Psoriasis

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Psoriasis
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Psoriasis

• Definition and causes
• Types
• GP management
• Pitfalls
• Hospital treatments

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Psoriasis

• Definition
• A chronic, non-infectious, inflammatory skin
  disorder, with well defined, erythematous plaques
  large adherent silvery scales
• Prevalence 1.5-3
• Age onset 20-30y or 50-60y

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Psoriasis

• Epidermal hyperproliferation
• Vascular dilatation
• Inflammatory infiltrate

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What causes psoriasis ?

• T cell mediated autoimmune disease
• ? increased keratinocyte proliferation
• Environmental and genetic factors

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Psoriasis

• Genetics
• 40 have FHx
• 73 monozygotic twins concordant v 20 dizygotic
  twins
• 1st degree relatives have 4-6 fold increased risk
• Environmental triggers

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GP Management

• Time (for proper examination and to communicate
  with the patient)
• Explanation
• Information and support sources (patient.co.uk,
  psoriasis-association.org.uk)
• Follow-up

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GP Management

• Emollients
• Bath oils
• Site-specific topical treatments

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Topical treatments

• Vitamin D analoguesDovonex (calcipotriol)Dovobet
  (calcipotriol betamethasone)Silkis
  (calcitriol)Curatorderm (tacalcitol)Zorac
  (tazarotene)
• Dovonex cream and scalp application no longer
  available

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Topical treatments

• Tar(Carbo-dome)(Exorex)Psoriderm(Alphosyl
  HC)Sebco(Cocois)Tar-based bath oils shampoos

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Topical Treatments

• SteroidsOften in conjunction with Vit D analogue
  as Dovobet or separate steroidEumovate(Trimovate
  )Scalp preparations (eumovate to dermovate
  strength)
• BE CAREFUL (but not mean)

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Topical Treatments

• DithranolDithrocreamMicanolPsorin
• Stains skinHas to be washed offStart and low
  strength and build up

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Topical treatments

• Nails
• difficult
• potent topical steroids
• dovonex
• tazarotene
• systemic therapy

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Topical Treatments

• Scalp
• Remove scale firstCocois or Sebco messy but
  effective
• Tar or salicylic acid shampoo
• Topical steroids if necessary for short periods

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Types of psoriasis

• Plaque
• Guttate
• Rupioid
• Unstable
• Pustular
• Erythrodermic
• ?palmo-plantar pustulosis

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Guttate psoriasis
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Pustular psoriasis
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Erythrodermic psoriasis
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Plantar pustulosis
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Acrodermatitis continua of Hallopeau
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Pitfalls

• 'It's not working Doc'
• It did work, but then he stopped using it and the
  psoriasis returned
• It was too greasy/time-consuming/smelly so he
  stopped using it
• He wasn't applying it properly
• It really didn't work

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Hospital Treatment

• Out-patient advice and support
• UVB
• PUVA
• Acitretin
• Methotrexate
• Ciclosporin
• Biologics
• Admission (tar, other topicals)

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UVB phototherapy

• Suitability age, PH skin cancer, medication,
  radiotherapy, photosensitive disease
• X3 / week for 6 weeks
• Shield genitalia, uninvolved sites
• SE burning (30)
• ? risk skin cancer (screen yearly if gt150
  treatments)

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PUVA

• Suitability as for UVB CI in renal/hepatic
  disease, cataracts, pregnancy, children
• X2 / week for 6-8 weeks
• Need eye protection for 24 h after psoralen
• SE burning, nausea, itch
• ? risk skin cancer (screen yearly if gt150
  treatments)

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Systemic therapy
acitretin methotrexate ciclosporin
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7-20 of patients with psoriasis have arthritis
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Acitretin
mec affects keratinocyte differentiation CI ?
fertile women (as must avoid pregnancy for 2
years) SE dry lips, teratogenicity, abnormal
LFT, lipids, DISH
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Methotrexate
mec inhibits DNA synthesis by inhibiting
dihydrofolate reductase ? reduces proliferation
of lymphocytes keratinocytes CI pregnancy,
lactation, infection, liver/renal disease, peptic
ulcers given once weekly SE anorexia,
nausea, myelosuppression, hepatotoxicity, mouth
ulcers, pulmonary toxicity, oligospermia, skin
cancer Interactions NSAIDs, septrin,
trimethoprim, penicillin, phenytoin
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Ciclosporin
Mec Inhibits T cell activation CI uncontrolled
HBP, malignancy, infection SE HBP,
nephrotoxicity, skin cancer, other malignancy,
gum hypertrophy Not recommended for long term
treatment
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New Biologicals

• Anti TNF drugs
• Infliximab, etanercept, adalimumab
• Targeted T - cell therapy
• alefacept (binds CD2 blocks LFA3)
• efalizumab (binds to LFA-1 blocks ICAM-1)
• Anti-IL 17 receptor antibodies
• Brodalumab
• Ixekizumab

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GP Issues

• Know what your patient is on (?record as outside
  script on EMIS)
• Know what monitoring you are responsible for
• Keep a look out for myelosuppression
• Don't be afraid of your local Derm department!

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SIGN 121

• Patients with psoriasis or psoriatic arthritis
  should have an annual review with their GP
  involving the following
• ?documentation of severity using DLQI
• ?screening for depression
• ?assessment of vascular risk (in patients with
  severe disease)
• ?assessment of articular symptoms
• ?optimisation of topical therapy
• ?consideration for referral to secondary care

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Streptococcal theory

• Streptococcal infection can
• super-antigen immune stimulation
• very high cytokine excretion, especially TNF-a

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• In guttate psoriasis, all strep isolates from the
  throat stimulate this pathway. Once activated,
  these T cells infiltrate the skin, however the
  thereafter pathogenic pathways diverge
• keratinocyte death exfoliation in scarlet fever
• keratinocyte proliferation in guttate psoriasis

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Case Studies

• Paul, age 45
• Carpet fitter
• Large plaque psoriasis knees, elbows, natal
  cleft. Hand and nail involvement

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Case studies

• Robert, age 35
• Psoriasis since teens
• Lives in a hostel, alcoholic

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Case studies

• Anne, age 15
• Recent onset guttate psoriasis
• Wants skin to be clear for sisters wedding

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Case studies

• David, age 25
• Severe psoriasis
• Has had multiple admissions, MTX, Ciclosporin,
  acitretin, UVB
• Treatment so far has produced partial success
  only
• Very keen to improve his skin as finds holding
  down a job very difficult

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