Transcript Psoriasis - bums.ac.ir

Psoriasis
Dr Abbas Pardakhty, 2011
Kerman Faculty of Pharmacy
Prevalence
Psoriasis occurs in 2% of the world’s
population
Prevalence in the U.S may be as high as
4.6%
Highest in Caucasians
In Africans, African Americans and Asians
between 0.4% and 0.7%
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Prevalence
Equal frequency in males and females •
May occur at any age from infancy to the •
10th decade of life
First signs of psoriasis •
Females mean age of 27 years –
Males mean age of 29 years –
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Prevalence
Two Peaks of Occurrence •
One at 20-30 years –
One at 50-60 years –
Psoriasis in children •
Low – between 0.5 and 1.1% in children 16 –
years old and younger
Mean age of onset - between 8 and 12.5 years –
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Prevalence
Two-thirds of patients have mild disease
One-third have moderate to severe disease
Early onset (prior to age 15)
Associated with more severe disease –
More likely to have a positive family history –
Life-long disease
Remitting and relapsing unpredictably –
Spontaneous remissions of up to 5 years have been –
reported in approximately 5% of patients
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Genetics and Pathogenesis
Psoriasis and the Immune System •
The major histocompatibility complex (MHC) –
Short arm of chromosome 6 •
Histocompatibility Antigens (HLA) –
HLA (human leukocyte antigen)-Cw6 •
HLA-B13, -B17, -B37, -Bw16 •
T-lymphocyte-mediated mechanism –
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Psoriasis as a Systemic Disease
Koebner Phenomenon
Elevated ESR
Increased uric acid levels → gout
Mild anemia
Elevated α2-macroglobulin
Elevated IgA levels
Increased quantities of Immune Complexes
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Psoriasis as a Systemic Disease
Psoriatic arthropathy •
Aggravation of psoriasis by systemic factors •
Medication –
Focal infections –
Stress –
Life-threatening forms of psoriasis •
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• Physical trauma: These injuries include
endogenous and exogenous causes such as
photosensitivity, dermatitis, herpes zoster,
abrasions, burns, bites, shaving, surgery, and
tattoos, among others.
• Infection: Streptococcal pharyngitis and HIV
type 1 appear to be triggers
Clinical Variants of Psoriasis
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Clinical Types
Guttate
Chronic Plaque
Flexural
Pustular
Nail Psoriasis
Erythroderma
Arthropathy
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Characteristic Lesion of Psoriasis
Sharply demarcated erythematous plaque •
with micaceous silvery white scale
Histopathology •
Thickening of the epidermis –
Tortuous and dilated blood vessels –
Inflammatory infiltrate primarily of –
lymphocytes
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Psoriatic Plaque
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Severity of Disease
Three Cardinal Signs of Psoriatic Lesions •
Plaque elevation –
Erythema –
Scale –
Body Surface Area •
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Chronic Plaque Psoriasis
Most Common Variant
Plaques may be as large as 20 cm
Symmetrical disease
Sites of Predilection
Elbows –
Knees –
Presacrum –
Scalp –
Hands and Feet –
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Chronic Plaque Psoriasis
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Chronic Plaque Psoriasis
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Chronic Plaque Psoriasis
May be widespread – up to 90% BSA •
Genitalia involved in up to 30% of patients •
Most patients have nail changes •
Nail pitting –
“Oil Spots” –
Involvement of the entire nail bed –
Onychodystrophy •
Loss of nail plate •
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Widespread Chronic Plaque Psoriasis
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Chronic Psoriasis
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Psoriasis of the Nail
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Psoriasis of the Nail
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Symptoms of Chronic Plaque Psoriasis
Pruritus
Pain
Excessive heat loss
Patient Complaints
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Unsightliness of the lesions –
Low self-esteem –
Feelings of being socially outcast –
Excessive scale –
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Guttate Psoriasis
Characterized by numerous 0.5 to 1.5 cm
papules and plaques
Early age of onset
Most common form in children
Streptococcal throat infection often a
trigger
Spontaneous remissions in children
Often chronic in adults
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Guttate Psoriasis
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Life–Threatening Forms of Psoriasis
Generalized Pustular Psoriasis •
Erythrodermic Psoriasis •
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Generalized Pustular Psoriasis
Unusual manifestation of psoriasis
Can have a gradual or an acute onset
Characterized by waves of pustules on
erythematous skin often after short episodes of
fever of 39˚ to 40˚C
Weight loss
Muscle Weakness
Hypocalcemia
Leukocytosis
Elevated ESR
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Generalized Pustular Psoriasis
Cause is obscure •
Triggering Factors •
Infection –
Pregnancy –
Lithium –
Hypocalcemia secondary to hypoalbuminemia –
Irritant contact dermatitis –
Withdrawal of glucocorticosteroids, primarily –
systemic
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Generalized Pustular Psoriasis
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Erythrodermic Psoriasis
Classic lesion is lost •
Entire skin surface becomes markedly •
erythematous with desquamative scaling.
Often only clues to underlying psoriasis are •
the nail changes and usually facial sparing
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Erythrodermic Psoriasis
Triggering Factors •
Systemic Infection –
Withdrawal of high potency topical or oral –
steroids
Withdrawal of Methotrexate –
Phototoxicity –
Irritant contact dermatitis –
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Erythrodermic Psoriasis
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Psoriasis Treatment
Session 3
Psoriasis treatment
Topical •
Systemic •
Phototherapy •
Rx Psoriasis Lotion (100 mL)
Coal tar solution 5 mL •
Salicylic acid 5 g •
Urea 10 g •
Triamcinolone acetonide 160 mg •
Propylene glycol qs 100 mL •
Dissolve the urea and salicylic acid in about 75 mL of propylene •
glycol; this may take 30 to 45 minutes. Add the triamcinolone
acetonide and mix well. Incorporate the coal tar solution and mix
well. Add sufficient propylene glycol to make 100 mL and thoroughly
mix. Package and label.
Coal tar Solution: coal tar 20%, polysorbate 80 5%, in alcohol •
(96%),
Coal tar and Salicylic acid ointment
Coal tar
2g
SA
2g
Emulsifying wax 11.4g
Polysorbate 80
4g
Liquid paraffin
7.6g
White soft paraffin 19g
Coconut oil
50g
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Tar-based shampoos (Neutrogena T/Gel). Coal tar, •
a byproduct of the coal manufacturing process,
helps conditions such as dandruff, seborrheic
dermatitis and psoriasis by slowing cell turnover.
[email protected]
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Neutrogena T/Gel
1% Coal Tar •
[email protected]
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Coal tar shampoo
Dandruff
Seborrheic dermatitis
Psoriasis
Wash first time
Remain the foam for 5 min at second time
Photosensitizer
[email protected]
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Polytar
Wet the scalp and hair. Apply the medicine to the •
scalp, massage into a lather, and allow it to
remain on the scalp for 5 minutes. Rinse
thoroughly and repeat.
Wash your hands after using Coal Tar Shampoo. •
If you miss a dose of Coal Tar Shampoo, use it as •
soon as possible. If it is almost time for your next
dose, skip the missed dose and go back to your
regular dosing schedule. Do not use 2 doses at
once.
[email protected]
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‫سالیسیلیک اسید‬
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‫منع مصرف در‪:‬‬
‫کودکان زیر دو سال‬
‫خانمهای باردار‬
‫دیابت‬
‫آبله مرغان‪ ،‬زونا و آنفلوآنزا‬
‫بیماران دارای اختالالت گردش خون‬
‫‪[email protected]‬‬
Neutrogena T/Sal
3% Salicylic Acid
Fragrance-free
Preservative-free
Color-free
[email protected]
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To use shampoo as a scalp treatment: Use before
bathing.
Do not wet hair.
Apply Salicylic Acid Shampoo with the applicator
directly to affected areas of the scalp.
Leave on for 5 minutes, gradually increasing the
treatment time up to 1 hour.
After treatment, rinse thoroughly with water.
Wash your hands after each use. You may use a
non-medicated shampoo after using Salicylic Acid
Shampoo, if desired.
[email protected]
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To use shampoo as a medicated shampoo: •
Wet hair, apply Salicylic Acid Shampoo with
the applicator directly to scalp, and massage
vigorously for several minutes.
Rinse thoroughly. •
Be sure to wash your hands after each use. •
Use Salicylic Acid Shampoo daily until the •
condition clears, or as directed by your doctor
[email protected]
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Ceanel
A clear, viscous golden-yellow colored liquid
containing: Undecenoic acid 1% v/v, Cetrimide
10% w/v, Phenylethyl alcohol 7.5% v/v
Dandruff
Seborrhoeic dermatitis
Psoriasis
[email protected]
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Tazarotene
Tazorac® (Tazarotene) •
Tazarotene
Tazarotene is a prodrug that is de-esterified in
the skin to its active form, tazarotenic acid.
Psoriasis: tazarotene 0.05% cream or gel is
used initially and increased to 0.1% if
necessary.
Acne: tazarotene is applied as a 0.1% gel or
cream once daily in the evening.
photodamage (facial fine wrinkling, mottled
hypo- and hyperpigmentation, and benign
facial lentigines): A 0.1% cream
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Acitretin
Soriatane®, Neotigason® (Acitretin) •
Acitretin
Acitretin is used by mouth in the treatment of •
severe psoriasis resistant to other forms of
therapy, palmo-plantar pustular psoriasis, and
in severe congenital ichthyosis and Darier's
disease (keratosis follicularis).
Acitretin is used alone or with PUVA or UVB in •
psoriasis.
Acitretin
In the UK, it is given in an initial daily dose of •
25 or 30 mg with food for 2 to 4 weeks
In the USA initial doses up to 50 mg daily are •
permitted. The daily dosage is adjusted
thereafter according to clinical response and
adverse effects
Daivonex® (Calcipotriene, Calcipotriol) •
Calcipotriol
Calcipotriol is a vitamin D3 derivative. In vitro •
it appears to induce differentiation and to
suppress proliferation of keratinocytes.
Calcipotriol is used in a cream or ointment for •
the management of plaque psoriasis and as a
solution in the management of scalp psoriasis;
the concentration of calcipotriol used is
0.005%.
Alefacept
Amevive® (alefacept) •
Alefacept is a recombinant human fusion •
protein that binds to CD2 on memory Tlymphocytes, preventing their activation and
reducing their number.
Alefacept
blood test every 2 weeks to check your T-cell •
levels
Cancers (mostly skin cancers), lymphomas, •
serious infections, including wound infections
and pneumonia.
Liver injury •
Efalizumab
Raptiva® (efalizumzb) •
Efalizumab
Efalizumab is a humanised monoclonal •
antibody that binds to human CD11a on
leucocytes to inhibit the activation of Tlymphocytes.
Efalizumab is given by subcutaneous •
injection.
Enbrel® (Etanercept) •
Etanercept
Etanercept is a recombinant version of soluble
human tumour necrosis factor (TNF) receptor
that binds specifically to TNF and blocks its
interaction with endogenous cell-surface TNF
receptors.
rheumatoid arthritis
psoriatic arthritis
ankylosing spondylitis
juvenile idiopathic arthritis
In the USA, etanercept is also used in the
treatment of chronic, moderate to severe plaque
psoriasis in patients over 18 years.
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Tacrolimus (Prograf®)
Tacrolimus is a potent macrolide
(macrolactam) immunosuppressant derived
from Streptomyces tsukubaensis, and has
actions similar to those of ciclosporin.
transplantation
atopic eczema
Tacrolimus has been shown to be effective in
the treatment of psoriasis when used orally or
topically.
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Methotrexate
Folic acid antagonist •
Usually reserved for severe, recalcitrant, •
disabling psoriasis
Maximum improvement can be expected after •
8 -12 weeks
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Contraindications - Methotrexate
Nursing mothers
Patients with alcoholism
Alcoholic liver disease
Other chronic liver disease
Patients with overt or laboratory evidence of
immunodeficiency syndromes
Patients who have preexisting blood dyscrasias
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Methotrexate
Pregnancy Category X drug product •
Contraindicated in pregnant women with psoriasis –
Pregnancy must be excluded in women of childbearing potential –
Pregnancy should be avoided if either partner is receiving MTX during –
and for a minimum of 3 months after therapy for male patients and for
at least one ovulatory cycle after therapy for female patients
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Methotrexate – Side Effects
Acute or chronic hepatotoxicity
Hepatic cirrhosis
Leukopenia
Thrombocytopenia
Anemia, including aplastic anemia
Rarely, interstitial pneumonitis
Stomatitis
Nausea/vomiting
Alopecia
Photosensitivity
Burning of skin lesions
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Neoral
Potent Immunosuppressive •
Adult, non-immunocompromised patients •
with severe, recalcitrant plaque psoriasis
Maximum efficacy achieved at 16 weeks of •
therapy
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Contraindications - Neoral
Concomitant PUVA or UVB therapy
Methotrexate or other immunosuppressive agents
Coal tar or radiation therapy
Patients with abnormal renal function
Patients with uncontrolled hypertension
Patients with malignancies
Nursing mothers
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Neoral – Side Effects
Possibility of Irreversible renal damage
Hypertension
Headache
Hypertriglyceridemia
Hirsutism/hypertrichosis
Paresthesia/hyperesthesia
Influenza-like symptoms
Nausea/vomiting
Diarrhea
Lethargy
Arthralgia
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Neoral
Multiple prescreening tests are required •
Tests must continue throughout treatment •
with dosage adjustment as necessary to
prevent end-organ damage
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Photo(chemo)therapy
Two types of phototherapy •
Ultraviolet B (UVB) –
Ultraviolet A + psoralen (PUVA) –
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UVB
Two types •
Broadband UVB –
Narrowband UVB (311-313 nm) –
Treatment is time consuming •
2-3 visits/week for several months –
Side effect – possibility of experiencing an •
acute sunburn reaction
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PUVA
Consists of ingestion of or topical treatment with
a psoralen followed by UVA
Usually reserved for severe, recalcitrant, disabling
psoriasis
Time consuming – 2-3 visits/wk; at least 6 weeks
Precautions
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Patients must be protected from further UV light for –
24 hours post treatment
With oral psoralen, wrap around UV-blocking glasses –
must be worn for 24 hours post treatment
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PUVA
Side effects with oral psoralen •
Nausea –
Dizziness –
Headache –
Side effects with PUVA •
Early –
Pruritus •
Late –
Skin damage •
Increased risk for skin cancer, particularly squamous •
cell (SCC) and after 200 - 250 treatments, increased risk
for melanoma
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Day Goeckerman
UVA + Coal tar •
Contraindications to PUVA
Patients less than 12 years of age
Patients with a history of light sensitive
disease states
Patients with, or with a history of melanoma
Patients with invasive SCC
Patients with aphakia (the absence of the lens
of the eye)
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