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PSORIASIS
Diagnosis and management
Dr.Md. Shshidul Islam
Assistant professor
Dermatology & VD, CBMC’B
OVERVIEW
5. Case studies
2
4. Managing psoriasis
3. Diagnosing psoriasis
2. Clinical presentation
1. Epidemiology and path...
WHAT IS PSORIASIS?
– Inflammatory and hyperplastic
disease of skin
– Characterised by erythema and
elevated scaly plaques
...
SYMPTOMS OF PSORIASIS
Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.
4
Most frequently
experienced symptoms
SOCIAL IMPACT OF PSORIASIS
40
48
57
0 10 20 30 40 50 60
Percentageofrespondents with severe psoriasis (n = 502)
Adapted fr...
PSORIASIS AFFECTS EMOTIONAL STATE 6
EPIDEMIOLOGY
• Common skin disorder
• Prevalence variable: ~ 0.3–2.5%
• Prevalence equal in males and females
• Estimated ...
AGE OF ONSET
• Mean age: ~ 23–37 years
• Current theory:
2 distinct peaks with possible genetic associations
– Early onset...
GENETIC INFLUENCE
• Evidence suggests strong genetic association
– Studies of monozygotic twins show concordance
for psori...
COMMON TRIGGER FACTORS FOR PSORIASIS
• Infections (e.g. streptococcal, viral)
• Skin trauma (Koebner phenomenon)
• Psychol...
PSORIASIS IS A T-CELL MEDIATED,
AUTOIMMUNE DISEASE1
Current hypothesis:
– Unknown skin antigens stimulate immune response
...
CLINICAL PRESENTATION:
CLASSIC PSORIASIS
– Well-defined and
sharply demarcated
– Round/oval-shaped
lesions
– Usually
symme...
COMMON SITES
AFFECTED BY PSORIASIS
• Can affect any part
of the body –
typically scalp,
elbow, knees and
sacrum
• Extent o...
TYPES OF PSORIASIS
• Chronic plaque
• Guttate
• Flexural
• Erythrodermic
• Pustular
– Localised and generalised
• Local fo...
CHRONIC PLAQUE PSORIASIS
– Most common type – affects
approximately 85%
– Features pink, well-defined
plaques with silvery...
CHRONIC PLAQUE PSORIASIS 16
CHRONIC PLAQUE PSORIASIS 17
CHRONIC PLAQUE PSORIASIS 18
CHRONIC PLAQUE PSORIASIS 19
GUTTATE PSORIASIS
– Numerous and small lesions
– ~ 1 cm diameter
– Pink with less scale than
plaque psoriasis
– Commonly f...
FLEXURAL PSORIASIS
– Lesions in skin folds
articularly groin,
gluteal cleft, axillae and
submammary regions
– Often minima...
ERYTHRODERMIC PSORIASIS
– Generalised erythema
covering entire skin surface
– May evolve slowly from
chronic plaque psoria...
PUSTULAR PSORIASIS
– Two forms:
• Localised form
• More common
• Presents as deep-seated
lesions with multiple small
pustu...
PALMOPLANTAR PSORIASIS
– Can be hyperkeratotic
or pustular
– May mimic dermatitis –
look for psoriatic
manifestations
else...
SCALP PSORIASIS
– Varies from minor
scaling with erythema
to thick hyperkeratotic
plaques
– May extend beyond
hairline
– P...
NAIL PSORIASIS
– May be present in patients with
any type of psoriasis
– Can take several forms:
• Pitting: discrete, well...
NAIL PSORIASIS 27
NAIL PSORIASIS 28
NAIL PSORIASIS 29
PSORIATIC ARTHRITIS
– Approximately 5–20%
have associated arthritis
– Five major patterns of
psoriatic arthritis:
• Distal...
DIAGNOSING PSORIASIS
• Other dermatological disorders
can resemble psoriasis
• Diagnosed clinically according to appearanc...
DIFFERENTIAL DIAGNOSIS
• Localised patches/plaques
– Tinea
– Eczema
– Superficial basal cell
carcinoma and Bowen’s
disease...
LOCALISED PATCHES/PLAQUES
Tinea corporis
• Affects body
• Lacks
symmetrical
lesions
• Presence of
peripheral scale
and ce...
LOCALISED PATCHES/PLAQUES
– Discoid eczema
• Individualised patches
more pruritic than
psoriasis
• Lack silvery scale
• Le...
LOCALISED PATCHES/PLAQUES
– Superficial basal
cellcarcinoma/Bowen’
s disease
• Asymmetrical lesions,
either single or few ...
LOCALISED PATCHES/PLAQUES
– Seborrhoeic dermatitis
• Characterised by yellowish
scaling and erythema
– Localised to many o...
LOCALISED PATCHES/PLAQUES
– Cutaneous T-cell lymphoma
(mycosis fungoides)
• Red, discoid lesions
• Asymmetrical and less s...
GUTTATE PSORIASIS
– Pityriasis rosea
• Difficult to distinguish from acute
guttate psoriasis
• Presents first as single la...
GUTTATE PSORIASIS
– Secondary syphilis
• Search for characteristic primary
syphilitic lesion, lymphadenopathy,
and lesions...
FLEXURAL PSORIASIS
– Tinea cruris
• Affects groin area
• Characterised by central clearing
with advancing edge
• Non-silve...
FLEXURAL PSORIASIS
– Atopic eczema
• Often associated with asthma
and hay fever
• Lacks classic psoriatic nail
involvement...
FLEXURAL PSORIASIS
– Candidiasis
• Characteristic
peripheral pustules and
scaling differ to
psoriasis
• Yeast cultures are...
PALMOPLANTAR PSORIASIS
– Tinea manum
• Ringworm of hands
• Fine powdery scale,
particularly involving
palms and palmar
cre...
PALMOPLANTAR PSORIASIS
– Hand and foot eczema
• Hyperkeratotic forms
difficult to distinguish
from psoriasis
• Biopsies ca...
PALMOPLANTAR PSORIASIS
– Pompholyx of palms
and soles (dishydrotic
eczema)
• Presents as clear vesicles
– contrast to
whit...
DETERMINING PSORIASIS SEVERITY
• Psoriasis Area and Severity Index (PASI)
– Score indicates severity of disease at a given...
MANAGING PSORIASIS
• Before starting treatment
– Establish relationship of trust with patient
– Provide patient with infor...
MANAGING PSORIASIS
• Determine clinical setting before
selecting treatment, considering
– Disease pattern, severity and ex...
MANAGING PSORIASIS
• Goals of management
– Tailor management to individual and address both
medical and psychological aspe...
TREATMENT OPTIONS FOR PSORIASIS
• Stepwise approach is advised
• Treatments include:
– General measures and topical therap...
TREATING PSORIASIS:
GENERAL MEASURES
• Reduce/eliminate potential trigger
factors:
– Stress
– Smoking
– Alcohol
– Trauma
–...
TOPICAL THERAPIES
• Approximately 70% of patients with
mild-to-moderate psoriasis can be managed
with topical therapies al...
TOPICAL THERAPIES:
EMOLLIENTS
• Include aqueous cream, sorbolene cream, white soft
paraffin and wool fats
• Regular use ca...
TOPICAL THERAPIES:
KERATOLYTICS
• Over-the-counter products include:
– Salicylic acid
– Urea
• Help dissolve keratin to so...
TOPICAL THERAPIES:
COAL TAR
• Help reduce inflammation and pruritus
• May induce longer remissions
• Use limited by distin...
TOPICAL THERAPIES:
DITHRANOL
• Anti-proliferative properties
• Particularly effective in thick plaque psoriasis
• Initiate...
TOPICAL THERAPIES:
TAZAROTENE
• Topical synthetic retinoid
• For treatment of chronic plaque psoriasis
• Applied once dail...
TOPICAL THERAPIES:
CORTICOSTEROIDS
• Possess anti-inflammatory, antiproliferative and
immunomodulatory properties
• Reduce...
TOPICAL THERAPIES:
CORTICOSTEROIDS
• Adverse effects associated
with long-term use include:
– Skin atrophy and telangiecta...
TOPICAL THERAPIES:
CALCIPOTRIOL (DAIVONEX®
)
• Synthetic vitamin D analogue
• For chronic plaque-type psoriasis
• Reverses...
TOPICAL THERAPIES:
CALCIPOTRIOL (DAIVONEX®
)
• Response may require 4–6 weeks
• Adverse effects include erythema and irrit...
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE OINTMENT (DAIVOBET®
)
• For plaque-type psoriasis
• Combination...
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE OINTMENT (DAIVOBET®
)
– Combination of calcipotriol and betamet...
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE OINTMENT (DAIVOBET®
)
• Once-daily treatment with the
potential...
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE GEL
• Newly TGA approved product not yet available in
Australia...
OTHER THERAPIES
• Phototherapy
• Systemic therapies
• Biological agents
66
PHOTOTHERAPY
• For psoriasis resistant to topical therapy and covering >
10% of body surface area
• Immunomodulatory and a...
SYSTEMIC THERAPIES
• Reserved for patients with widespread
or severe psoriasis
• Potentially serious adverse effects
and d...
SYSTEMIC THERAPIES:
METHOTREXATE
• Most commonly used systemic
treatment for psoriasis
• Slows epidermal cell proliferatio...
SYSTEMIC THERAPIES:
CYCLOSPORIN
• Immunosuppressive agent
• For patients with severe psoriasis
that is refractory to other...
SYSTEMIC THERAPIES:
ACITRETIN
• Oral retinoid
• For treatment of all forms of severe psoriasis
• Once-daily oral therapy
•...
BIOLOGICAL AGENTS
• Proteins derived from living organisms that
exert pharmacological actions
• For adults with moderate-t...
BIOLOGICAL AGENTS
• Target key parts of immune system
that drive psoriasis
• Biological agents include:
– Tumour necrosis ...
CASE STUDY 1
• ((insert image of condition))
• ((insert information under headings below))
• Presentation
• Clinical exami...
CASE STUDY 2
• ((insert image of presenting condition))
• ((insert information under headings below))
• Presentation
• Cli...
DIAGNOSIS AND MANAGEMENT OF
PSORIASIS: SUMMARY
• Chronic, inflammatory disease of skin
• T-cell mediated disorder
• Classi...
THANK
YOU
ALL
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  1. 1. PSORIASIS Diagnosis and management Dr.Md. Shshidul Islam Assistant professor Dermatology & VD, CBMC’B
  2. 2. OVERVIEW 5. Case studies 2 4. Managing psoriasis 3. Diagnosing psoriasis 2. Clinical presentation 1. Epidemiology and pathophysiology
  3. 3. WHAT IS PSORIASIS? – Inflammatory and hyperplastic disease of skin – Characterised by erythema and elevated scaly plaques – Chronic, relapsing condition – Course of disease often unpredictable . 3
  4. 4. SYMPTOMS OF PSORIASIS Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4. 4 Most frequently experienced symptoms
  5. 5. SOCIAL IMPACT OF PSORIASIS 40 48 57 0 10 20 30 40 50 60 Percentageofrespondents with severe psoriasis (n = 502) Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4. 5 Psoriasis mistaken for other disease Trouble receiving equal treatment in service establishments (e.g. hair salons, public pools) Psoriasis mistaken as contagious
  6. 6. PSORIASIS AFFECTS EMOTIONAL STATE 6
  7. 7. EPIDEMIOLOGY • Common skin disorder • Prevalence variable: ~ 0.3–2.5% • Prevalence equal in males and females • Estimated incidence: ~ 60 per 100,000 per year 7
  8. 8. AGE OF ONSET • Mean age: ~ 23–37 years • Current theory: 2 distinct peaks with possible genetic associations – Early onset (16–22 years) • More severe and extensive • More likely to have affected first-degree family member – Late onset (57–60 years) • Milder form • Affected first-degree family members nearly absent 8
  9. 9. GENETIC INFLUENCE • Evidence suggests strong genetic association – Studies of monozygotic twins show concordance for psoriasis (e.g. 64% in a Danish Study) – Multiple susceptibility loci have been identified • Disease expression – likely result of genetic and environmental factors 9
  10. 10. COMMON TRIGGER FACTORS FOR PSORIASIS • Infections (e.g. streptococcal, viral) • Skin trauma (Koebner phenomenon) • Psychological stress • Drugs (e.g. lithium, beta blockers) • Sunburn • Metabolic factors (e.g. calcium deficiency) • Hormonal factors (e.g. pregnancy) 10
  11. 11. PSORIASIS IS A T-CELL MEDIATED, AUTOIMMUNE DISEASE1 Current hypothesis: – Unknown skin antigens stimulate immune response • Antigen-specific memory T-cells are primary mediators • Leads to impaired differentiation and hyperproliferation of keratinocytes 11
  12. 12. CLINICAL PRESENTATION: CLASSIC PSORIASIS – Well-defined and sharply demarcated – Round/oval-shaped lesions – Usually symmetrical – Erythematous, raised plaques – Covered by white, silvery scales 12
  13. 13. COMMON SITES AFFECTED BY PSORIASIS • Can affect any part of the body – typically scalp, elbow, knees and sacrum • Extent of disease varies 1 13
  14. 14. TYPES OF PSORIASIS • Chronic plaque • Guttate • Flexural • Erythrodermic • Pustular – Localised and generalised • Local forms – Palmoplantar – Scalp – Nail (psoriatic onychodystrophy) 14
  15. 15. CHRONIC PLAQUE PSORIASIS – Most common type – affects approximately 85% – Features pink, well-defined plaques with silvery scale – Lesions may be single or numerous – Plaques may involve large areas of skin – Classically affects elbows, knees, buttocks and scalp 15
  16. 16. CHRONIC PLAQUE PSORIASIS 16
  17. 17. CHRONIC PLAQUE PSORIASIS 17
  18. 18. CHRONIC PLAQUE PSORIASIS 18
  19. 19. CHRONIC PLAQUE PSORIASIS 19
  20. 20. GUTTATE PSORIASIS – Numerous and small lesions – ~ 1 cm diameter – Pink with less scale than plaque psoriasis – Commonly found on trunk and proximal limbs – Typically seen in individuals < 30 years – Often preceded by an upper respiratory tract streptococcal infection 1. 20
  21. 21. FLEXURAL PSORIASIS – Lesions in skin folds articularly groin, gluteal cleft, axillae and submammary regions – Often minimal or absent scaling – May cause diagnostic difficulty when genital or perianal region is affected in isolation 1 21
  22. 22. ERYTHRODERMIC PSORIASIS – Generalised erythema covering entire skin surface – May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon – Patients may become febrile, hypo/hyperthermic and dehydrated – Complications include cardiac failure, infections, malabsorption and anaemia – Relatively uncommon 22
  23. 23. PUSTULAR PSORIASIS – Two forms: • Localised form • More common • Presents as deep-seated lesions with multiple small pustules on palms and soles • Generalised form • Uncommo Associated with fever and widespread pustules across the body • inflamed body surface 23
  24. 24. PALMOPLANTAR PSORIASIS – Can be hyperkeratotic or pustular – May mimic dermatitis – look for psoriatic manifestations elsewhere to aid diagnosis – Possibly aggravated by trauma 24
  25. 25. SCALP PSORIASIS – Varies from minor scaling with erythema to thick hyperkeratotic plaques – May extend beyond hairline – Patient scratching may produce asymmetric plaques 25
  26. 26. NAIL PSORIASIS – May be present in patients with any type of psoriasis – Can take several forms: • Pitting: discrete, well- circumscribed depressions on nail surface • Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate • Onycholysis: nail separates from nail bed at free edge • ‘Oil-drop sign’: pink/red colour change on nail surface 26
  27. 27. NAIL PSORIASIS 27
  28. 28. NAIL PSORIASIS 28
  29. 29. NAIL PSORIASIS 29
  30. 30. PSORIATIC ARTHRITIS – Approximately 5–20% have associated arthritis – Five major patterns of psoriatic arthritis: • Distal interphalangeal involvement • Symmetrical polyarthritis • Psoriatic spondylarthropathy • Arthritis mutilans • Oligoarticular, asymmetrical arthritis – Clinical expressions often overlap 30
  31. 31. DIAGNOSING PSORIASIS • Other dermatological disorders can resemble psoriasis • Diagnosed clinically according to appearance, distribution, history of lesions and family history • Important to consider non-cutaneous complications 31
  32. 32. DIFFERENTIAL DIAGNOSIS • Localised patches/plaques – Tinea – Eczema – Superficial basal cell carcinoma and Bowen’s disease – Seborrhoeic dermatitis – Cutaneous T-cell lymphoma (mycosis fungoides) • Guttate – Pityriasis rosea – Drug eruption – Secondary syphilis • Flexural – Tinea – Eczema – Candidiasis – Seborrhoeic dermatitis • Erythrodermic – Eczema – Cutaneous T-cell lymphoma – Pityriasis rubra pilaris – Lichen planus – Drug • Palmoplantar – Tinea 32
  33. 33. LOCALISED PATCHES/PLAQUES Tinea corporis • Affects body • Lacks symmetrical lesions • Presence of peripheral scale and central clearing . 33 Tinea coporis Psoriasis
  34. 34. LOCALISED PATCHES/PLAQUES – Discoid eczema • Individualised patches more pruritic than psoriasis • Lack silvery scale • Less vivid colour than psoriasis 1. 34 Discoid eczema Psoriasis
  35. 35. LOCALISED PATCHES/PLAQUES – Superficial basal cellcarcinoma/Bowen’ s disease • Asymmetrical lesions, either single or few in number • Perform biopsy if lesions resistant to topical psoriasis treatment, or to confirm diagnosis 35 Bowen’s disease Psoriasis
  36. 36. LOCALISED PATCHES/PLAQUES – Seborrhoeic dermatitis • Characterised by yellowish scaling and erythema – Localised to many of the same areas as psoriasis • Diffuse scaling differs from sharply defined psoriasis plaques • Affects furrows of face (facial psoriasis is generally restricted to hairline) 36 Dermatitis Psoriasis
  37. 37. LOCALISED PATCHES/PLAQUES – Cutaneous T-cell lymphoma (mycosis fungoides) • Red, discoid lesions • Asymmetrical and less scaly than psoriasis • Lesions may present with fine atrophy and be resistant to antipsoriatic therapy • Biopsy to confirm diagnosis 37 Mycosis fungoides Psoriasis
  38. 38. GUTTATE PSORIASIS – Pityriasis rosea • Difficult to distinguish from acute guttate psoriasis • Presents first as single large patch, progresses to a truncal rash of multiple red scaly plaques (‘Christmas tree’ distribution) • Resolves over 8–12 weeks 1 38 < Psoriasis ^ Pityriasis rosea
  39. 39. GUTTATE PSORIASIS – Secondary syphilis • Search for characteristic primary syphilitic lesion, lymphadenopathy, and lesions of face, palm and soles • Conduct serology and skin biopsies to confirm 1 39 < Psoriasis ^ Secondary syphilis
  40. 40. FLEXURAL PSORIASIS – Tinea cruris • Affects groin area • Characterised by central clearing with advancing edge • Non-silvery lesion with fine scale, particularly at periphery • Lesion frequently extends more on left side 1 40 < Psoriasis ^ Tinea cruris
  41. 41. FLEXURAL PSORIASIS – Atopic eczema • Often associated with asthma and hay fever • Lacks classic psoriatic nail involvement and sharply demarcated scaly plaques 1. 41 < Psoriasis ^ Atopic eczema
  42. 42. FLEXURAL PSORIASIS – Candidiasis • Characteristic peripheral pustules and scaling differ to psoriasis • Yeast cultures are diagnostic – Seborrhoeic dermatits 1 42 Flexural psoriasis
  43. 43. PALMOPLANTAR PSORIASIS – Tinea manum • Ringworm of hands • Fine powdery scale, particularly involving palms and palmar creases • Usually asymmetrical 1. 43 Tinea corporis Psoriasis
  44. 44. PALMOPLANTAR PSORIASIS – Hand and foot eczema • Hyperkeratotic forms difficult to distinguish from psoriasis • Biopsies can assist diagnosis • Look for history of atopy, a lack of psoriasis elsewhere on body, and evidence of eczema elsewhere on skin 44 Eczema Psoriasis
  45. 45. PALMOPLANTAR PSORIASIS – Pompholyx of palms and soles (dishydrotic eczema) • Presents as clear vesicles – contrast to white/yellow pustules in pustular psoriasis • Accompanied by intense pruritus 45 Eczema Psoriasis
  46. 46. DETERMINING PSORIASIS SEVERITY • Psoriasis Area and Severity Index (PASI) – Score indicates severity of disease at a given time – Single number that considers severity of lesions and extent of disease across four major body sites (head, trunk, upper limbs and lower limbs) – Score ranges from 0 (no disease) to 72 (maximal disease) 46
  47. 47. MANAGING PSORIASIS • Before starting treatment – Establish relationship of trust with patient – Provide patient with information • Emphasise benign nature of disease • Explain that psoriasis tends to be chronic and recurrent 47
  48. 48. MANAGING PSORIASIS • Determine clinical setting before selecting treatment, considering – Disease pattern, severity and extent – Sites of disease – Coexistent medical conditions – Patient’s perception of disease severity – Time commitments and treatment expense – Previous treatments for psoriasis 48
  49. 49. MANAGING PSORIASIS • Goals of management – Tailor management to individual and address both medical and psychological aspects – Improve quality of life – Achieve long-term remission and disease control – Minimise drug toxicity – Evaluate and monitor efficacy and suitability of individual treatments – Remain flexible and respond to changing needs 49
  50. 50. TREATMENT OPTIONS FOR PSORIASIS • Stepwise approach is advised • Treatments include: – General measures and topical therapy – Phototherapy – Systemic and biological therapies • Combination therapies : may reduce toxicity and improve outcomes 50
  51. 51. TREATING PSORIASIS: GENERAL MEASURES • Reduce/eliminate potential trigger factors: – Stress – Smoking – Alcohol – Trauma – Drugs – Infections 1 51
  52. 52. TOPICAL THERAPIES • Approximately 70% of patients with mild-to-moderate psoriasis can be managed with topical therapies alone • Tailor to needs of patient • Potency, delivery vehicle and patient motivation may affect compliance • Application may be time-consuming for patients 52
  53. 53. TOPICAL THERAPIES: EMOLLIENTS • Include aqueous cream, sorbolene cream, white soft paraffin and wool fats • Regular use can: – alleviate pruritus – reduce scale – enhance penetration of concomitant topical therapy – hydrate dry and cracked skin • Soap should be avoided . 53
  54. 54. TOPICAL THERAPIES: KERATOLYTICS • Over-the-counter products include: – Salicylic acid – Urea • Help dissolve keratin to soften and lift psoriasis scales • May enhance penetration of other actives 1 54
  55. 55. TOPICAL THERAPIES: COAL TAR • Help reduce inflammation and pruritus • May induce longer remissions • Use limited by distinctive smell and ability to stain clothing and skin • May cause local skin irritation 55
  56. 56. TOPICAL THERAPIES: DITHRANOL • Anti-proliferative properties • Particularly effective in thick plaque psoriasis • Initiate therapy at very low concentrations – can burn skin • Not suitable for face, flexures or genitals • Stains clothes permanently and skin temporarily 56
  57. 57. TOPICAL THERAPIES: TAZAROTENE • Topical synthetic retinoid • For treatment of chronic plaque psoriasis • Applied once daily in evening • Commonly causes local irritation 1 57
  58. 58. TOPICAL THERAPIES: CORTICOSTEROIDS • Possess anti-inflammatory, antiproliferative and immunomodulatory properties • Reduce superficial inflammation within plaques • Potency choice depends on disease severity, location and patient preference 1 58
  59. 59. TOPICAL THERAPIES: CORTICOSTEROIDS • Adverse effects associated with long-term use include: – Skin atrophy and telangiectasia – Hypopigmentation – Striae – Rapid relapse or rebound on stopping therapy – Precipitation of pustular psoriasis – Pituitary-adrenal axis suppression through significant systemic absorption (rare) 59
  60. 60. TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX® ) • Synthetic vitamin D analogue • For chronic plaque-type psoriasis • Reverses abnormal keratinocyte changes by: – Inducing differentiation – Suppressing proliferation of keratinocytes 60
  61. 61. TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX® ) • Response may require 4–6 weeks • Adverse effects include erythema and irritation 61
  62. 62. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET® ) • For plaque-type psoriasis • Combination of calcipotriol and a potent topical corticosteroid (betamethasone dipropionate) – Stable formulation for both actives • Provides rapid, effective psoriasis control 62
  63. 63. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET® ) – Combination of calcipotriol and betamethasone dipropionate in Daivobet is more effective than either active constituent used alone • 39.2% mean reduction in PASI score after 1 week . 63
  64. 64. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET® ) • Once-daily treatment with the potential to improve compliance • Can be used intermittently in 4-weekly cycles with Daivonex® used in between for maintenance • Most common adverse events include pruritus, rash and burning sensation 1 64
  65. 65. TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE GEL • Newly TGA approved product not yet available in Australia • Specially formulated for the scalp • Provides rapid, effective control of scalp psoriasis – More effective than treatment with individual actives alone – 53.2% (more than half) of patients had absent or very mild disease after just two weeks of gel application • Once-daily formulation may encourage compliance 65
  66. 66. OTHER THERAPIES • Phototherapy • Systemic therapies • Biological agents 66
  67. 67. PHOTOTHERAPY • For psoriasis resistant to topical therapy and covering > 10% of body surface area • Immunomodulatory and anti-inflammatory effects • Three main types of phototherapy: – Broadband UVB – Narrowband UVB – PUVA (administration of psoralen before UVA exposure) • Treatment usually administered 2–3 times/week 1 67
  68. 68. SYSTEMIC THERAPIES • Reserved for patients with widespread or severe psoriasis • Potentially serious adverse effects and drug interactions • Many require PBS authority prescription from dermatologist 68
  69. 69. SYSTEMIC THERAPIES: METHOTREXATE • Most commonly used systemic treatment for psoriasis • Slows epidermal cell proliferation and acts as immunosuppressant • Closely monitor kidney, liver and bone-marrow function • Perform PASI score before starting treatment 69
  70. 70. SYSTEMIC THERAPIES: CYCLOSPORIN • Immunosuppressive agent • For patients with severe psoriasis that is refractory to other treatments • Requires ongoing monitoring of blood elements, and renal and liver function 1 70
  71. 71. SYSTEMIC THERAPIES: ACITRETIN • Oral retinoid • For treatment of all forms of severe psoriasis • Once-daily oral therapy • Teratogenic – pregnancy must be avoided 71
  72. 72. BIOLOGICAL AGENTS • Proteins derived from living organisms that exert pharmacological actions • For adults with moderate-to-severe chronic plaque-type psoriasis who are candidates for phototherapy or systemic therapy • Most administered sub-cutaneously 72
  73. 73. BIOLOGICAL AGENTS • Target key parts of immune system that drive psoriasis • Biological agents include: – Tumour necrosis factor-alpha inhibitors • Etanercept • Adalimumab • Infliximab – Interleukin (IL-12 and IL-32) inhibitor • Ustekinumab 73
  74. 74. CASE STUDY 1 • ((insert image of condition)) • ((insert information under headings below)) • Presentation • Clinical examination • Diagnosis • Management • ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred)) 74
  75. 75. CASE STUDY 2 • ((insert image of presenting condition)) • ((insert information under headings below)) • Presentation • Clinical examination • Diagnosis • Management • ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred)) 75
  76. 76. DIAGNOSIS AND MANAGEMENT OF PSORIASIS: SUMMARY • Chronic, inflammatory disease of skin • T-cell mediated disorder • Classic presentation characterised by red, scaly plaques • Management should address both medical and psychological aspects • Treatments include topical therapy, phototherapy, systemic therapy and biological agents 76
  77. 77. THANK YOU ALL 77
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Psoriasis- Definition,Epidemiology,Clinicalfeatures,Deferential diagnosis and management .

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