Psoriasis

Pharmacotherapeutis of Psoriasis

1. Psoriasis Dr. V. S. S wathi Assistant Professor

2. Definition It is defined as chronic inflammatory disorder of skin and joints characterised by well demarcated red papules with an overlying scale.

3. Epidemiology In the world, prevalence of Psoriasis is approximately 2-3%. In India, prevalence of Psoriasis is ranges from 0.44%-2.8%.

4. Types Psoriasis vulgaris Guttate Psoriasis Scalp Psoriasis Psoriatic nail disease Palmoplantar Psoriasis Flexural Psoriasis Erythrodermic Psoriasis Generalised Pustular Psoriasis Psoriatic Arthropathy

5. Psoriasis vulgaris Also called as Chronic Plaque Psoriasis Mostly begin in young adulthood Patients presented with well demarcated red, sharp plaque with overlying silvery scale Symmetrical distribution of lesions at knees and elbows Sacrum, scalp and nails also affected

6. Guttate Psoriasis Commonly seen in children and young adults Patients presented with a widespread scaly eruption of small teardrop like scaly plaques Presentation is acute or appears 10-14 days after a streptococcal upper respiratory tract infection

7. Scalp Psoriasis In some patients scalp only involves Also occurs in Psoriasis vulgaris patients Patients presented with demarcated plaques extending to hairline and around the ears Hair loss is rare

8. Psoriatic nail disease Nails are affected mostly Patients presented with nail pitting, nail ridging, onycholysis, hyperkeratosis under the nail and complete nail destruction It affects cosmetic appearance

9. Palmoplantar Psoriasis Palms and soles are affected Two types: Painful inflamed hyperkerartotic fissured skin Sterile pustules on an erythematous base which dry to leave small brown macules (Palmoplantar Pustulosis) - Common in smokers

10. Flexural Psoriasis It affects axillae, groin, sub mammary areas and genitalia It occurs due to friction and moisture within skin folds Patients presented with well demarcated red glazy lesion at affected site Secondary infections may occur like Candida infection

11. Erythrodermic Psoriasis Also called as Exfoliative dermatitis It is severe potentially life threatening condition More than 90% of body appears as red and scaly Patients presented with dehydration, electrolyte imbalance, temperature dysregulation and serious secondary infection Patients require urgent hospital admission

12. Generalised Pustular Psoriasis It is acute and unstable form of Psoriasis Patients presented with wide spread sheets of tiny sterile pustules on an erythematous base, fever and malaise

13. Psoriatic Arthropathy It affects 25% of patients with psoriasis Here Rheumatoid factor is negative Patients presented with pain, swelling, erythema at affected joints

14. Risk factors Infections- Streptococcal pharyngitis and HIV infection Drugs like: Lithium Beta blockers Anti malarial drugs Tetracyclines Rapid withdrawl of systemic steroids Alcohol Smoking Stress Cuts, burns, scratch or surgical scars- Koebner Phenomenon

15. Etiology Abnormal activation of innate and adaptive immunity

16. Pathogenesis

17. Clinical Presentation Red patches of skin covered with thick and silvery scales Small scaling spots in case of children Dry, cracked and bleedy skin Itching and burning skin Thickened, pitted and ridged nails- Nail Psoriasis Swollen and stiff joints- Psoriatic Arthropathy

18. Complications Psoriatic arthritis Conjunctivitis Uveitis Obesity Diabetes Hypertension Cardiovascular diseases Chronic renal disease Crohn’ s disease Parkinson’s disease Depression

19. Diagnosis Medical and medication history Clinical presentation Type Body Surface Area (BSA) Psoriatic Area Severity Index ( PASI) Dermatology Life Quality Index (DLQI) Mild Psoriasis ≤10 ≤10 ≤10 Moderate to Severe Psoriasis > 10 > 10 > 10

20. Non Pharmacological Treatment Stress reduction Avoid exposure to triggering factors Physical exercise Protect skin from sun by using sunscreen lotions Use moisturizers for dry skin

21. Treatment Algorithm for Mild to Moderate Psoriasis

22. Treatment Algorithm for Moderate to Severe Psoriasis

23. Drugs used in treatment of Psoriasis Drug Category Mode of Action Dose Adverse effects Betamethasone Topical corticosteroid Decreases release of inflammatory mediators Decrease proliferation of keratinocytes 0.05% topical formulations Local atrophy Itching Erythema Skin dryness Rebound effect on withdrawl Hydrocortisone Topical corticosteroid Decreases release of inflammatory mediators Decrease proliferation of keratinocytes 0.5% topical formulations Acne Skin redness Tingling and Prickling feeling Skin dryness Hair bumps Calcipotriol Vitamin D3 Analogue Inhibit keratinocytes differentiation and proliferation 0.005% ointment Burning Itching Dry skin Erythema Peeling of skin

24. Dithranol Synthetic anthracene derivative Decreases release of inflammatory mediators Decrease proliferation of keratinocytes 0.5%-3% cream Allergy Temporary discoloration of skin Lesion soreness Staining of hair, nail and skin Salicyclic acid Keratinolytic agent Dissolves intracellular cement and makes hyperkerartotic tissue to swell, macerate, soften and desquamate 3% ointment 2.5% cream 3% shampoo Burning of skin Peeling of skin Scaling of skin Head ache Hyperventilation Methotrexate Immunosuppressant Inhibit rapid proliferation of epithelial cells in skin 10-25mg/week PO/IV/IM/SC Erythema Hyperurecemia Glossitis Leukopenia Renal failure Cyclosporine Immunosuppressant Suppresses production of T cells 1.25mg/kg-PO-BID Tremor Nephrotoxicity Hypertension Infection Hirsutism Drugs used in treatment of Psoriasis

25. Drugs used in treatment of Psoriasis Azathioprine Immunosuppressant Suppresses production of T cells 1mg/kg/day Leukopenia Infection Alopecia Arthralgia Bone marrow suppression Hepatotoxicity Acetretin Vitamin A derivative Inhibit epidermal cell proliferation 25-30mg daily PO Hair loss Lethargy Teratogenesity Cheilitis Dry skin PUVA Psoralen+ UV A rays Inhibit epidermal cell proliferation 320-400nm UVA+ Psoralen taken orally 2 hours before exposure to radiation – Twice/ week for 6 weeks Nausea Cataracts Skin cancer Photosensitivity Burns

26. Resources https ://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513809/pdf/40257_2018_Article_396.pdf https://www.aafp.org/afp/2000/0201/p725.html https://reader.elsevier.com/reader/sd/pii/S0022202X17331718?token=C8D671EE1E4723B13B03C83035B71C0597B8307FCABC174FBCF18563AF65E57814FA55F6BF9F13CE7358C46737AABF74 https://reader.elsevier.com/reader/sd/pii/S0022202X17327446?token=6B8742C944F78B9A5A0AFF6ADF5AB0AD82C160E88BD82B002BF362AF4112D77960CEF0E42839C99FCE91C3F51F1CB989 https://reader.elsevier.com/reader/sd/pii/S0022202X15357067?token=B329A026CA8098C71146672CFEA49A89830CD986A1B1186E8956E0F6E8DF7C9EB9BA61AF8B8A19AFB21C8FD072E8852A