Pharmacotherapy of psoriasis

learning objectives : Pathophysiology of Psoriasis
Common sites with pictures
Pharmacotherapy of Psoriasis
Local Drug therapy
Systemic Drug therapy
Biological therapy
Phototherapy

1. Dr.Uma Advani
Assistant Professor
Pharmacology,
SMS,MC Jaipur

2. Introduction
Pathophysiology of Psoriasis
Common sites with pictures
Pharmacotherapy of Psoriasis
Local Drug therapy
Systemic Drug therapy
Biological therapy
Phototherapy

3. Chronic proliferative epidermal disease .
Affects 1 to 3% of world’s population .
Rapid increase in epidermal transit time.
The time taken for a psoriatic epidermal cell
to travel from the basal layer to the surface
and be cast off is 3 to 4 days , in marked
contrast to the normal 26 to 28 days.
In most cases the disease remains as discrete
localized plaques
Stress and anxiety frequently precede flare
ups of the disease.

4. Psoriatic lesions are usually erythematous
and sharply circumscribed plaques.
The lesions are covered by silvery white
micaceous scales.
Lesions occur most commonly on the
elbows , knees , scalp, genitalia ,
lumbosacral area and intergluteal cleft.

5. 50% of psoriatic patients will have some degree
of nail involvement
Intense pruritus seen in 30 –40% of patients.
Psoriatic arthritis.
Reduction in the quality of life.

6. Topical agents (corticosteroids,tar,anthralin,calcipotriol,tazarotene)
Phototherapy
Immunosuppressive agents and retinoids
Biologic agents (Infliximab)
Mild Moderate Severe

7. Topical therapy
1. Corticosteroids
2. Vitamin D analogues (calcipotriene and
calcitriol)
3. Coal tar
4. Anthralin

8. Topical therapy
5. Tazarotene
6. Immunomodulators (tacrolimus and
pimecrolimus)
7. Keratolytics –salicylic acid
Drugs used in Psoriasis.

9. Systemic therapy
1.Methotrexate
2.Acitretin
3.Cyclosporine
4.Mycophenolate mofetil
5.Sulfasalazine
6.6-Thioguanine
7.Tacrolimus
8.Hydroxyurea
Drugs used in Psoriasis.

10. Biologic therapy
1. Infliximab
2. Etanercept
3. Alefacept
4. Efalizumab
Photochemotherapy
Drugs used in Psoriasis.

11. Topical Corticosteroids.
Classified according to their potency
(Stoughton Cornell classification) .
High potency steroids like clobetasol,
halobetasol and betamethasone used in
chronic plaque psoriasis.
Used for finite periods of time
Should be used only for small body surface
areas.

12. Low potency steroids like hydrocortisone
safer
Can be used for long term and also in
infants and children.
ADR: Local tissue atrophy, striae,
suppression of HPA axis, hyperglycemia,
cushingoid features.

14. Do not abruptly cease topical steroids as
rebound flare is known to occur.
Main role is as an adjunct.
Ointment form considered the clinically
most effective .

15. Vitamin D analogues
Inhibits keratinocyte differentiation and
proliferation.
Calcipotriene, calcitriol, tacalcitol
Rapidly metabolized locally.
Marked improvement seen after 8 weeks of
therapy.
expensive.

16. Tazarotene -synthetic retinoid.
Prodrug , metabolized to active tazarotenic
acid.
Modulates keratinocyte proliferation and
differentiation.
Effective for mild to moderate plaque
psoriasis.
Used in combination with steroids to
decrease ADR.

17. Coal tar
Down regulates epidermal
proliferation rate.
Used in thick plaques and
in scalp psoriasis.
Disadvantages:
burdensome,timeconsuming, unpleasant
odourand staining of skin and clothing.
Can be combined with UVB.

18. Anthralin
Inhibit DNA synthesis by
intercalating between DNA
strands
Inflammation , irritation and
staining of skin and clothing.
Staining of affected plaques is a
positive response.
Dose to be gradually increased.

19. Keratolytics-Salicylic acid
Removes scales.
Makes skin smooth .
Decreases hyperkeratosis.
Used in mild cases.
Salicylism-nausea , vomiting, tinnitus and
hyperventilation.

20. Synthetic analogue of folic acid.
Competitive inhibitor of the enzyme
dihydrofolate reductase.
Inhibits the replication and function of T and B
cells.
Suppresses the secretion of cytokines such as
IL-1, IFN-g, TNF-a.
Indicated in severe psoriasis

21. Can be given as thrice weekly oral dose.
Nausea , anorexia, headache and alopecia.
Sign of MTX overdose-leukopenia and
thrombocytopenia.
Hepatotoxicity , nephrotoxicity and
pneumonitis.
Avoid all immunosuppressives in active
infection.

22. Oral retinoid
Active metabolite of etretinate.
Indicated for the treatment of severe
psoriasis.
Combination of acitretin and PUVA is
highly effective.

23. ADR: hypervitaminoses A, hepatotoxicity,
skeletal changes, hypercholesterolemia and
hypertriglyceridemia.
C/I in pregnancy and in women who are
planning pregnancy within 3 years following
drug discontinuation.

24. Effective immunosuppressant.
Inhibits the release of inflammatory mediators
from mast cells, basophils and PMN
leukocytes.
Effective in both the cutaneous lesions and also
the arthritic symptoms.

25. Effective in generalisedpustularpsoriasis
Prolonged use causes nephrotoxicity and
hypertension.
Use for more than two years leads to increased
risk of malignancy.

26. UVA combined with oral / topical
methoxsalenon alternate days
Immunomodulatory–induces Tcellapoptosis.
Reserved for moderate to severe psoriasis.
Short term adverse effect-mottling,
erythema,burns,blistering,premature aging of
skin,nervousnessand insomnia.
Long term adverse effect-increased risk of skin
cancer.

30. Thank you.