Drug Risk Factors for psoriasis Most evidence for worsening
• Beta-blockers
• Lithium
• Indomethacin (and other
NSAIDs) (but useful for psoriatic
arthritis)
• Tetracyclines
• Chloroquine (synthetic antimalarials
Drug Risk Factors for psoriasis less evidence for worsening
• Cardio: ACEI, amiodarone, clonidine, digoxin, quinidine,
CCBs
• Antibiotics: doxycycline, amox, ampicillin,
penicillin
• Psych: Fluoxetine, olanzapine,
benzodiazepines
• AEDs: CBZ, alpha interferon, VPA
• Others:
acetazolamide, cimetidine, gemfibrozil, GCSF, morphine, K iodide,
progesterone, imiquimod, salicylate (used for
topical tx)
if a lesion is flat and greater than 1 cm it is called a ....
plaque
if a lesion is raise and greater than 0.5 mm it is called a ....
papule
if a lesion is raised and less than 0.5mm and filled with puss it is called a ....
pustule
psoriasis is less common in skin folds, palms and soles.
facts
• well-demarcated,
irregular, erythematous, flat-topped, round-oval
plaques.
• adherent silvery scaling
• extensor surfaces, scalp, trunk, or buttocks.(location)
Plaque psoriasis
(aka intertriginous, aka flexural)
• erythematous plaques
• minimal scale
• skin folds (genital, perineal,
intergluteal, inframammary) or flexural surfaces (antecubital fossae, inguinal).
Inverse psoriasis
• generalized erythema
• varying degrees of scaling
• covering nearly the entire
body surface
erythrodermic psoriasis-THIS IS A MEDICAL EMERGENCY
treated very heavy handedly with anti inflammatorie
Pustular psoriasis-less common=puss involved
• Localized, monomorphic, sterile pustules on painful, inflammed
skin
• can be with or without plaque psoriasis
• Limited to
soles and palms = palmoplantar psoriasis
Guttate psoriasis. spots look like hyperpigments fine spots on back
• 1- to 10-mm (dew-drop like) pink papules
• fine scaling
• primarily on trunk and proximal
eczema and plaq psoriasis affect the same spots.
and use the same treatment=topical steroid
plaq psoriasis itchy but milder than atopic dermatitis
the difference is that atopic dermatitis(eczema) is dry/inflammed but no scaling.
history of asthma or allergic rhinitis is a precipitating factor
psoriasis is auto immune
more symetrical compared to tinea corporis (ring worm)
plaq psoriasis has multiple lesions usually, tinea has singular lesions.
mild psoriasis =<3-5% BSA , moderate =3-10% BSA
no involvement of hands, feet ,scalp, face, or genitals
note: sever=>10% involves most parts + genitals
treatment options for mild to moderate are?
topical treatments
sever= eligible for systemic treatments
kk has smooth erythematous lesions on his armpits and antecubital fossae classify his condition?
flexural psoriasis
does psoriasis involvement of other areas (e.g nails, joints)change treatment approach?
nail=no change
joints(psoriatic arthritis)= changes therapeutic options
Complications and Comorbidities
Think about screening for these other conditions
• Psoriatic arthritis
• Metabolic syndrome (obesity,
hypertension, dyslipidemia, insulin resistance)
• Psych:
depression, anxiety
• Cardiovascular disease
• Stroke
•
Inflammatory bowel diseases: Crohn's disease, ulcerative colitis
Measures of Disease
note: PASI has no MCID
Physician global assessment (aka total severity score)=has MCID
• Psoriasis area and severity index (PASI)
•
75% improvement in PASI (PASI-75) commonly used to measure
efficacy
• 0 (normal) to 72 (maximal disease)
• Rarely used
in clinical practice
• Includes
• Body
surface area
• Erythema
• Induration
• Scaling
Physician global assessment (aka total severity score)=has MCID
what are the 3 items of the PGA?
Eryethma
Induration
Scaling of major lesions
min=0 max=4
3 item PGA MCID= 0.5
Investigator assessment of global improvement Improvement from baseline
0-4
0= clear, no signs of psoriasis
4 = severe
psoriasis
Unknown MCID
patient outcome scales for psoriasis
SF-36- (0 worst-100 best)Physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health.
MCID: 2 points in the SF-36 PCS 3 points in the SF-36 MCS
Dermatology Quality of Life (10 items:0 no effect-30 extremely large effect) MCID: 2.2-6.9 (let’s call it about 5)
Patient global improvement-Improvement from baseline(0 clear-4 severe)
If 0-10 scale, then MCID = 3, < 2 ~ PASI-90
Therapeutic Options Topical Therapies
• Topical corticosteroids
• Topical vitamin D analogue
+/-
corticosteroid
• Topical tazarotene
+/-
corticosteroid
• Topical calcineurin inhibitors
+/-
salicylic acid
• Topical PUVA phototherapy
• Topical coal
tar
• Topical anthralin
Systemic Therapies for psoriasis
• Methotrexate
• Cyclosporine
• Acitretin
•
Fumarates
• Biologics
- TNF inhibitors (infliximab,
adalimumab,
certolizumab, etanercept)
- IL inhibitors
Anti-IL 12/23: Ustekinumab
Anti-IL 17: Secukinumab, ixekizumab,
brodalumab
• Anti-IL 23: Fuselkumab, Risankizumab, tildrakizumab
MC is a 23 year old female who presents with well-demarcated,
irregular, round-oval, flat topped lesions with silvery scale on her
forearms, hands, and legs affecting a total of ~7% BSA. Which of the
following is the most appropriate assessment?
a) Plaque
psoriasis, moderate
b) Plaque psoriasis, severe
c) Flexural
psoriasis, moderate
d) Flexural psoriasis, severe
b) Plaque psoriasis, severe
KK is a 59 year old male who presents with smooth, erythematous
lesions on his armpits and antecubital fossae. Which of the following
is the most appropriate assessment?
a) Plaque psoriasis
b)
Flexural psoriasis
c) Guttate psoriasis
d) Erythrodermic psoriasis
b) Flexural psoriasis
Approximately how many people out of 10 will experience improvement
in plaque symptoms with topical corticosteroids?
a) 1/10
b)
3/10
c) 7/10
d) 9/10
c) 7/10
Which of the following statements best describes the average
magnitude of improvement by potent topical corticosteroids according
to a 6-point scale investigator assessment of global improvement (IAGI
0-5)?
a) 1 point improvement
b) 3 point improvement
c)
5 point improvement
a) 1 point improvement
Which of the following statements are true regarding potent and
superpotent corticosteroids?
a) Superpotent corticosteroids are
about twice as effective than potent corticosteroids
b)
Superpotent corticosteroids are similarly effective than potent
corticosteroids
c) Superpotent corticosteroids are about 50% less
effective than potent corticosteroids
a) Superpotent corticosteroids are about twice as effective than potent corticosteroids
MC is a 23 year old female who presents with well-demarcated,
irregular,
round-oval, flat topped lesions with silvery scale on
her forearms, hands, and
legs affecting a total of ~7% BSA.
Which of the following is the most
appropriate first line
treatment?
a) Potent topical corticosteroid
b) Potent
topical corticosteroid + vitamin D analogue
c) Potent topical
corticosteroid + methotrexate
c) Potent topical corticosteroid + methotrexate
Which of the following is the most appropriate starting dose of
methotrexate?
a) Methotrexate 5 mg PO once daily
b)
Methotrexate 15 mg PO once daily
c) Methotrexate 5 mg PO once
weekly
d) Methotrexate 15 mg PO once weekly
d) Methotrexate 15 mg PO once weekly
Category of TCS based on ability to produce ............... (not clinical endpoint)
vasoconstriction
class 1 corticosteroids example creams (very potent steroids)
Clobetasol, Halobetasol, betamethasone dipropionate glycol, amcinonide
Class 2 and 3 Corticosteroids -aka Potent steroids
Betamethasone dipropionate, amcinonide (class 3 )
Desoximetasone 0.25%, fluocinonide (class 2)
Class 4 and 5 Corticosteroids= mid potency
Beclomethasone dipropionate, clobetasone, desoximetasone
0.05%,
mometasone, triamcinolone (class 4)
Class V Corticosteroids Betamethasone valerate 0.1%,
hydrocortisone valerate 0.2% (class 5)
Class VI and Class VII (Low potency)
Class VI Corticosteroids Desonide 0.05% (few studies included in
potent steroid category)
Low potency
Class VII
Corticosteroids Hydrocortisone 0.5-2.5%
Class I Corticosteroids aka very potent steroids are equivalent to a ........................on a 6-point IAGI scale
Equivalent to 1.8 on a
6-point IAGI scale
ex: Clobetasol, Halobetasol, betamethasone dipropionate glycol, amcinonide
potent steroids: class 2-5 steroids are equivalent to a .........on a 6-point IAGI scale
Equivalent to 1.0 on a 6-point IAGI scale
note: no direct head to head comparison of very potent and potent steroids
Once daily or twice daily dosing? Conflicting.
• Twice-daily application of the same intervention offers no
important
benefit over once-daily application for most treatments.
• Combination TCS + Vit D analogue BID application > once daily application
• BID IAGI improvement 1.44 (1.12-1.76)
• Once daily IAGI
improvement 1.21 (0.91-1.50)
The most common local skin adverse effects of topical corticosteroid use include?
burning,
itching,
skin atrophy,
striae,
folliculitis,
telangiectasia,
purpura
Areas of greater risk: Face, intertriginous areas,
chronically treated areas
(e.g. forearms), hands if gloves/hand
washing not adhered to
“The daily use of ultrahigh- and high-potency (class 1-3) corticosteroids for up to 4weeks is generally safe with minimal risk of skin atrophy”
• Otherwise only general comments.
TCS Systemic Adverse Effects
• Hypothalamic pituitary adrenal axis suppression
• Decreased morning cortisol: 0% with halobetasol or
fluocinonide, 0% to 48% with clobetasol propionate, and 0% to 18% with
betamethasone dipropionate
• ACTH stim test (gold standard test)
always normal, even after 6-12 months of TCS use
• Rare systemic adverse effects include Cushing syndrome and
osteonecrosis
of the femoral head
• Greatest risk for systemic adverse effects occurs when
ultrahigh- or high-potency corticosteroids are used over a large
surface (>20% body surface area [BSA]) or under occlusion for a
prolonged period (<4 weeks)
1.1 Methotrexate is recommended for the treatment of moderate to
severe psoriasis in adults. A
2.1 Apremilast is recommended for the treatment of moderate to
severe psoriasis in adults A
3.1 Cyclosporine is recommended for patients with severe,
recalcitrant psoriasis. A
4.1 Acitretin can be recommended as monotherapy for plaque
psoriasis B
A=strong recomendation
MTX Safety
•Fatigue, anorexia, nausea, stomatitis
-Change PO to SC or IM
-Divide single weekly dose TID over 24h
• Pneumonitis = change
•Biologics abt 70-80% achieve a PASI-75 what are common ADRs?
• URTIs, injection site reaction
• Precautions when using biologics for psoriasis
• TNF: infection history, malignancies, HF, demyelinating disease,
live
attenuated vaccines
• IL-17: Infection history, IBD,
live-attenuated vaccines
• IL -23: Infections, live-attenuated vaccines