetretin Vitamin A derivative Inhibit epidermal
cell proliferation
25-30mg daily PO  Hair loss
 Lethargy
 Teratogenesity
 Cheilitis
 Dry skin
PUVA Psoralen+
UV A rays
Inhibit epidermal
cell proliferation
320-400nm UVA+
Psoralen taken
orally 2 hours
before exposure to
radiation – Twice/
week for 6 weeks
 Nausea
 Cataracts
 Skin cancer
 Photosensitivity
 Burns

28. Resources
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513809/pdf/40257_2018_Article_396.pdf
 https://www.aafp.org/afp/2000/0201/p725.html
 https://reader.elsevier.com/reader/sd/pii/S0022202X17331718?token=C8D671EE1E4723B13B03C
83035B71C0597B8307FCABC174FBCF18563AF65E57814FA55F6BF9F13CE7358C46737AABF74
 https://reader.elsevier.com/reader/sd/pii/S0022202X17327446?token=6B8742C944F78B9A5A0AF
F6ADF5AB0AD82C160E88BD82B002BF362AF4112D77960CEF0E42839C99FCE91C3F51F1CB98
9
 https://reader.elsevier.com/reader/sd/pii/S0022202X15357067?token=B329A026CA8098C711466
72CFEA49A89830CD986A1B1186E8956E0F6E8DF7C9EB9BA61AF8B8A19AFB21C8FD072E8852
A