Psoriasis: Psoriasis: Treatment and Treatment and ManagementManagement

Ann DaviesAnn Davies

Clinical Nurse Specialist in Clinical Nurse Specialist in DermatologyDermatology

University Hospital Of Wales, University Hospital Of Wales, CardiffCardiff

Psoriasis: Psoriasis: backgroundbackground

Psoriasis is an inflammatory skin disorder. The Psoriasis is an inflammatory skin disorder. The inflammatory process involves the recruitment inflammatory process involves the recruitment and activation of inflammatory cells.and activation of inflammatory cells.

Non-contagious condition – transmitted Non-contagious condition – transmitted genetically genetically

Lifelong disease characterised by recurrent Lifelong disease characterised by recurrent exacerbationsexacerbations

Aetiology:Aetiology: T-cells are activated, to the extent that they T-cells are activated, to the extent that they

trigger other immune responses, which lead to trigger other immune responses, which lead to release of cytokines that promote inflammation release of cytokines that promote inflammation and rapid turnover of skin cellsand rapid turnover of skin cells

What is Psoriasis(cont).What is Psoriasis(cont).

The role of the thymus derived The role of the thymus derived lymphocyte (T- cell) in the lymphocyte (T- cell) in the expression of psoriatic plaques has expression of psoriatic plaques has made it and its action a target for made it and its action a target for new therapies.new therapies.

Who gets Psoriasis?Who gets Psoriasis?

It affects males and females equally.It affects males and females equally. Affects children, adults and older Affects children, adults and older

people and may occur at any age.people and may occur at any age. Usual age of onset between 20 – 35 Usual age of onset between 20 – 35

years with 75% of all cases years with 75% of all cases occurring before the age of 40. It occurring before the age of 40. It can also affect people in their 50’s can also affect people in their 50’s for the first time (Menter et al 2004).for the first time (Menter et al 2004).

Who gets Psoriasis Who gets Psoriasis (cont).(cont).

Studies have proven there is a genetic Studies have proven there is a genetic link.link.

There is a positive family history in one There is a positive family history in one third of sufferers. Less likely in late onset third of sufferers. Less likely in late onset psoriasis.psoriasis.

If one parent has psoriasis there is a 10 – If one parent has psoriasis there is a 10 – 25% risk to the child. If both parents are 25% risk to the child. If both parents are affected the risk increases from 50 – 60%.affected the risk increases from 50 – 60%.

Investigators are using molecular Investigators are using molecular genetics technology to try and unravel the genetics technology to try and unravel the genes that causes psoriasis.genes that causes psoriasis.

Different Types Of Different Types Of PsoriasisPsoriasis

Chronic Plaque PsoriasisChronic Plaque Psoriasis

Can be large and/or smallCan be large and/or small

Localised or generalisedLocalised or generalised

Well demarcated edgesWell demarcated edges

Silvery white scale on erythematous Silvery white scale on erythematous basebase

Affects elbows, knees, buttocks, scalp, Affects elbows, knees, buttocks, scalp, face trunk, arms, legs, hands and feet.face trunk, arms, legs, hands and feet.

Guttate PsoriasisGuttate Psoriasis

Name comes from Latin word ‘gutta’ Name comes from Latin word ‘gutta’ meaning ‘droplet’. meaning ‘droplet’.

Can affect the body, limbs, hands and Can affect the body, limbs, hands and feetfeet

Usually generalisedUsually generalised

Pustular PsoriasisPustular Psoriasis

Generalised (body & limbs) - Generalised (body & limbs) - requires hospitalisationrequires hospitalisation

Localised (hands and feet) – only Localised (hands and feet) – only appears to affect smokersappears to affect smokers

Palmoplantar PustulosisPalmoplantar Pustulosis Cause unknown, appears to be a Cause unknown, appears to be a

disorder of the eccrine glands which are disorder of the eccrine glands which are mostly on palms and solesmostly on palms and soles

Probably autoimmune in origin as there Probably autoimmune in origin as there is an association with other autoimmune is an association with other autoimmune diseases such as thyroid diseases such as thyroid disease/diabetesdisease/diabetes

Was previously considered to be a Was previously considered to be a localised form of pustular psoriasis but localised form of pustular psoriasis but about 10% to 20% of patients have about 10% to 20% of patients have psoriasis elsewherepsoriasis elsewhere

Palmoplantar Pustulosis Palmoplantar Pustulosis (cont)(cont)

Rarely occurs before adulthood, Rarely occurs before adulthood, more common in women than men, more common in women than men, genetic linkgenetic link

More common in current smokers More common in current smokers and those who have smoked in the and those who have smoked in the pastpast

It is thought that activated nicotine It is thought that activated nicotine receptors in the sweat glands cause receptors in the sweat glands cause an inflammatory processan inflammatory process

Nail PsoriasisNail Psoriasis

Can affect any nail on hands and feetCan affect any nail on hands and feet

PittingPitting

Thickening (onycholysis)Thickening (onycholysis)

Colour change (oil spots)Colour change (oil spots)

Scalp PsoriasisScalp Psoriasis

Flexural PsoriasisFlexural Psoriasis

Affects areas within skin folds.Affects areas within skin folds.

Can affect under breast, under the Can affect under breast, under the arms, groins, between buttocks arms, groins, between buttocks and abdominal skin folds.and abdominal skin folds.

Erythrodermic PsoriasisErythrodermic Psoriasis

Generalised red skinGeneralised red skin

Can be life threateningCan be life threatening

Requires hospitalisationRequires hospitalisation

Koebner PhenomenonKoebner Phenomenon

The Treatment Of The Treatment Of PsoriasisPsoriasis

Topical Therapy (ointments, Topical Therapy (ointments, creams & lotions)creams & lotions)

Ultraviolet light therapy Ultraviolet light therapy (phototherapy)(phototherapy)

Tablet therapy (systemic)Tablet therapy (systemic)

Biological therapyBiological therapy

Topical TherapyTopical Therapy

Emollients / MoisturisersEmollients / Moisturisers

Vitamin D AnaloguesVitamin D Analogues

Coal Tar PreparationsCoal Tar Preparations

DithranolDithranol

Vitamin A analogueVitamin A analogue

Emollients/MoisturisersEmollients/Moisturisers

What is the best moisturiser?What is the best moisturiser?

The one the patient will use!!The one the patient will use!!

Emollients / MoisturisersEmollients / Moisturisers

Soap substitutes / shower Soap substitutes / shower preparationspreparations

Bath OilsBath Oils

CreamsCreams

OintmentsOintments

LotionsLotions

Bath Additives & Shower Bath Additives & Shower PreparationsPreparations

Aveeno® Balneum® Cetraben® Dermalo® Diprobath® Doublebase® E45® Hydromol® Oilatum® QV® Zerolatum® Zeroneum® Zerozole®

with antimicrobialswith antimicrobials Dermol® Emulsiderm® Oilatum® Plus Zerolatum® Plus

with tarwith tar Coal Tar Solution, BP Pinetarsol® Polytar Emollient® Psoriderm®

MoisturisersMoisturisersProprietaryProprietary

Aquamol® Aveeno® Cetraben® Dermamist® Diprobase® Doublebase® E45® Emollin® Epaderm® Hydromol® Lipobase® Oilatum® QV®

Ultrabase® Unguentum M® ZeroAQS® Zerobase® Zerocream® Zeroguent®

Non-ProprietaryNon-Proprietary Aqueous Cream, BP Emulsifying Ointment,

BP Hydrous Ointment, BP Liquid and White Soft

Paraffin Ointment, NPF Paraffin, White Soft, BP Paraffin, Yellow Soft,

BP

Moisturisers cont’dMoisturisers cont’d

with ureawith urea Aquadrate® Balneum® Calmurid® Dermatonics Heel

Balm® E45® Itch Relief

Cream Eucerin® Intensive Hydromol® Intensive Nutraplus®

with with antimicrobialsantimicrobials Dermol® Eczmol®

Vitamin D AnaloguesVitamin D Analogues

Calcipotriol ointment Calcipotriol ointment

Calcitriol ointment (Silkis) Calcitriol ointment (Silkis)

Tacalcitol ointment (Curatoderm) Tacalcitol ointment (Curatoderm)

Calcipotriol & Betnovate ointment /gel Calcipotriol & Betnovate ointment /gel (Dovobet) (Dovobet)

Calcipotriol (Dovonex)Calcipotriol (Dovonex) Apply twice daily to individual plaques Apply twice daily to individual plaques

(body & limbs only)(body & limbs only)

Adults: Maximum weekly dose should not Adults: Maximum weekly dose should not exceed 100g. exceed 100g.

Children over 12 years: Maximum weekly Children over 12 years: Maximum weekly dose should not exceed 75g. dose should not exceed 75g.

Children aged 6 to 12 years: Maximum Children aged 6 to 12 years: Maximum weekly dose should not exceed 50g weekly dose should not exceed 50g

Calcitriol (Silkis)Calcitriol (Silkis)

Adult & child over 12 yearsAdult & child over 12 years

Apply twice daily to individual Apply twice daily to individual plaques (face, hairline, scalp, axillae plaques (face, hairline, scalp, axillae and other flexures). and other flexures).

Maximum 35% body surface area or Maximum 35% body surface area or 30 g of ointment per day 30 g of ointment per day

Tacalcitol oint / lotion Tacalcitol oint / lotion (Curatoderm)(Curatoderm)

Adult & child over 12 yearsAdult & child over 12 years

Apply once daily to individual plaques Apply once daily to individual plaques (face, hairline, scalp, axillae and other (face, hairline, scalp, axillae and other flexures). flexures).

Maximum 10g/10ml per day Maximum 10g/10ml per day

N.B.N.B. When lotion and ointment used When lotion and ointment used together, max. total tacalcitol 280 together, max. total tacalcitol 280 micrograms in any one week (e.g. lotion micrograms in any one week (e.g. lotion 30 mL with ointment 40 g)30 mL with ointment 40 g)

Calcipotriol & Betnovate Calcipotriol & Betnovate oint (Dovobet)oint (Dovobet)

Apply once daily for up to 4 weeks to body & limbs Apply once daily for up to 4 weeks to body & limbs (may be continued beyond 4 weeks or repeated on (may be continued beyond 4 weeks or repeated on the advice of a specialist)the advice of a specialist)

Maximum 15 g per day Maximum 15 g per day

Maximum 100 g per week Maximum 100 g per week

Treated area should not be more than 30% of the Treated area should not be more than 30% of the body surfacebody surface

Child 12–18 yearsChild 12–18 years Stable plaque psoriasis (specialist use only)Stable plaque psoriasis (specialist use only) apply once daily to max. 30% of body surface for apply once daily to max. 30% of body surface for

up to 4 weeks; max. 75 g weekly; if necessary, up to 4 weeks; max. 75 g weekly; if necessary, subsequent courses repeated on the advice of a subsequent courses repeated on the advice of a specialistspecialist

Calcipotriol & Betnovate Calcipotriol & Betnovate gel (Dovobet)gel (Dovobet)

Body & limbsBody & limbs Apply once daily for up to 8 weeks to body & limbs Apply once daily for up to 8 weeks to body & limbs

(may be continued beyond 8 weeks or repeated on (may be continued beyond 8 weeks or repeated on the advice of a specialist)the advice of a specialist)

Maximum 15 g per day Maximum 15 g per day

Maximum 100 g per week Maximum 100 g per week

Treated area should not be more than 30% of the Treated area should not be more than 30% of the body surface body surface

Stable plaque psoriasis (specialist use only)Stable plaque psoriasis (specialist use only) Child 12–18 years apply once daily to max. 30% of Child 12–18 years apply once daily to max. 30% of

body surface for up to 4 weeks; max. 75 g weekly; if body surface for up to 4 weeks; max. 75 g weekly; if necessary, subsequent courses repeated on the necessary, subsequent courses repeated on the advice of a specialistadvice of a specialist

Calcipotriol & Betnovate Calcipotriol & Betnovate gel (Dovobet)gel (Dovobet)

Scalp Scalp adult and child over 12 yearsadult and child over 12 years

Apply 1-4g once daily for up to 4 weeks (may be Apply 1-4g once daily for up to 4 weeks (may be continued beyond 4 weeks or repeated on the continued beyond 4 weeks or repeated on the advice of a specialist)advice of a specialist)

shampoo off after leaving on scalp overnight or shampoo off after leaving on scalp overnight or during dayduring day

Maximum 4g per day Maximum 4g per day

N.B. When different preparations containing N.B. When different preparations containing calcipotriol used together, max. total calcipotriol 5 calcipotriol used together, max. total calcipotriol 5 mg in any one weekmg in any one week

Coal Tar PreparationsCoal Tar Preparations Exorex Exorex (1% coal tar) (1% coal tar)

apply 2-3 times per dayapply 2-3 times per day

Psoriderm creamPsoriderm cream(6% coal tar)(6% coal tar) apply 1-2 times dailyapply 1-2 times daily

Carbo-dome cream Carbo-dome cream (10% coal tar)(10% coal tar) apply 1-2 times dailyapply 1-2 times daily

Crude Coal Tar (1% - 20%) in a Crude Coal Tar (1% - 20%) in a moisturising base +/- salicylic acidmoisturising base +/- salicylic acid apply once daily for up to 6 hours apply once daily for up to 6 hours

Dithranol (Anthralin)Dithranol (Anthralin)

Creams:Creams: Dithrocream (0.1%, 0.25%, 0.5%, 1% & 2%)Dithrocream (0.1%, 0.25%, 0.5%, 1% & 2%) Micanol cream (1% & 3%)Micanol cream (1% & 3%)

Ointments:Ointments: Dithranol (in hard paraffin base) 0.1% - 20%Dithranol (in hard paraffin base) 0.1% - 20% Psorin ointment (0.11%)Psorin ointment (0.11%)

N.B. All preparations – apply once daily to N.B. All preparations – apply once daily to individual individual

plaquesplaques

PhototherapyPhototherapy

UVA (PUVA) - can be topical or UVA (PUVA) - can be topical or systemic :systemic : TopicalTopical

PPsoralens & soralens & UVAUVA

SystemicSystemic 8-mop (methoxypsoralens)8-mop (methoxypsoralens) 5-mop5-mop

UVB UVB

Tablet / Systemic TherapyTablet / Systemic Therapy Neotigason (Acitretin) – once dailyNeotigason (Acitretin) – once daily

Ciclosporin (Neoral) – twice dailyCiclosporin (Neoral) – twice daily

Methotrexate – Methotrexate – once weeklyonce weekly

Mycophenolate Mofetil – twice dailyMycophenolate Mofetil – twice daily

Fumaric Acid Esters – 1 – 3 times dailyFumaric Acid Esters – 1 – 3 times daily

Hydroxyurea – once dailyHydroxyurea – once daily

Propylthiouracil – dailyPropylthiouracil – daily

Biological TherapyBiological Therapy

Target TNFTarget TNFάά Infliximab (Remicade) infusion 8 weeklyInfliximab (Remicade) infusion 8 weekly Adalimumab (Humira) fortnightly sub-cut Adalimumab (Humira) fortnightly sub-cut

injectioninjection Etanercept (Enbrel) weekly sub-cut Etanercept (Enbrel) weekly sub-cut

injectioninjection

Target IL 12 & IL 23Target IL 12 & IL 23 Ustekinumab (Stelara) 3 monthly Ustekinumab (Stelara) 3 monthly sub-cut sub-cut

injectioninjection

Psoriatic Arthritis.Psoriatic Arthritis.

Onset most common in patients in their 20s or Onset most common in patients in their 20s or 30s, occurring with equal prevalence in men 30s, occurring with equal prevalence in men and women.and women.

In 75% of cases, onset of skin disease precedes In 75% of cases, onset of skin disease precedes the development of arthritis, often by a decade the development of arthritis, often by a decade or more.or more.

Up to 40% of people with psoriasis have some Up to 40% of people with psoriasis have some signs of psoriatic arthritis.signs of psoriatic arthritis.

Most common presentation is asymmetrical Most common presentation is asymmetrical oligoarthropathy, affecting the interphalangeal oligoarthropathy, affecting the interphalangeal joints(distal or proximal).joints(distal or proximal).

Psychological Impact of Psychological Impact of Psoriasis.Psoriasis.

A study by Krueger et al (2001) for the A study by Krueger et al (2001) for the National Psoriasis Foundation found that National Psoriasis Foundation found that psoriasis has a profound impact on a psoriasis has a profound impact on a patient’s quality of life.patient’s quality of life.

40,350 questionnaires were sent and there 40,350 questionnaires were sent and there was a response rate of 43%. was a response rate of 43%.

Most frequent symptoms experienced by Most frequent symptoms experienced by respondents were scaling (94%), itching respondents were scaling (94%), itching (79%), erythema (71%). Thirty nine per (79%), erythema (71%). Thirty nine per cent also reported that psoriasis covered cent also reported that psoriasis covered 10% of their body.10% of their body.

Psychological Impact of Psychological Impact of Psoriasis (cont’d).Psoriasis (cont’d).

6,194 Patients with severe psoriasis were 6,194 Patients with severe psoriasis were entered into a database and of those 79% entered into a database and of those 79% reported a negative impact on their lives.reported a negative impact on their lives.

40% felt frustrated with their ineffective 40% felt frustrated with their ineffective treatment.treatment.

32% felt their treatment was not 32% felt their treatment was not aggressive enough.aggressive enough.

This is strong evidence that individuals This is strong evidence that individuals with psoriasis believe that the disease has with psoriasis believe that the disease has a profound emotional and social as well as a profound emotional and social as well as physical impact on their quality of life.physical impact on their quality of life.

Any Any Questions?Questions?