Psoriasis-The best Presentation
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PSORIASIS
Diagnosis and management
Dr.Md. Shshidul Islam
Assistant professor
Dermatology & VD, CBMC’B
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OVERVIEW
5. Case studies
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4. Managing psoriasis
3. Diagnosing psoriasis
2. Clinical presentation
1. Epidemiology and pathophysiology
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WHAT IS PSORIASIS?
– Inflammatory and hyperplastic disease of skin
– Characterised by erythema and elevated scaly plaques
– Chronic, relapsing condition
– Course of disease often unpredictable
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SYMPTOMS OF PSORIASIS
Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.
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Most frequently experienced symptoms
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SOCIAL IMPACT OF PSORIASIS
40
48
57
0 10 20 30 40 50 60Percentage of respondents with severe psoriasis (n = 502)
Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.
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Psoriasis mistaken for other disease
Trouble receiving equal treatment in service
establishments (e.g. hair salons,
public pools)
Psoriasis mistaken as contagious
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PSORIASIS AFFECTS EMOTIONAL STATE 6
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EPIDEMIOLOGY
• Common skin disorder
• Prevalence variable: ~ 0.3–2.5%
• Prevalence equal in males and females
• Estimated incidence: ~ 60 per 100,000 per year
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AGE OF ONSET
• Mean age: ~ 23–37 years
• Current theory: 2 distinct peaks with possible genetic associations
– Early onset (16–22 years)
• More severe and extensive
• More likely to have affected first-degree family member
– Late onset (57–60 years)
• Milder form
• Affected first-degree family members nearly absent
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GENETIC INFLUENCE
• Evidence suggests strong genetic association
– Studies of monozygotic twins show concordance
for psoriasis (e.g. 64% in a Danish Study)
– Multiple susceptibility loci have been identified
• Disease expression – likely result of genetic and environmental factors
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COMMON TRIGGER FACTORS FOR PSORIASIS
• Infections (e.g. streptococcal, viral)
• Skin trauma (Koebner phenomenon)
• Psychological stress
• Drugs (e.g. lithium, beta blockers)
• Sunburn
• Metabolic factors (e.g. calcium deficiency)
• Hormonal factors (e.g. pregnancy)
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PSORIASIS IS A T-CELL MEDIATED, AUTOIMMUNE DISEASE1
Current hypothesis:
– Unknown skin antigens stimulate immune response
• Antigen-specific memory T-cells are primary mediators
• Leads to impaired differentiation and
hyperproliferation of keratinocytes
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CLINICAL PRESENTATION: CLASSIC PSORIASIS
– Well-defined and sharply demarcated
– Round/oval-shaped lesions
– Usually symmetrical
– Erythematous, raised plaques
– Covered by white, silvery scales
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COMMON SITES AFFECTED BY PSORIASIS
• Can affect any part of the body – typically scalp, elbow, knees and sacrum
• Extent of disease varies
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TYPES OF PSORIASIS
• Chronic plaque
• Guttate
• Flexural
• Erythrodermic
• Pustular– Localised and generalised
• Local forms– Palmoplantar
– Scalp
– Nail (psoriatic onychodystrophy)
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CHRONIC PLAQUE PSORIASIS
– Most common type – affects approximately 85%
– Features pink, well-defined plaques with silvery scale
– Lesions may be single or numerous
– Plaques may involve large areas of skin
– Classically affects elbows, knees, buttocks and scalp
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CHRONIC PLAQUE PSORIASIS 16
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CHRONIC PLAQUE PSORIASIS 17
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CHRONIC PLAQUE PSORIASIS 18
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CHRONIC PLAQUE PSORIASIS 19
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GUTTATE PSORIASIS
– Numerous and small lesions – ~ 1 cm diameter
– Pink with less scale than plaque psoriasis
– Commonly found on trunk and proximal limbs
– Typically seen in individuals < 30 years
– Often preceded by an upper respiratory tract streptococcal infection
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FLEXURAL PSORIASIS
– Lesions in skin folds
articularly groin, gluteal cleft, axillae and submammary regions
– Often minimal or absent scaling
– May cause diagnostic difficulty when genital or perianal region is affected in isolation
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ERYTHRODERMIC PSORIASIS
– Generalised erythema covering entire skin surface
– May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon
– Patients may become febrile, hypo/hyperthermic and dehydrated
– Complications include cardiac failure, infections, malabsorption and anaemia
– Relatively uncommon
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PUSTULAR PSORIASIS
– Two forms:
• Localised form
• More common
• Presents as deep-seated lesions with multiple small pustules on palms and soles
• Generalised form
• Uncommo Associated with fever and widespread pustules across the body
• inflamed body surface
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PALMOPLANTAR PSORIASIS
– Can be hyperkeratotic or pustular
– May mimic dermatitis – look for psoriatic manifestations elsewhere to aid diagnosis
– Possibly aggravated by trauma
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SCALP PSORIASIS
– Varies from minor scaling with erythema to thick hyperkeratotic plaques
– May extend beyond hairline
– Patient scratching may produce asymmetric plaques
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NAIL PSORIASIS
– May be present in patients with any type of psoriasis
– Can take several forms:
• Pitting: discrete, well-circumscribed depressions on nail surface
• Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate
• Onycholysis: nail separates from nail bed at free edge
• ‘Oil-drop sign’: pink/red colour change on nail surface
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NAIL PSORIASIS 27
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NAIL PSORIASIS 28
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NAIL PSORIASIS 29
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PSORIATIC ARTHRITIS
– Approximately 5–20% have associated arthritis
– Five major patterns of psoriatic arthritis:
• Distal interphalangeal involvement
• Symmetrical polyarthritis
• Psoriatic spondylarthropathy
• Arthritis mutilans
• Oligoarticular, asymmetrical arthritis
– Clinical expressions often overlap
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DIAGNOSING PSORIASIS
• Other dermatological disorders can resemble psoriasis
• Diagnosed clinically according to appearance, distribution, history of lesions and family history
• Important to consider non-cutaneous complications
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DIFFERENTIAL DIAGNOSIS
• Localised patches/plaques– Tinea– Eczema– Superficial basal cell
carcinoma and Bowen’s disease
– Seborrhoeic dermatitis– Cutaneous T-cell lymphoma
(mycosis fungoides)
• Guttate– Pityriasis rosea– Drug eruption– Secondary syphilis
• Flexural– Tinea– Eczema– Candidiasis– Seborrhoeic dermatitis
• Erythrodermic– Eczema– Cutaneous T-cell lymphoma– Pityriasis rubra pilaris– Lichen planus– Drug
• Palmoplantar– Tinea
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LOCALISED PATCHES/PLAQUES
Tinea corporis
• Affects body
• Lacks symmetrical lesions
• Presence of peripheral scale and central clearing
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Tinea coporis Psoriasis
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LOCALISED PATCHES/PLAQUES
– Discoid eczema
• Individualised patches more pruritic than psoriasis
• Lack silvery scale
• Less vivid colour than psoriasis
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Discoid eczema Psoriasis
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LOCALISED PATCHES/PLAQUES
– Superficial basal cellcarcinoma/Bowen’s disease
• Asymmetrical lesions, either single or few in number
• Perform biopsy if lesions resistant to topical psoriasis treatment, or to confirm diagnosis
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Bowen’s disease Psoriasis
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LOCALISED PATCHES/PLAQUES
– Seborrhoeic dermatitis
• Characterised by yellowish scaling and erythema
– Localised to many of the same areas as psoriasis
• Diffuse scaling differs from sharply defined psoriasis plaques
• Affects furrows of face (facial psoriasis is generally restricted to hairline)
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Dermatitis
Psoriasis
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LOCALISED PATCHES/PLAQUES
– Cutaneous T-cell lymphoma (mycosis fungoides)
• Red, discoid lesions
• Asymmetrical and less scaly than psoriasis
• Lesions may present with fine atrophy and be resistant to antipsoriatic therapy
• Biopsy to confirm diagnosis
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Mycosis fungoides
Psoriasis
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GUTTATE PSORIASIS
– Pityriasis rosea
• Difficult to distinguish from acute guttate psoriasis
• Presents first as single large patch, progresses to a truncal rash of multiple red scaly plaques (‘Christmas tree’ distribution)
• Resolves over 8–12 weeks
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< Psoriasis ^ Pityriasis rosea
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GUTTATE PSORIASIS
– Secondary syphilis• Search for characteristic primary
syphilitic lesion, lymphadenopathy, and lesions of face, palm and soles
• Conduct serology and skin biopsies to confirm
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< Psoriasis ^ Secondary syphilis
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FLEXURAL PSORIASIS
– Tinea cruris
• Affects groin area
• Characterised by central clearing with advancing edge
• Non-silvery lesion with fine scale, particularly at periphery
• Lesion frequently extends more on left side
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< Psoriasis ^ Tinea cruris
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FLEXURAL PSORIASIS
– Atopic eczema
• Often associated with asthma and hay fever
• Lacks classic psoriatic nail involvement and sharply demarcated scaly plaques
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< Psoriasis ^ Atopic eczema
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FLEXURAL PSORIASIS
– Candidiasis
• Characteristic peripheral pustules and scaling differ to psoriasis
• Yeast cultures are diagnostic
– Seborrhoeic dermatits
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Flexural psoriasis
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PALMOPLANTAR PSORIASIS
– Tinea manum• Ringworm of hands
• Fine powdery scale, particularly involving palms and palmar creases
• Usually asymmetrical
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Tinea corporis Psoriasis
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PALMOPLANTAR PSORIASIS
– Hand and foot eczema
• Hyperkeratotic forms difficult to distinguish from psoriasis
• Biopsies can assist diagnosis
• Look for history of atopy, a lack of psoriasis elsewhere on body, and evidence of eczema elsewhere on skin
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Eczema
Psoriasis
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PALMOPLANTAR PSORIASIS
– Pompholyx of palms and soles (dishydrotic eczema)
• Presents as clear vesicles – contrast to white/yellow pustules in pustular psoriasis
• Accompanied by intense pruritus
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Eczema
Psoriasis
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DETERMINING PSORIASIS SEVERITY
• Psoriasis Area and Severity Index (PASI)– Score indicates severity of disease at a given time
– Single number that considers severity of lesions and extent of disease across four major body sites (head, trunk, upper limbs and lower limbs)
– Score ranges from 0 (no disease) to 72 (maximal disease)
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MANAGING PSORIASIS
• Before starting treatment– Establish relationship of trust with patient
– Provide patient with information
• Emphasise benign nature of disease
• Explain that psoriasis tends to be chronic and recurrent
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MANAGING PSORIASIS
• Determine clinical setting before selecting treatment, considering– Disease pattern, severity and extent
– Sites of disease
– Coexistent medical conditions
– Patient’s perception of disease severity
– Time commitments and treatment expense
– Previous treatments for psoriasis
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MANAGING PSORIASIS
• Goals of management– Tailor management to individual and address both
medical and psychological aspects
– Improve quality of life
– Achieve long-term remission and disease control
– Minimise drug toxicity
– Evaluate and monitor efficacy and suitability of individual treatments
– Remain flexible and respond to changing needs
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TREATMENT OPTIONS FOR PSORIASIS
• Stepwise approach is advised
• Treatments include:
– General measures and topical therapy
– Phototherapy
– Systemic and biological therapies
• Combination therapies : may reduce toxicity and improve outcomes
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TREATING PSORIASIS: GENERAL MEASURES
• Reduce/eliminate potential trigger factors:– Stress
– Smoking
– Alcohol
– Trauma
– Drugs
– Infections
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TOPICAL THERAPIES
• Approximately 70% of patients with mild-to-moderate psoriasis can be managed with topical therapies alone
• Tailor to needs of patient
• Potency, delivery vehicle and patient motivation may affect compliance
• Application may be time-consuming for patients
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TOPICAL THERAPIES: EMOLLIENTS
• Include aqueous cream, sorbolene cream, white soft paraffin and wool fats
• Regular use can:– alleviate pruritus
– reduce scale
– enhance penetration of concomitant topical therapy
– hydrate dry and cracked skin
• Soap should be avoided
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TOPICAL THERAPIES: KERATOLYTICS
• Over-the-counter products include:– Salicylic acid
– Urea
• Help dissolve keratin to soften and lift psoriasis scales
• May enhance penetration of other actives
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TOPICAL THERAPIES: COAL TAR
• Help reduce inflammation and pruritus
• May induce longer remissions
• Use limited by distinctive smell and ability to stain clothing and skin
• May cause local skin irritation
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TOPICAL THERAPIES: DITHRANOL
• Anti-proliferative properties
• Particularly effective in thick plaque psoriasis
• Initiate therapy at very low concentrations – can burn skin
• Not suitable for face, flexures or genitals
• Stains clothes permanently and skin temporarily
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TOPICAL THERAPIES: TAZAROTENE
• Topical synthetic retinoid
• For treatment of chronic plaque psoriasis
• Applied once daily in evening
• Commonly causes local irritation
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TOPICAL THERAPIES: CORTICOSTEROIDS
• Possess anti-inflammatory, antiproliferative and immunomodulatory properties
• Reduce superficial inflammation within plaques
• Potency choice depends on disease severity, location and patient preference
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TOPICAL THERAPIES: CORTICOSTEROIDS
• Adverse effects associated with long-term use include:– Skin atrophy and telangiectasia
– Hypopigmentation
– Striae
– Rapid relapse or rebound on stopping therapy
– Precipitation of pustular psoriasis
– Pituitary-adrenal axis suppression through significant systemic absorption (rare)
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TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX®)
• Synthetic vitamin D analogue
• For chronic plaque-type psoriasis
• Reverses abnormal keratinocyte changes by:– Inducing differentiation
– Suppressing proliferation of keratinocytes
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TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX®)
• Response may require 4–6 weeks
• Adverse effects include erythema and irritation
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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET®)
• For plaque-type psoriasis
• Combination of calcipotriol and a potent topical corticosteroid (betamethasone dipropionate)– Stable formulation for both actives
• Provides rapid, effective psoriasis control
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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET®)
– Combination of calcipotriol and betamethasone dipropionate in Daivobet is more effective than either active constituent used alone
• 39.2% mean reduction in PASI score after 1 week
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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET®)
• Once-daily treatment with the potential to improve compliance
• Can be used intermittently in 4-weekly cycles with Daivonex® used in between for maintenance
• Most common adverse events include pruritus, rash and burning sensation
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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE GEL
• Newly TGA approved product not yet available in Australia
• Specially formulated for the scalp
• Provides rapid, effective control of scalp psoriasis– More effective than treatment with individual actives alone
– 53.2% (more than half) of patients had absent or very mild disease after just two weeks of gel application
• Once-daily formulation may encourage compliance
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OTHER THERAPIES
• Phototherapy
• Systemic therapies
• Biological agents
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PHOTOTHERAPY
• For psoriasis resistant to topical therapy and covering > 10% of body surface area
• Immunomodulatory and anti-inflammatory effects
• Three main types of phototherapy:– Broadband UVB
– Narrowband UVB
– PUVA (administration of psoralen before UVA exposure)
• Treatment usually administered 2–3 times/week
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SYSTEMIC THERAPIES
• Reserved for patients with widespread or severe psoriasis
• Potentially serious adverse effects and drug interactions
• Many require PBS authority prescription from dermatologist
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SYSTEMIC THERAPIES: METHOTREXATE
• Most commonly used systemic treatment for psoriasis
• Slows epidermal cell proliferation and acts as immunosuppressant
• Closely monitor kidney, liver and bone-marrow function
• Perform PASI score before starting treatment
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SYSTEMIC THERAPIES: CYCLOSPORIN
• Immunosuppressive agent
• For patients with severe psoriasis that is refractory to other treatments
• Requires ongoing monitoring of blood elements, and renal and liver function
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SYSTEMIC THERAPIES: ACITRETIN
• Oral retinoid
• For treatment of all forms of severe psoriasis
• Once-daily oral therapy
• Teratogenic – pregnancy must be avoided
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BIOLOGICAL AGENTS
• Proteins derived from living organisms that exert pharmacological actions
• For adults with moderate-to-severe chronic plaque-type psoriasis who are candidates for phototherapy or systemic therapy
• Most administered sub-cutaneously
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BIOLOGICAL AGENTS
• Target key parts of immune system that drive psoriasis
• Biological agents include:– Tumour necrosis factor-alpha inhibitors
• Etanercept
• Adalimumab
• Infliximab
– Interleukin (IL-12 and IL-32) inhibitor
• Ustekinumab
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CASE STUDY 1
• ((insert image of condition))
• ((insert information under headings below))
• Presentation
• Clinical examination
• Diagnosis
• Management
• ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred))
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CASE STUDY 2
• ((insert image of presenting condition))
• ((insert information under headings below))
• Presentation
• Clinical examination
• Diagnosis
• Management
• ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred))
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DIAGNOSIS AND MANAGEMENT OF PSORIASIS: SUMMARY
• Chronic, inflammatory disease of skin
• T-cell mediated disorder
• Classic presentation characterised by red, scaly plaques
• Management should address both medical and psychological aspects
• Treatments include topical therapy, phototherapy, systemic therapy and biological agents
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THANK
YOU
ALL
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