Psoriasis: Treatment and Management Ann Davies Clinical Nurse Specialist in Dermatology University Hospital Of Wales, Cardiff

Psoriasis: background Psoriasis is an inflammatory skin disorder. The inflammatory process involves the recruitment and activation of inflammatory cells. Psoriasis is an inflammatory skin disorder. The inflammatory process involves the recruitment and activation of inflammatory cells. Non-contagious condition – transmitted genetically Non-contagious condition – transmitted genetically Lifelong disease characterised by recurrent exacerbations Lifelong disease characterised by recurrent exacerbationsAetiology: T-cells are activated, to the extent that they trigger other immune responses, which lead to release of cytokines that promote inflammation and rapid turnover of skin cells T-cells are activated, to the extent that they trigger other immune responses, which lead to release of cytokines that promote inflammation and rapid turnover of skin cells

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

Who gets Psoriasis? It affects males and females equally. It affects males and females equally. Affects children, adults and older people and may occur at any age. Affects children, adults and older people and may occur at any age. Usual age of onset between 20 – 35 years with 75% of all cases occurring before the age of 40. It can also affect people in their 50’s for the first time (Menter et al 2004). Usual age of onset between 20 – 35 years with 75% of all cases occurring before the age of 40. It can also affect people in their 50’s for the first time (Menter et al 2004).

Who gets Psoriasis (cont). Studies have proven there is a genetic link. Studies have proven there is a genetic link. There is a positive family history in one third of sufferers. Less likely in late onset psoriasis. There is a positive family history in one third of sufferers. Less likely in late onset psoriasis. If one parent has psoriasis there is a 10 – 25% risk to the child. If both parents are affected the risk increases from 50 – 60%. If one parent has psoriasis there is a 10 – 25% risk to the child. If both parents are affected the risk increases from 50 – 60%. Investigators are using molecular genetics technology to try and unravel the genes that causes psoriasis. Investigators are using molecular genetics technology to try and unravel the genes that causes psoriasis.

Different Types Of Psoriasis

Chronic Plaque Psoriasis Can be large and/or small Can be large and/or small Localised or generalised Localised or generalised Well demarcated edges Well demarcated edges Silvery white scale on erythematous base Silvery white scale on erythematous base Affects elbows, knees, buttocks, scalp, face trunk, arms, legs, hands and feet. Affects elbows, knees, buttocks, scalp, face trunk, arms, legs, hands and feet.

Guttate Psoriasis Name comes from Latin word ‘gutta’ meaning ‘droplet’. Name comes from Latin word ‘gutta’ meaning ‘droplet’. Can affect the body, limbs, hands and feet Can affect the body, limbs, hands and feet Usually generalised Usually generalised

Pustular Psoriasis Generalised (body & limbs) - requires hospitalisation Generalised (body & limbs) - requires hospitalisation Localised (hands and feet) – only appears to affect smokers Localised (hands and feet) – only appears to affect smokers

Palmoplantar Pustulosis Cause unknown, appears to be a disorder of the eccrine glands which are mostly on palms and soles Cause unknown, appears to be a disorder of the eccrine glands which are mostly on palms and soles Probably autoimmune in origin as there is an association with other autoimmune diseases such as thyroid disease/diabetes Probably autoimmune in origin as there is an association with other autoimmune diseases such as thyroid disease/diabetes Was previously considered to be a localised form of pustular psoriasis but about 10% to 20% of patients have psoriasis elsewhere Was previously considered to be a localised form of pustular psoriasis but about 10% to 20% of patients have psoriasis elsewhere

Palmoplantar Pustulosis (cont) Rarely occurs before adulthood, more common in women than men, genetic link Rarely occurs before adulthood, more common in women than men, genetic link More common in current smokers and those who have smoked in the past More common in current smokers and those who have smoked in the past It is thought that activated nicotine receptors in the sweat glands cause an inflammatory process It is thought that activated nicotine receptors in the sweat glands cause an inflammatory process

Nail Psoriasis Can affect any nail on hands and feet Can affect any nail on hands and feet Pitting Pitting Thickening (onycholysis) Thickening (onycholysis) Colour change (oil spots) Colour change (oil spots)

Scalp Psoriasis

Flexural Psoriasis Affects areas within skin folds. Affects areas within skin folds. Can affect under breast, under the arms, groins, between buttocks and abdominal skin folds. Can affect under breast, under the arms, groins, between buttocks and abdominal skin folds.

Erythrodermic Psoriasis Generalised red skin Generalised red skin Can be life threatening Can be life threatening Requires hospitalisation Requires hospitalisation

Koebner Phenomenon

The Treatment Of Psoriasis Topical Therapy (ointments, creams & lotions) Topical Therapy (ointments, creams & lotions) Ultraviolet light therapy (phototherapy) Ultraviolet light therapy (phototherapy) Tablet therapy (systemic) Tablet therapy (systemic) Biological therapy Biological therapy

Topical Therapy Emollients / Moisturisers Emollients / Moisturisers Vitamin D Analogues Vitamin D Analogues Coal Tar Preparations Coal Tar Preparations Dithranol Dithranol Vitamin A analogue Vitamin A analogue

Emollients/Moisturisers What is the best moisturiser? The one the patient will use!!

Emollients / Moisturisers Soap substitutes / shower preparations Soap substitutes / shower preparations Bath Oils Bath Oils Creams Creams Ointments Ointments Lotions Lotions

Bath Additives & Shower Preparations Aveeno® Balneum® Cetraben® Dermalo® Diprobath® Doublebase® E45® Hydromol® Oilatum® QV® Zerolatum® Zeroneum® Zerozole® with antimicrobials Dermol® Emulsiderm® Oilatum® Plus Zerolatum® Plus with tar Coal Tar Solution, BP Pinetarsol® Polytar Emollient® Psoriderm®

Moisturisers Proprietary Aquamol® Aveeno® Cetraben® Dermamist® Diprobase® Doublebase® E45® Emollin® Epaderm® Hydromol® Lipobase® Oilatum® QV® Ultrabase® Unguentum M® ZeroAQS® Zerobase® Zerocream® Zeroguent®Non-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’d with urea with urea Aquadrate® Balneum® Calmurid® Dermatonics Heel Balm® E45® Itch Relief Cream Eucerin® Intensive Hydromol® Intensive Nutraplus® with antimicrobials with antimicrobials Dermol® Eczmol®

Vitamin D Analogues Calcipotriol ointment Calcipotriol ointment Calcitriol ointment (Silkis) Calcitriol ointment (Silkis) Tacalcitol ointment (Curatoderm) Tacalcitol ointment (Curatoderm) Calcipotriol & Betnovate ointment /gel (Dovobet) Calcipotriol & Betnovate ointment /gel (Dovobet)

Calcipotriol (Dovonex) Apply twice daily to individual plaques (body & limbs only) Apply twice daily to individual plaques (body & limbs only) Adults: Maximum weekly dose should not exceed 100g. Adults: Maximum weekly dose should not exceed 100g. Children over 12 years: Maximum weekly dose should not exceed 75g. Children over 12 years: Maximum weekly dose should not exceed 75g. Children aged 6 to 12 years: Maximum weekly dose should not exceed 50g Children aged 6 to 12 years: Maximum weekly dose should not exceed 50g

Calcitriol (Silkis) Adult & child over 12 years Adult & child over 12 years Apply twice daily to individual plaques (face, hairline, scalp, axillae and other flexures). Apply twice daily to individual plaques (face, hairline, scalp, axillae and other flexures). Maximum 35% body surface area or 30 g of ointment per day Maximum 35% body surface area or 30 g of ointment per day

Tacalcitol oint / lotion (Curatoderm) Adult & child over 12 years Adult & child over 12 years Apply once daily to individual plaques (face, hairline, scalp, axillae and other flexures). Apply once daily to individual plaques (face, hairline, scalp, axillae and other flexures). Maximum 10g/10ml per day Maximum 10g/10ml per day N.B. When lotion and ointment used together, max. total tacalcitol 280 micrograms in any one week (e.g. lotion 30 mL with ointment 40 g)

Calcipotriol & Betnovate oint (Dovobet) Apply once daily for up to 4 weeks to body & limbs (may be continued beyond 4 weeks or repeated on the advice of a specialist) Apply once daily for up to 4 weeks to body & limbs (may be continued beyond 4 weeks or repeated on 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 body surface Treated area should not be more than 30% of the body surface Child 12–18 years Child 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 up to 4 weeks; max. 75 g weekly; if necessary, subsequent courses repeated on the advice of a specialist apply once daily to max. 30% of body surface for up to 4 weeks; max. 75 g weekly; if necessary, subsequent courses repeated on the advice of a specialist

Calcipotriol & Betnovate gel (Dovobet) Body & limbs Body & limbs Apply once daily for up to 8 weeks to body & limbs (may be continued beyond 8 weeks or repeated on the advice of a specialist) Apply once daily for up to 8 weeks to body & limbs (may be continued beyond 8 weeks or repeated on 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 body surface Treated area should not be more than 30% of the 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 body surface for up to 4 weeks; max. 75 g weekly; if necessary, subsequent courses repeated on the advice of a specialist Child 12–18 years apply once daily to max. 30% of body surface for up to 4 weeks; max. 75 g weekly; if necessary, subsequent courses repeated on the advice of a specialist

Calcipotriol & Betnovate gel (Dovobet) Scalp Scalp adult and child over 12 years adult and child over 12 years Apply 1-4g once daily for up to 4 weeks (may be continued beyond 4 weeks or repeated on the advice of a specialist) Apply 1-4g once daily for up to 4 weeks (may be continued beyond 4 weeks or repeated on the advice of a specialist) shampoo off after leaving on scalp overnight or during day shampoo off after leaving on scalp overnight or during day Maximum 4g per day Maximum 4g per day N.B. When different preparations containing calcipotriol used together, max. total calcipotriol 5 mg in any one week

Coal Tar Preparations Exorex (1% coal tar) Exorex (1% coal tar) apply 2-3 times per day apply 2-3 times per day Psoriderm cream(6% coal tar) Psoriderm cream(6% coal tar) apply 1-2 times daily apply 1-2 times daily Carbo-dome cream (10% coal tar) Carbo-dome cream (10% coal tar) apply 1-2 times daily apply 1-2 times daily Crude Coal Tar (1% - 20%) in a moisturising base +/- salicylic acid Crude Coal Tar (1% - 20%) in a moisturising base +/- salicylic acid apply once daily for up to 6 hours apply once daily for up to 6 hours

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 individual plaques

Phototherapy UVA (PUVA) - can be topical or systemic : UVA (PUVA) - can be topical or systemic : Topical Topical Psoralens & UVA Psoralens & UVA Systemic Systemic 8-mop (methoxypsoralens) 8-mop (methoxypsoralens) 5-mop 5-mop UVB UVB

Tablet / Systemic Therapy Neotigason (Acitretin) – once daily Neotigason (Acitretin) – once daily Ciclosporin (Neoral) – twice daily Ciclosporin (Neoral) – twice daily Methotrexate – once weekly Methotrexate – once weekly Mycophenolate Mofetil – twice daily Mycophenolate Mofetil – twice daily Fumaric Acid Esters – 1 – 3 times daily Fumaric Acid Esters – 1 – 3 times daily Hydroxyurea – once daily Hydroxyurea – once daily Propylthiouracil – daily Propylthiouracil – daily

Biological Therapy Target TNFά Target TNFά Infliximab (Remicade) infusion 8 weekly Infliximab (Remicade) infusion 8 weekly Adalimumab (Humira) fortnightly sub-cut injection Adalimumab (Humira) fortnightly sub-cut injection Etanercept (Enbrel) weekly sub-cut injection Etanercept (Enbrel) weekly sub-cut injection Target IL 12 & IL 23 Target IL 12 & IL 23 Ustekinumab (Stelara) 3 monthly sub-cut injection Ustekinumab (Stelara) 3 monthly sub-cut injection

Psoriatic Arthritis. Onset most common in patients in their 20s or 30s, occurring with equal prevalence in men and women. Onset most common in patients in their 20s or 30s, occurring with equal prevalence in men and women. In 75% of cases, onset of skin disease precedes the development of arthritis, often by a decade or more. In 75% of cases, onset of skin disease precedes the development of arthritis, often by a decade or more. Up to 40% of people with psoriasis have some signs of psoriatic arthritis. Up to 40% of people with psoriasis have some signs of psoriatic arthritis. Most common presentation is asymmetrical oligoarthropathy, affecting the interphalangeal joints(distal or proximal). Most common presentation is asymmetrical oligoarthropathy, affecting the interphalangeal joints(distal or proximal).

Psychological Impact of Psoriasis. A study by Krueger et al (2001) for the National Psoriasis Foundation found that psoriasis has a profound impact on a patient’s quality of life. A study by Krueger et al (2001) for the National Psoriasis Foundation found that psoriasis has a profound impact on a patient’s quality of life. 40,350 questionnaires were sent and there was a response rate of 43%. 40,350 questionnaires were sent and there was a response rate of 43%. Most frequent symptoms experienced by respondents were scaling (94%), itching (79%), erythema (71%). Thirty nine per cent also reported that psoriasis covered 10% of their body. Most frequent symptoms experienced by respondents were scaling (94%), itching (79%), erythema (71%). Thirty nine per cent also reported that psoriasis covered 10% of their body.

Psychological Impact of Psoriasis (cont’d). 6,194 Patients with severe psoriasis were entered into a database and of those 79% reported a negative impact on their lives. 6,194 Patients with severe psoriasis were entered into a database and of those 79% reported a negative impact on their lives. 40% felt frustrated with their ineffective treatment. 40% felt frustrated with their ineffective treatment. 32% felt their treatment was not aggressive enough. 32% felt their treatment was not aggressive enough. This is strong evidence that individuals with psoriasis believe that the disease has a profound emotional and social as well as physical impact on their quality of life. This is strong evidence that individuals with psoriasis believe that the disease has a profound emotional and social as well as physical impact on their quality of life.

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