1. Psoriasis

2. Definition and causes Types GP management Pitfalls Hospital treatments Case studies

3. Psoriasis Definition a chronic relapsing and remitting scaling skin disease which may appear at any age and affect any part of the skin Prevalence 1.5-3% Age onset 20-30y or 50-60y

4. Psoriasis Epidermal hyperproliferation Vascular dilatation Inflammatory infiltrate

5. What causes psoriasis ? T cell mediated autoimmune disease → increased keratinocyte proliferation Environmental and genetic factors

7. Psoriasis GeneticsGenetics 73% monozygotic twins concordant V 20% dizygotic twins if 1 parent affected →14/40% risk for offspring Environmental triggersEnvironmental triggers

8. Types of psoriasis Plaque Guttate Rupioid Unstable Pustular Erythrodermic ?palmo-plantar pustulosis

28. Guttate psoriasis

32. Pustular psoriasis

35. Erythrodermic psoriasis

37. Plantar pustulosis

41. Acrodermatitis continua of Hallopeau

43. 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

45. GP Management Emollients Bath oils Site-specific topical treatments

46. Topical treatments Vitamin D analogues Dovonex (calcipotriol) Dovobet (calcipotriol & betamethasone) Silkis (calcitriol) Curatorderm (tacalcitol) Zorac (tazarotene) Dovonex cream and scalp application no longer available

47. Topical treatments Tar Carbo-dome Exorex Psoriderm Alphosyl HC Sebco Cocois Tar-based bath oils & shampoos

48. Topical Treatments Steroids Often in conjunction with Vit D analogue as Dovobet or separate steroid Eumovate Trimovate Scalp preparations (eumovate to dermovate strength) BE CAREFUL (but not mean)

49. Topical Treatments Dithranol Dithrocream Micanol Psorin Stains skin Has to be washed off Start and low strength and build up

50. Topical treatments Nails difficult potent topical steroids dovonex tazarotene systemic therapy

51. Topical Treatments Scalp Remove scale first Cocois or Sebco messy but effective Tar or salicylic acid shampoo Topical steroids if necessary for short periods

52. Pitfalls '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

53. Hospital Treatment Out-patient advice and support UVB PUVA Acitretin Methotrexate Ciclosporin Biologics Admission (tar, other topicals)

54. 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)

56. 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)

57. Systemic therapy acitretin methotrexate ciclosporin

58. 7-20% of patients with psoriasis have arthritis

59. Acitretin mec: affects keratinocyte differentiation CI: ? fertile women (as must avoid pregnancy for 2 years) SE: dry lips, teratogenicity, abnormal LFT, lipids, DISH

60. Methotrexate mec: inhibits DNA synthesis by inhibiting dihydrofolate reductase → reduces proliferation of lymphocytes + keratinocytes CI: pregnancy, lactation, infection, liver/renal disease, peptic ulcers given once weekly SE: anorexia, nausea, myelosuppression, hepatotoxicity, mouth ulcers, pulmonary toxicity, oligospermia, skin cancer Interactions: NSAIDs, septrin, trimethoprim, penicillin, phenytoin

61. Ciclosporin Mec Inhibits T cell activation CI uncontrolled HBP, malignancy, infection SE HBP, nephrotoxicity, skin cancer, other malignancy, gum hypertrophy Not recommended for long term treatment

62. New Biologicals Anti TNF drugs infliximab etanercept Adalimumab Targeted T - cell therapy alefacept (binds CD2 & blocks LFA3) efalizumab (binds to LFA-1 & blocks ICAM-1)

63. GP Issues 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!

64. Case Studies Paul, age 45 Carpet fitter Large plaque psoriasis knees, elbows, natal cleft. Hand and nail involvement Also has MS

65. Case studies Robert, age 35 Psoriasis since teens Lives in a hostel, alcoholic

66. Case studies Anne, age 15 Recent onset guttate psoriasis Wants skin to be clear for sister’s wedding

67. Case studies David, age 25 Severe psoriasis Has had multiple admissions, MTX, Ciclosporin, acitretin, UVB Treatment so far has produced partial success only Very keen to improve his skin as finds holding down a job very difficult