Psoriasis. Definition and causes Definition and causes Types Types GP management GP management...
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Transcript of Psoriasis. Definition and causes Definition and causes Types Types GP management GP management...
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Psoriasis
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• Definition and causes• Types• GP management• Pitfalls• Hospital treatments
Psoriasis
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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 keratinocyteproliferation
• Environmental and genetic factors
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PsoriasisGenetics• 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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• Emollients• Bath oils• Site-specific topical treatments
GP Management
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• Vitamin D analoguesDovonex (calcipotriol) ointDovobet (calcipotriol & betamethasone) oint or gelSilkis (calcitriol) ointCuratorderm (tacalcitol) oint & lotionZorac (tazarotene) gel (retinoid)
• Dovonex cream and scalp application no longer available
Topical treatments
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• TarCarbo-domeExorexPsoridermAlphosyl HCSebcoCocoisTar-based bath oils & shampoos
Topical treatments
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• SteroidsOften in conjunction with Vit D analogue as Dovobet or separate steroidEumovate (only oint available)TrimovateScalp preparations (eumovate to dermovate strength)
• BE CAREFUL (but not mean)
Topical Treatments
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• DithranolDithrocreamMicanolPsorin
• Stains skinHas to be washed offStart and low strength and build up
Topical Treatments
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Topical treatments• Nails
difficultpotent topical steroidsdovonextazarotenesystemic therapy
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Scalp• Remove scale first• Sebco messy but effective• Tar or salicylic acid shampoo• Topical steroids if necessary for
short periods
Topical Treatments
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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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• '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
Pitfalls
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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 >150 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 >150
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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Methotrexatemec: inhibits DNA synthesis by inhibiting
dihydrofolatereductase → reduces proliferation of lymphocytes + keratinocytes
CI: pregnancy, lactation, infection, liver/renal disease, peptic ulcers
SE: anorexia, nausea, myelosuppression, hepatotoxicity, mouth ulcers, pulmonary toxicity, oligospermia, skin cancer
Interactions: NSAIDs, septrin, trimethoprim, penicillin, phenytoin
Given once a WEEK
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CiclosporinMec 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 drugsInfliximab, etanercept, adalimumab
Targeted T - cell therapyalefacept (binds CD2 & blocks LFA3)
efalizumab (binds to LFA-1 & blocks ICAM-1)
Anti-IL 17 receptor antibodies
Brodalumab Ixekizumab
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• 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!
GP Issues
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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 DLQIscreening 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�