Psoriasis

clinical manifestations and treatment of Psoriasis

1. PSORIASIS Prepared By, Dr.A.Infant Smily Pharm-D., Asst.Professor , Dpt . of Pharmacy Practice, RVSCOPS, Coimbatore .

2. INTRODUCTION Psoriasis is a complex, chronic, multifactorial, inflammatory disease that involves hyperproliferation of the keratinocytes in the epidermis, with an increase in the epidermal cell turnover rate. A problem with the immune system causes psoriasis. In a process called cell turnover, skin cells that grow deep in skin rise to the surface .

3. Environmental, genetic, and immunologic factors appear to play a role. The disease most commonly manifests on the skin of the elbows, knees, scalp, lumbosacral areas, intergluteal clefts, and glans penis. Some people who have psoriasis also get a form of arthritis called psoriatic arthritis.

4. DEFINITION P soriasis is defined as a persistent skin disease causes cell to build rapidly on the surface of the skin, forming thick silvery ”scales , itchy,dry and red patches

5. EPIDEMIOLOGY Although psoriasis occurs worldwide, its prevalence varies considerably. In the USA, approximately 2% of the population is affected. High rates of psoriasis have been reported in people of the Faroe islands, where one study found 2.8% of the population to be affected. The prevalence of psoriasis is low in certain ethnic groups such as the Japanese, and may be absent in aboriginal Australians and Indians from South America

6. E T IOLOGY Idiopathic cause . It can last a long time, even a lifetime. Symptoms come and go. Some of the factors that may trigger psoriasis are : Genetic Infection Autoimmune reaction Infection Injury to skin , Dry skin. Medication: lithium, antimalarial medications, inderal, indomethacin Stress Obesity s m o k i n g

7. CLASSIFICATION There are several types of psoriasis include Plaque pso r iasis Guttate psoriasis Inverse psoriasis Pustular psoriasis Erythrodermic psoriasis Nail psoriasis Psoriatic arthritis

8. PLAQUE PSORIASIS It is the most common type of psoriasis It is also known as psoriasis- vulgaris It is appear as raised, inflammed,- red skin covered by silvery patches or scales Sites :Elbows, Knees, sacrum,- Scalp, lower back, Hands and Feet

9. GUTTATE PSORIASIS Characterized by eruption of small (0.5 to 1.5 cm in diameter) papules over the upper trunk and proximal extremities Streptococcal throat infection frequently precedes or is concomitant with the onset or flare

10. INVERSE PSORIASIS Localized in the major skin folds, such as the axilla, the inguinal and inflammatory areas and sweating areas Scaling is usually minimal or absent, and the lesions appear glossy, smooth and bright red. Its is commonly seen in obese client.

11. PUSTULAR PSORIASIS It is usually uncommon but mostly appear in adult. It appear as pus filled lesion surrounded by red skin. It appear mostly at hands and feet. It is the serious condition so immediate medical attention is required.

12. E R Y T HROD E RM I C PSORIASIS The disease affects all body sites Erythema is the most prominent feature with superficial scaling / peeling that may appear like burning Causes: sun burn, allergic reaction, strong coal product use

13. NAIL PSORIASIS PSORIATIC ARTHRITIS Commonly seen along with- psoriatic arthritis It appear as a pitting –small- bit nail, yellow-brown nail, tender and painful nail with chalk like debris build up under nails This is the condition which involve both psoriasis and joint Inflammation The most distinctive features of psoriatic arthritis are Distal interphalangeal joint arthritis Dactylitis

14. CLINICAL MANIFESTATIONS Red patches of skin covered with thick, silvery scales. Small scaling spots (commonly seen in children) Dry, cracked skin that may bleed. Itching, burning or soreness. Thickened, pitted or ridged nails. Swollen and stiff joints.

15. PATHOPHYSIOLOGY

16. DIAGNOS IS Psoriasis can be hard to diagnose because it can look like other skin diseases. Collect history Physical examinations Skin biopsy : under local- anesthesia Blood and radiography- test was done to rule out psoriatic arthritis

17. Lifestyle and home remedies Take daily baths Use moisturizer Expose your skin to small amounts of sunlight.  Avoid drinking alcohol. Avoid psoriasis triggers eg: Infections, injuries to your skin, stress, smoking and intense sun exposure can all worsen psoriasis.

18. TREATMENT Treatment is based on surface areas of involvement, body site(s) affected, the presence or absence of arthritis, and the thickness of the plaques and scale. Psoriasis treatments reduce inflammation and clear the skin. Psoriasis treatment is divided into three main type Topical treatment Light therapy systemic medications

19. 1. TOPICAL AGENTS

20. Drugs Indication Topical corticosteroids (triamcinolone acetonide aqueous suspension 10 mg/mL diluted with normal saline is injected into the lesion) To treat mild to moderate psoriasis. It reduce inflammation and relieve itching and may be used with other treatments. Long-term use or overuse of strong corticosteroids can cause thinning of the skin. Improvement is usually achieved within 2 to 4 weeks. Vitamin D analogues. Calcipotriene (calcipotriol) These synthetic forms of vitamin D slow skin cell growth. Anthralin (Dritho-Scalp) This medication helps slow skin cell growth. It removes scales and make skin smoother Topical retinoids Tazarotene(zar, Zarotex) These are vitamin A derivatives that may decrease inflammation. The most common side effect is skin irritation. These medications may also increase sensitivity to sunlight

21. Calcineurin inhibitors Tacrolimus Pimecrolimus They inhibit activation of T- cells which inturn reduces inflammation and plaque build up. treatment of inverse and facial psoriasis Salicylic acid promotes sloughing of dead skin cells and reduces scaling. Coal tar coal tar reduces scaling, itching and inflammation. Coal tar can irritate the skin. Moisturizers Moisturizing creams alone won't heal psoriasis, but they can reduce itching, scaling and dryness. Moisturizers in an ointment base are usually more effective than are lighter creams and lotions. Apply immediately after a bath or shower to lock in moisture.

22. 2. Light therapy (phototherapy) This treatment uses natural or artificial ultraviolet light. The simplest and easiest form of phototherapy involves exposing your skin to controlled amounts of natural sunlight. Other forms of light therapy include the use of artificial ultraviolet A (UVA) or ultraviolet B (UVB) light, either alone or in combination with medications.

23. THERAPY INDICATION Sunlight Exposure to ultraviolet (UV) rays in sunlight or artificial light slows skin cell turnover and reduces scaling and inflammation. UVB phototherapy Controlled doses of UVB light from an artificial light source may improve mild to moderate psoriasis symptoms. Short-term side effects may include redness, itching and dry skin. Using a moisturizer may help decrease these side effects. Narrow band UVB phototherapy administered two or three times a week until the skin improves, and then maintenance may require only weekly sessions. Goeckerman therapy Combination of UVB treatment and coal tar treatment, which is known as Goeckerman treatment. The two therapies together are more effective than either alone because coal tar makes skin more receptive to UVB light.

24. Psoralen plus ultraviolet A (PUVA) This form of photochemotherapy involves taking a light-sensitizing medication (psoralen) before exposure to UVA light. UVA light penetrates deeper into the skin than does UVB light, and psoralen makes the skin more responsive to UVA exposure. side effects include nausea, headache, burning and itching. Excimer laser used for mild to moderate psoriasis, treats only the involved skin without harming healthy skin. A controlled beam of UVB light is directed to the psoriasis plaques to control scaling and inflammation. Side effects can include redness and blistering.

25. 3. SYSTEMIC THERAPY Retinoids  Related to vitamin A, this group of drugs may help if you have severe psoriasis that doesn't respond to other therapies. Side effects may include lip inflammation and hair loss. And because retinoids such as acitretin (Soriatane) can cause severe birth defects, women must avoid pregnancy for at least three years after taking the medication.

26. Cyclosporin A 100mg/ml Suspension & 100 mg capsules M.O.A: Binds cyclo-philin producing a complex that blocks calci- neurin, reducing the effect of the NF-AT in T cells, resulting in inhibition of interleukin 2 Dosage : High-dose method: 5 mg/kg daily, then tapered Low-dose method: 2.5 mg/kg daily, increased every 2-4 wk up to 5 mg/kg daily, then tapered Side Effects : Nephrotoxicity Hypertension Immuno-suppression Neurotoxicity, Increased risk of malignancy Contraindication: Prior bone marrow depression Pregnancy, Lactation, Renal abnormalities.

27. METHOTREXATE Dose: 2.5 mg tab & 50 mg/lm vial Action : Blocks dihydrofolate reductase leading to inhibition of purine and pyrimidine synthesis Leading to accumulation of anti-inflammatory adenosine Dosage : Start with a test dose of 2.5 mg and then gradually increase dose until a therapeutic level is achieved (average range, 10-15 mg weekly; maximum, 25- 30 mg weekly Side effect: Chronic use may lead to hepatic fibrosis, Fetal abnormalities or death Pulmonary fibrosis Contraindication : Liver toxicity Pregnancy

28. ACITRETIN Dose : Acitretin 25 mg cap Action : Binds to retinoic acid receptors. May contribute to improvement by normalizing keratinization and proliferation of the epidermis Dosage : Initiate at 25-50 mg daily Side effect : Hepatotoxicity, Lipid abnormalities, Fetal abnormalities or death , Alopecia C o n t r a i n d i c ati o n Severe infections Malignancy

29. Drugs that alter the immune system (biologics) etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), ustekinumab (Stelara), golimumab (Simponi), apremilast (Otezla), secukinumab (Cosentyx) and ixekizumab (Taltz). Most of these drugs are given by injection (apremilast is oral) and are usually used for people who have failed to respond to traditional therapy or who have associated psoriatic arthritis.

30. Alternative Medicine Aloe vera.  Taken from the leaves of the aloe vera plant, aloe extract cream may reduce redness, scaling, itching and inflammation. Fish oil.  Omega-3 fatty acids found in fish oil supplements may reduce inflammation associated with psoriasis, although results from studies are mixed. Taking 3 grams or less of fish oil daily is generally recognized as safe. Oregon grape.  Also known as barberry, topical applications of Oregon grape may reduce inflammation and ease psoriasis symptoms.

31. COMPLICATIONS Psoriatic arthritis: This  complication of psoriasis  can cause joint damage and a loss of function in some joints, which can be debilitating. Eye conditions. Obesity. Type 2 diabetes. High blood pressure. Cardiovascular disease. Metabolic syndrome. Other autoimmune diseases.

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