PSORIASIS ETIOPATOGENESIS AND PHARMACOTHERAPY

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PSORIASIS ETIOPATOGENESIS AND PHARMACOTHERAPY

• BY
• VINEETHA B MENON
• PHARM.D (PB)
• FIRST YEAR
• JSS COLLEGE OF PHARMACY, MYSORE

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CONTENTS

• INTRODUCTION
• EPIDEMIOLOGY
• AETIOLOGY
• PATHOGENESIS
• DIAGNOSIS
• CLINICAL FEATURES
• TREATMENT

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INTRODUCTION

• Psoriasis is a chronic inflammatory condition
  that may affect the skin and joints

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• EPIDEMIOLOGY

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EPIDEMIOLOGY

• Psoriasis affects both sexes equally
• Can occur at any age, although it most commonly
  appears for the first time between the ages of 15
  and 25 years

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• AETIOLOGY

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AETIOLOGY

• Genetic predisposition DR7 CW6
• Non-hereditary factors
• Infection
• Koebner phenomenon
• Lithium, chloroquine, ß-blockers
• Stress
• Smoking Alcohol

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• PATHOGENESIS

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PATHOGENESIS

• Many changes occur in the skin
• Epidermis Acanthosis, Parakeratosis
• Dermis capillaries are dilated, twisted, closer
  to the surface of the skin

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• Large number of inflammatory cells are present in
  all layers of the skin- granulocytes are
  predominant and form micro-abscessess in the
  epidermis
• Langerhan cells and lymphocytes are also
  increased
• Main abnormality is the increased epidermal cell
  turn over

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Two hypothesis

1. Hyperproliferation may be due to immunological
   response. Cytokines released by lymphocytes and
   langerhan cells may further stimulate the
   inflammatory cells which cause epidermal cell
   turn over at an increased rate

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• 2. Epithelial cells themselves produce cytokines
  which promote proliferation of epithelial cells
  and attract lymphocytes

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• DIAGNOSIS

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DIAGNOSIS

• A diagnosis of psoriasis is usually based on the
  appearance of the skin
• There are no special blood tests or diagnostic
  procedures
• Skin biopsy, may be needed to rule out other
  disorders and to confirm the diagnosis
• Skin from a biopsy will show clubbed rete
  pegs, if positive for psoriasis
• Another sign of psoriasis is that when the
  plaques are scraped, one can see pinpoint
  bleeding from the skin below 

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• Rete pegs are the epithelial extensions that
  project into the underlying connective tissue

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• CLINICAL FEATURES

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CLINICAL FEATURES

• Typical psoriatic lesion
• is red, scaly, sharply
• demarcated plaque

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• It can be on any
• size and can affect
• any part of the
• body

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• The scales are silvery and easily scraped off
  revealing tiny bleed points
• Psoriasis is not typically itchy, but it can
  cause itching when severely inflammed and rapidly
  spreading to the palms and soles

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• Different patterns of psoriasis are
• Guttate psoriasis
• Chronic plaque psoriasis
• Psoriasis of scalp
• Psoriasis of nails
• Psoriasis of palms and soles
• Flexural psoriasis
• Erythrodermic and generalized pustular psoriasis
• Psoriatic arthropathy

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GUTTATE PSORIASIS

• Multiple small plaques are seen all over the body
• Mainly seen in children after streptococcal sore
  throat
• Self limiting after a few weeks

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CHRONIC PLAQUE PSORIASIS

• Medium and large plaques occur on the limb and
  trunk
• Very persistent

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PSORIASIS OF THE SCALP

• May occur as demarcated plaques or may involve
  the entire scalp extending to the hairline
• Scales are white, thick and chalky
• Hair loss will occur if the scalp is thickly
  scaled
• Recover if the scales are cleared and kept under
  control

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PSORIASIS OF THE NAILS

• Pitting, onycholysis and hyperkeratosis under the
  nail
• Very resistant

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PSORIASIS OF THE PALMS AN SOLES

• Sharp demarcation of the involved areas
• Affected areas are inflammed and scaly and may
  contain sterile pustules of large pin head size.
  These pustules dry up and form brown macules
• Affected skin becomes hyperatotic and fissuring
• Secondary infection with itching and pain are
  common

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FLEXURAL PSORIASIS

• Psoriasis occurs in the axillae, submammary
  areas, groin and genitalia
• Demarcation is present, but the affected areas
  are glazy rather than scaly and is bright red in
  color

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ERYTHRODERMIC AND GENERALIZED PUSTULAR PSORIASIS

• Severe and life threatening condition
• Uncommon
• Whole skin surface is involved and highly
  inflammed and the patient is sick
• Pustules are sterile and coalesce to form sheets
  of pus

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PSORIATIC ARTHROPATHY

• Occurs in 5 of the patients with psoriasis
• Similar to RA, but RF is negative
• Different patterns
• Distal Arthritis
• Large Joint Involvement
• Spodilitis/ Sacroiliitis

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• TREATMENT

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TREATMENTAimed at controlling the
current attack and not curing, and does not
influence future progress of the disease

• TOPICAL THERAPY
• Emolients
• Topical Steroids
• Dithranol
• Coal Tar
• Salicylic Acid
• Vitamin D Analogues
• UVB

• SYSTEMIC THERAPY
• PUVA
• Cytotoxic Drugs
• Immunosuppressant Drugs
• Acitretin
• Photodynamic Therapy
• Systemic Steroids

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TOPICAL THERAPY

• EMOLIENTS
• Used alone in very mild cases
• Used along with other therapies for moderate to
  severe disease

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• 2. TOPICAL STEROIDS
• Most useful for acutely inflammed psoriasis
• Mild steroids are used on face and flexures
• Potent steroids are used on hands and feet in
  combination with Clioquinol or Salicylic acid
• Aq. and alcoholic solutions cause stinging and
  burning, thus usually ointments, creams and
  mousse are prefered
• Use of potent steroids on large areas of
  psoriasis may cause rebound flare when
  discontinued

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• 3. DITHRANOL
• Burns the skin
• Stains the skin, clothes and bath fittings
• Unsuitable for use on face and flexures and
  acutely inflamed psoriasis
• 2 regimens - Ingram regimen
• - Short contact regimen

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• 4. COAL TAR
• Used in combination with emolients, topical
  steroids, and salicylic acid
• Used for guttate psoriasis, psoriasis of the
  scalp, and localized pustular psoriasis of the
  palms and soles
• Efficiency of coal tar is enhanced when used with
  UVB

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• 5. SALICYLIC ACID
• Useful to remove the scales
• Used in preparation for other treatment

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• 6. VITAMIN D ANALOGUES
• Efficacy of topical vit D analogues is enhanced
  when used in combination with topical steroids
  and UVB
• Calciptriol Tacalcitol
• Calciptriol is more effective than coal tar and
  dithranol. It cannot be used on face.
• Tacalcitol is used for once daily treatment of
  chronic plaque psoriasis. It can be used on the
  face

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• 7. UVB
• Short wavelength ultraviolet light is used in
  combination with coal tar or dithranol
• Narrow band UVB is more effective

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SYSTEMIC THERAPY

• PUVA
• Used for the treatment of moderate to severe
  chronic plaque psoriasis
• PSORALENS drugs that are activated by UVA
  (320-400nm), to interfere with the DNA synthesis
  and reduce the epidermal cell turn over
• Eg 5-methoxy psoralen 8-methoxy psoralen
• Can be administered orally or it can be applied
  topically

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• The time of exposure is calculated based upon the
  previous light testing and the time interval is
  increased if tolerated by the patient as the
  treatment progresses
• Treatment is given twice weekly for 6 weeks
• Unless the disease is severe, maintenance dose is
  avoided to minimize the long term side effects
• Adverse effects Nausea, pruritis, dry skin,
  aging of the skin, melanoma and non-melanoma skin
  cancer

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• 2. CYTOTOXIC DRUGS
• Methotrexate hydroxycarbamide
• METHOTREXATE
• Most effective in the treatment of psoriatic
  arthritis
• Test dose- 2.5 mg
• Then 30 mg weekly
• Side effects nausea, fatigue, GI bleeding

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• HYDROXYCARBAMIDE
• It should be used continuously as relapse will
  occur when the drug is stopped
• Causes bone marrow depression

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• 3. IMMUNOSUPPRESSANT DRUGS
• CICLOSPORIN
• Severe psoriasis
• Dose is 2-5 mg/kg/day
• Relapse may occur when the drug is stopped but
  intermittent therapy is preferred to maintenance
  therapy
• Avoid sun over exposure, PUVA UVB therapy

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• 4. ACITRETIN
• Used for severe resistant psoriasis, acute
  pustular psoriasis, and palmoplantar psoriasis
• Has teratogenic effect
• Re-PUVA therapy acitretin PUVA
• It causes bone maturation abnormality, LFT and
  serum lipid levels
• Causes dry skin and hair loss

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• 5. PHOTODYNAMIC THERAPY
• 5-aminolaevullinic acid (ALA) causes local
  accumulation of proto porphyrin 9 which is
  activated by irradiation with visible light and
  causes tissue destruction
• Used for localized plaque psoriasis
• Causes burning sensation at the site of treatment

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• 6. SYSTEMIC STEROIDS
• Not commonly used
• May be used for the management of life
  threatening erythroderma
• Systemic steroids or their withdrawal may itself
  provoke acute generalised pustular psoriasis

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QUESTIONS???
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THANK YOU