How do I treat Psoriasis

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How do I treat Psoriasis

• Dr Jan von der Werth
• Consultant Dermatologist
• Conquest Hospital Hastings

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Psoriasis

• Plaque psoriasis
• Palmo-plantar pustular psoriasis
• Guttate psoriasis
• Acral posriasis
• Generalised pustular psoriasis
  (v. Zumbusch)
• Sebo-psoriasis

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Psoriasis - distribution
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Psoriasis Cause (Aetiology)

• Genetics
• Trauma
• Infection
• Drugs

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Psoriasis - Genetics

• Risk of Inheriting Psoriasis
• Both Parents 50
• One Parent 10
• One Sibling 7
• 2nd Degree Relative 4
• 3rd Degree Relative 1-2 (N)

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Mechanism (Pathogenesis)

• Epidermal proliferation
• Increased keratinocyte replication
• Immature keratinocytes
• Inflammatory infiltrate
• Dilated capillaries
• T-lymphocytes

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Psoriasis cell cycle

• NORMAL PSORIASIS
• Transit time 28 days 3-4 days
• Cell cycle 460 h 40 h
• Mitoses 0.4 2.5

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Plaque psoriasis
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Plaque psoriasis
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Psoriasis - resolving
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Guttate psoriasis
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Palmo-plantar pustular psoriasis( localised
pustular psoriasis)
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Palmo-plantar pustular psoriasis( localised
pustular psoriasis)
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Generalised pustular psoriasis(v. Zumbusch)
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Nail changes in psoriasis
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Psoriatic arthropathy

• 7 20 of psoriasis sufferers
• 5 variants
• Distal symmetrical (classic)
• Distal asymmetrical (most common)
• Arthritis mutilans
• Axial spondylitis
• RA-like
• Treatment often by rheumatologist

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Sebo-psoriasis

• Overlap between psoriasis and seborrhoeic
  dermatitis
• Psoriatic plaques at side of nose, eyebrows,
  proximal skin flexures, pre-sternal

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Sebo-Psoriasis
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Sebo-Psoriasis
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Psoriasis Differential Diagnosis

• Discoid eczema
• Tinea corporis
• Discoid LE
• Pityriasis rosea
• Pityriasis rubra pilaris
• Mycosis fungoides

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Prognosis

• 70 persistent
• 15 in temporary remission
• 15 clear up completely

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Psoriasis - Treatment

• MANAGE THE PATIENT NOT THE DISEASE
• The most difficult part in managing psoriasis is
  to deal with patient expectations

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Psoriasis The Patients Perspective

• Treatments need to be
• Effective (88), easy to use (69),non-staining
  (67), non-smelly (51)
• Treatment time topical
• Mild/moderate 10 30 min/day
• Severe 2 3 hours/day
• Costs
• Quality of Life
• DLQI
• SF36

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Psoriasis Treatment (1)

• 1st Line (80 of patients)
• creams Vit D analogues, steroid, tar,
  dithranol, Vit A derivate, emollients,
  salicylic acid
• 2nd Line
• UV
• TLO1 Narrow band UVB
• PUVA
• Tablets
• Methotrexate
• Cyclosporin
• Acitretin

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Psoriasis Treatment (2)

• 3rd Line
• New Biologics
• Infliximab Remicade (TNF ? blocker)
• Etanercept Enbrel (TNF ? receptor antagonist)
• Alefacept (T-cell activation inhibitor)
• Efalizumab Raptiva (T-cell activation
  inhibitor)

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Psoriasis Treatment (3)

• Lifestyle measures
• Relaxation
• Salt baths and other mollycoddeling
• Sun holidays !!!

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Psoriasis Treatment (4)

• 1st line treatments
• Moisturiser - clean, safe, ineffective
• Calcipotriol - clean, safe, effective (Dovonex
  )
• Topical steroids - clean, effective, less
  safe(Hydrocortisone, Eumovate, Betnovate,
  Elocon, Dermovate)
• Tar - stains, fairly safe, effective
• Dithranol - stains, irritates, effective
• Retinoids - clean, irritates, some effect

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Which Treatment?
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Which Treatment?
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Psoriasis Treatment (5)

• 2nd line treatment
• Methotrexate - once weekly tablet
• SE blood tests, liver damage, blood cell damage
• Cyclosporin A - daily tablet
• SE blood tests, kidney damage, weakened immune
  system
• Acitretin - daily capsule
• SE blood tests, dry lips, hair loss, birth
  defects!

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Which Treatment?
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Psoriasis Treatment (6)

• 2nd line treatment
• Light treatment
• UVB - Narrowband UVB (TLO1)
• PUVA - Psoralen UVA

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Which Treatment?
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Which Treatment?
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Which Treatment?
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How Do I Treat Psoriasis (1)

• Mild/Moderate - indolent patient
• Mild/Moderate - suffering patient
• Moderate/Severe - indolent patient
• Moderate/Severe - suffering patient

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How Do I Treat Psoriasis (2)

• Mild/Moderate indolent patient
• Tar shampoo
• Emollient (e.g. Aveeno lotion)
• Mild/Moderate suffering patient
• Rotate topical treatments, incl steroids
• 2nd line treatment (to gain confidence)

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How Do I Treat Psoriasis (3)

• Moderate/severe indolent patient
• Regular emollients
• Tar shampoo Cocois ointment /- Scalp Solution
• Occ 2nd line treatment
• Moderate/severe suffering patient
• 2nd line treatment rotational
• Topical treatment, incl topical steroids

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Psoriasis The Outlook

• Genetic research shows cause
• New treatments highlight unknown disease
  mechanisms
• New treatments reflect improved knowledge and
  understanding of disease

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New BiologicsMode of action

• T-cell activation
• T-cell trafficking to the dermis and epidermis
• T-cell reactivation

Raptiva
Remicade Enbrel Humira
Cytokines including TNF a
Amevive
T-cell re activation In skin
T-cell activation In lymph nodes
T-cell binding and trafficking
Raptiva
Krueger JG. J Am Acad Dermatol.
2002461-23. Singri P, et al. Arch Dermatol.
2002138657-663.