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PSORIASIS
Diagnosis and management
OVERVIEW 2
5. Case studies
4. Managing psoriasis
3. Diagnosing psoriasis
2. Clinical presentation
1. Epidemiology and pathophysiology
WHAT IS PSORIASIS? 3
– Inflammatory and
hyperplastic disease of
skin1
– Characterised by
erythema and elevated
scaly plaques1
– Chronic, relapsing
condition
– Course of disease often
unpredictable
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
5
19
21
29
31
71
79
94
0 20 40 60 80 100
Other
Fatigue
Burning sensation
Bleeding
Tightness of skin
Skin redness
Itching
Scaling
Percentage of respondents (n = 17,425)
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
Percentage of respondents 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
PSORIASIS AFFECTS
EMOTIONAL STATE
54
75
81
88
0 20 40 60 80 100
Depression
Feelings of unattractiveness
Feelings of embarrassment
Concern that disease would worsen
Percentage of 18-to-34-year-old respondents with severe psoriasis (n not reported)
Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.
6
EPIDEMIOLOGY
• Common skin disorder
• Prevalence variable: ~ 0.3–2.5%1
• Prevalence equal in males and females2
• Estimated incidence: ~ 60 per 100,000 per year3
1. Plunkett A et al. Australas J Dermatol 1998; 39: 225–232. 2. Griffiths CEM et al. In: Burns T et al., eds. Rook’s textbook of dermatology.
8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Bell LM et al. Arch Dermatol 1991; 127: 1184–7.
7
AGE OF ONSET
• Mean age: ~ 23–37 years1
• Current theory:
2 distinct peaks with possible genetic associations1
– Early onset (16–22 years)2
• More severe and extensive
• More likely to have affected first-degree family member
– Late onset (57–60 years)2
• Milder form
• Affected first-degree family members nearly absent
1. Plunkett A et al. Australas J Dermatol 1998; 39: 225-232. 2. Henseler T et al. J Am Acad Dermatol 1985; 13:450-6.
8
GENETIC INFLUENCE
• Evidence suggests strong
genetic association
– Studies of monozygotic twins show concordance
for psoriasis (e.g. 64% in a Danish Study)1
– Multiple susceptibility loci have been identified2
• Disease expression – likely result of genetic and environmental factors2
1.Brandup F et al. Acta Dermato-Vernerol 1982; 62L: 229–36. 2. Barker J. Clin Exp Dermatol 2001; 26(4): 321–5.
9
COMMON TRIGGER FACTORS
FOR PSORIASIS1
• 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)
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
10
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
1. Lee M et al. Australas J Dermatol 2006; 47: 151–9.
11
CLINICAL PRESENTATION:
CLASSIC PSORIASIS 12
– Well-defined and sharply
demarcated1,2
– Round/oval-shaped
lesions1,3
– Usually symmetrical1,3
– Erythematous, raised
plaques1–3
– Covered by white, silvery
scales1–3
1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology.
2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
COMMON SITES
AFFECTED BY PSORIASIS 13
• Can affect any part
of the body –
typically scalp,
elbow, knees and
sacrum1
• Extent of disease
varies
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
TYPES OF PSORIASIS
• Chronic plaque
• Guttate
• Flexural
• Erythrodermic
• Pustular
– Localised and generalised
• Local forms
– Palmoplantar
– Scalp
– Nail (psoriatic
onychodystrophy)
14
1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed. Australian medicines
handbook. Adelaide: AMH, 2010.
CHRONIC PLAQUE PSORIASIS 15
– Most common type –
affects approximately
85%1
– Features pink, well-defined
plaques with silvery scale2
– Lesions may be single or
numerous2
– Plaques may involve large
areas of skin2
– Classically affects elbows,
knees, buttocks and scalp3
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –
dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
CHRONIC PLAQUE PSORIASIS 16
CHRONIC PLAQUE PSORIASIS 17
CHRONIC PLAQUE PSORIASIS 18
CHRONIC PLAQUE PSORIASIS 19
GUTTATE PSORIASIS 20
– Numerous and small
lesions – ~ 1 cm
diameter1,2,3
– Pink with less scale than
plaque psoriasis1
– Commonly found on trunk
and proximal limbs1,3
– Typically seen in
individuals < 30 years4
– Often preceded by an
upper respiratory tract
streptococcal infection1,2
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A
et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –
dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
FLEXURAL PSORIASIS 21
– Lesions in skin folds1
– Particularly groin, gluteal
cleft, axillae and
submammary regions
– Often minimal or absent
scaling1,2
– May cause diagnostic
difficulty when genital or
perianal region is affected
in isolation
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Schon
MP et al. N Engl J Med 2005; 352(18): 1899–912.
ERYTHRODERMIC PSORIASIS 22
– Generalised erythema
covering entire skin
surface1,2
– May evolve slowly from
chronic plaque psoriasis or
appear as eruptive
phenomenon1,3
– Patients may become
febrile, hypo/hyperthermic
and dehydrated3
– Complications include
cardiac failure, infections,
malabsorption and
anaemia1
– Relatively uncommon
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller
PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
PUSTULAR PSORIASIS 23
– Two forms:
• Localised form
• More common1,2
• Presents as deep-seated
lesions with multiple small
pustules on palms and
soles1,2
• Generalised form
• Uncommon3
• Associated with fever and
widespread pustules
across inflamed body
surface3
1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds. Rook’s
textbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.
PALMOPLANTAR PSORIASIS1 24
– Can be hyperkeratotic or
pustular
– May mimic dermatitis –
look for psoriatic
manifestations elsewhere
to aid diagnosis
– Possibly aggravated by
trauma
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
SCALP PSORIASIS 25
– Varies from minor scaling
with erythema to thick
hyperkeratotic plaques1,2
– May extend beyond
hairline1,2
– Patient scratching may
produce asymmetric
plaques2
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A
et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
NAIL PSORIASIS1 26
– 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
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
NAIL PSORIASIS
27
NAIL PSORIASIS 28
NAIL PSORIASIS 29
PSORIATIC ARTHRITIS 30
– Approximately 5–20%
have associated arthritis1
– Five major patterns of
psoriatic arthritis:2
• Distal interphalangeal
involvement
• Symmetrical polyarthritis
• Psoriatic
spondylarthropathy
• Arthritis mutilans
• Oligoarticular,
asymmetrical arthritis
– Clinical expressions
often overlap2
1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
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
complications1
1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney:
Australasian Medical Publishing Company, 2005.
31
DIFFERENTIAL DIAGNOSIS1,2
• 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
1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd ed.
Oxford: Health Press, 2004.
LOCALISED PATCHES/PLAQUES 33
– Tinea corporis1
• Affects body
• Lacks symmetrical
lesions
• Presence of peripheral
scale and central
clearing
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Tinea coporis Psoriasis
LOCALISED PATCHES/PLAQUES 34
– Discoid eczema1
• Individualised patches
more pruritic than
psoriasis
• Lack silvery scale
• Less vivid colour than
psoriasis
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Discoid eczema Psoriasis
LOCALISED PATCHES/PLAQUES 35
– Superficial basal cell
carcinoma/Bowen’s
disease1,2
• Asymmetrical lesions,
either single or few in
number
• Perform biopsy if
lesions resistant to
topical psoriasis
treatment, or to
confirm diagnosis
1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd
ed. Oxford: Health Press, 2004.
Bowen’s disease Psoriasis
LOCALISED PATCHES/PLAQUES 36
– Seborrhoeic dermatitis
• Characterised by yellowish
scaling and erythema1
– Localised to many of the same
areas as psoriasis
• Diffuse scaling differs from
sharply defined psoriasis
plaques2
• Affects furrows of face
(facial psoriasis is generally
restricted to hairline)1
1. Marks R et al. Dermatology within the pharmacy. Australia: Department of Dermatology, St
Vincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press,
2004.
Dermatitis
Psoriasis
LOCALISED PATCHES/PLAQUES 37
– Cutaneous T-cell lymphoma
(mycosis fungoides)
• Red, discoid lesions1
• Asymmetrical and less scaly
than psoriasis1
• Lesions may present with fine
atrophy and be resistant to
antipsoriatic therapy2
• Biopsy to confirm diagnosis
1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. Menter A
et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Mycosis fungoides
Psoriasis
GUTTATE PSORIASIS 38
– Pityriasis rosea1
• 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. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press,
2004.
< Psoriasis ^ Pityriasis rosea
GUTTATE PSORIASIS 39
– Secondary syphilis
• Search for characteristic
primary syphilitic lesion,
lymphadenopathy, and
lesions of face, palm and
soles1
• Conduct serology and skin
biopsies to confirm1,2
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health
Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd
ed. Melbourne: Blackwell Publishing, 2003.
< Psoriasis ^ Secondary syphilis
FLEXURAL PSORIASIS 40
– Tinea cruris1
• 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. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
< Psoriasis ^ Tinea cruris
FLEXURAL PSORIASIS 41
– Atopic eczema1,2
• Often associated with
asthma and hay fever
• Lacks classic psoriatic nail
involvement and sharply
demarcated scaly plaques
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor. 16 April 2010: 29–36.
< Psoriasis ^ Atopic eczema
FLEXURAL PSORIASIS 42
– Candidiasis1,2
• Characteristic peripheral
pustules and scaling differ
to psoriasis
• Yeast cultures are
diagnostic
– Seborrhoeic dermatitis2
1. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003.
2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Flexural psoriasis
PALMOPLANTAR PSORIASIS 43
– Tinea manum1
• Ringworm of hands
• Fine powdery scale,
particularly involving palms
and palmar creases
• Usually asymmetrical
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Tinea corporis
Psoriasis
PALMOPLANTAR PSORIASIS 44
– Hand and foot eczema
• Hyperkeratotic forms
difficult to distinguish from
psoriasis1,2
• Biopsies can assist
diagnosis1
• Look for history of atopy, a
lack of psoriasis elsewhere
on body, and evidence of
eczema elsewhere on skin1
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
2. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne:
Blackwell Publishing, 2003.
Eczema
Psoriasis
PALMOPLANTAR PSORIASIS 45
– Pompholyx of palms and
soles (dishydrotic
eczema)1
• Presents as clear vesicles
– contrast to white/yellow
pustules in pustular
psoriasis
• Accompanied by intense
pruritus
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
Eczema
Psoriasis
DETERMINING PSORIASIS SEVERITY
• Psoriasis Area and Severity Index (PASI)1
– 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)
1. Dubertret L. Psoriasis from clinic to therapy. France: Med’com, 2005.
46
MANAGING PSORIASIS
• Before starting treatment
– Establish relationship of trust with patient1
– Provide patient with information
• Emphasise benign nature of disease2,3
• Explain that psoriasis tends to be chronic and recurrent2,3
1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,
2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
47
MANAGING PSORIASIS
• Determine clinical setting before
selecting treatment, considering
– Disease pattern, severity and extent1,2
– Sites of disease2
– Coexistent medical conditions1
– Patient’s perception of disease severity1
– Time commitments and treatment expense1,2
– Previous treatments for psoriasis1
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
48
MANAGING PSORIASIS
• Goals of management
– Tailor management to individual and address both medical and
psychological aspects1–3
– Improve quality of life3
– Achieve long-term remission and disease control3
– Minimise drug toxicity3
– Evaluate and monitor efficacy and suitability of individual treatments3
– Remain flexible and respond to changing needs1–3
1.Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,
2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3.
Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.
49
TREATMENT OPTIONS FOR PSORIASIS
• Stepwise approach is advised1
• Treatments include:1,2,3
– General measures and topical therapy
– Phototherapy
– Systemic and biological therapies
• Combination therapies may
reduce toxicity and improve outcomes2
1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,
2005. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
50
TREATING PSORIASIS:
GENERAL MEASURES1,2
• Reduce/eliminate potential trigger factors:
– Stress
– Smoking
– Alcohol
– Trauma
– Drugs
– Infections
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
51
TOPICAL THERAPIES
• Approximately 70% of patients with
mild-to-moderate psoriasis can be managed
with topical therapies alone1
• Tailor to needs of patient2
• Potency, delivery vehicle and patient
motivation may affect compliance1
• Application may be time-consuming for patients1
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
52
TOPICAL THERAPIES:
EMOLLIENTS
• Include aqueous cream, sorbolene cream, white
soft paraffin and wool fats1
• Regular use can:
– alleviate pruritus2
– reduce scale2
– enhance penetration of concomitant topical therapy2
– hydrate dry and cracked skin3
• Soap should be avoided4
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et
al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Rossi S, ed. Australian medicines handbook. Adelaide: AMH, 2010. 4. Weller
PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
53
TOPICAL THERAPIES:
KERATOLYTICS
• Over-the-counter products include:1
– Salicylic acid
– Urea
• Help dissolve keratin to soften
and lift psoriasis scales1,2
• May enhance penetration of other actives1
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
54
TOPICAL THERAPIES:
COAL TAR
• Help reduce inflammation and pruritus1
• May induce longer remissions2
• Use limited by distinctive smell
and ability to stain clothing and skin1,2
• May cause local skin irritation2
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller
PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.
55
TOPICAL THERAPIES:
DITHRANOL
• Anti-proliferative properties1
• Particularly effective in thick plaque psoriasis1
• Initiate therapy at very low concentrations
– can burn skin2
• Not suitable for face, flexures or genitals1,3
• Stains clothes permanently
and skin temporarily1,2,3
1. Dermatology Expert Group. Therapeutic Guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et
al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R,ed. MJA practice essentials – dermatology. 2nd
ed. Sydney: Australasian Medical Publishing Company, 2005.
56
TOPICAL THERAPIES:
TAZAROTENE
• Topical synthetic retinoid1,2
• For treatment of chronic plaque psoriasis1,2
• Applied once daily in evening1,2
• Commonly causes local irritation1,2
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Zorac
Product Information, 30 March 2007.
57
TOPICAL THERAPIES:
CORTICOSTEROIDS
• Possess anti-inflammatory, antiproliferative and
immunomodulatory properties1,2
• Reduce superficial inflammation within plaques3
• Potency choice depends on disease severity,
location and patient preference2
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A
et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009.
58
TOPICAL THERAPIES:
CORTICOSTEROIDS
• Adverse effects associated
with long-term use include:1,2
– 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)
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
59
TOPICAL THERAPIES:
CALCIPOTRIOL (DAIVONEX®)
• Synthetic vitamin D analogue1
• For chronic plaque-type psoriasis1
• Reverses abnormal keratinocyte changes by:1
– Inducing differentiation
– Suppressing proliferation of keratinocytes
1. Daivonex Product Information, 23 September, 2006.
60
TOPICAL THERAPIES:
CALCIPOTRIOL (DAIVONEX®)
• Response may require 4–6 weeks1,2
• Adverse effects include erythema and irritation3
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Weller PA. Psoriasis. In: Marks R, ed.
MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Daivonex
Product Information, 23 September, 2006.
61
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE OINTMENT (DAIVOBET®)
• For plaque-type psoriasis1
• Combination of calcipotriol and a potent topical
corticosteroid (betamethasone dipropionate)1
– Stable formulation for both actives1
• Provides rapid, effective psoriasis control1,2
1. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.
62
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE OINTMENT (DAIVOBET®)
Adapted from Kaufmann R et al. Dermatology 2002; 205(4): 389–93.
63
– 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
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE OINTMENT (DAIVOBET®)
• Once-daily treatment with the
potential to improve compliance1,2
• Can be used intermittently in 4-weekly cycles with
Daivonex® used in between for maintenance1
• Most common adverse events include pruritus,
rash and burning sensation1
1. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.
64
TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE
DIPROPIONATE GEL
• Newly TGA approved product not yet available in
Australia
• Specially formulated for the scalp1
• Provides rapid, effective control of scalp
psoriasis1,2,3
– 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 application1
• Once-daily formulation may
encourage compliance2
1. Daivobet ®Gel Product Information, 14 July 2010. 2. van de Kerkhof et al. BJD 2008; 160: 170–6.
3. Jemec GBE et al. J Am Acad Dermatol 2008; 59:455-463.
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OTHER THERAPIES
• Phototherapy
• Systemic therapies
• Biological agents
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PHOTOTHERAPY
• For psoriasis resistant to topical therapy and
covering > 10% of body surface area1
• Immunomodulatory and anti-inflammatory effects2
• Three main types of phototherapy:2
– Broadband UVB
– Narrowband UVB
– PUVA (administration of psoralen before UVA exposure)
• Treatment usually administered 2–3 times/week1,2
1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.2. Dermatology Expert Group. Therapeutic guidelines:
dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
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SYSTEMIC THERAPIES
• Reserved for patients with widespread
or severe psoriasis1
• Potentially serious adverse effects
and drug interactions2
• Many require PBS authority
prescription from dermatologist3
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A
et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Department of Health and Ageing. Schedule of Pharmaceutical Benefits.
http://www.pbs.gov.au (accessed online 14 August 2010).
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SYSTEMIC THERAPIES:
METHOTREXATE
• Most commonly used systemic
treatment for psoriasis1
• Slows epidermal cell proliferation
and acts as immunosuppressant1
• Closely monitor kidney, liver and
bone-marrow function2
• Perform PASI score before starting treatment
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
2. Methoblastin Product Information, 11 August 2004.
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SYSTEMIC THERAPIES:
CYCLOSPORIN
• Immunosuppressive agent1
• For patients with severe psoriasis
that is refractory to other treatments2
• Requires ongoing monitoring of
blood elements, and renal and liver function2
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.
2. Neoral Product Information, 22 October 2009.
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SYSTEMIC THERAPIES:
ACITRETIN1
• Oral retinoid
• For treatment of all forms of severe psoriasis
• Once-daily oral therapy
• Teratogenic – pregnancy must be avoided
1. Neotigason Product Information, 18 March 2008.
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BIOLOGICAL AGENTS
• Proteins derived from living organisms that exert
pharmacological actions1
• For adults with moderate-to-severe chronic
plaque-type psoriasis who are candidates for
phototherapy or systemic therapy2–5
• Most administered sub-cutaneously2–5
1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Humira Product Information, 18 September 2009. 3. Stelara
Product Information, 15 July 2009. 4. Remicade Product Information, 17 September 2008. 5. Enbrel Product Information, 16 February 2010.
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BIOLOGICAL AGENTS
• Target key parts of immune system
that drive psoriasis1
• Biological agents include:2–5
– Tumour necrosis factor-alpha inhibitors
• Etanercept
• Adalimumab
• Infliximab
– Interleukin (IL-12 and IL-32) inhibitor
• Ustekinumab
1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009 2. Humira
Product Information, 18 September 2009. 3. Stelara Product Information, 15 July 2009. 4. Remicade Product Information, 17 September 2008.
5. Enbrel Product Information, 16 February 2010.
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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))
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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))
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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
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MINIMUM PRODUCT INFORMATION
Minimum Product Information: DAIVONEX® cream (50mcg/g calcipotriol), scalp solution (50mcg/mL calcipotriol). Indications: Topical
treatment of chronic stable plaque type psoriasis vulgaris in adults (cream). Psoriasis of the scalp in adults (scalp solution). Contraindications:
hypersensitivity; calcium metabolism disorders; ophthalmic use. Precautions: severe extensive psoriasis, generalised pustular psoriasis,
guttate psoriasis, erythrodermic exfoliative psoriasis; facial use; skin fold use; occlusion; excessive, prolonged use; use in children. Monitor
serum calcium and renal function prior to therapy and then three monthly; max weekly dose, see dosage. No experience with: continuous use
for greater than 1 year in adults, sunlight and UV light, impaired renal or hepatic function, pregnancy (category B1), lactation. Adverse Effects:
Local irritation, photosensitivity, pigmentation changes, hypercalcaemia (excessive use). Dosage and Administration: In adults, twice daily on
affected areas, reduce frequency according to response; maximum dosage 100g/week of cream or 60mL of scalp solution; total calcipotriol
should not exceed 5mg/week; reinstate on recurrence. Minimum Product Information: DAIVONEX® cream (50mcg/g calcipotriol), scalp
solution (50mcg/mL calcipotriol). Indications: Topical treatment of chronic stable plaque type psoriasis vulgaris in adults (cream). Psoriasis of
the scalp in adults (scalp solution). Contraindications: hypersensitivity; calcium metabolism disorders; ophthalmic use. Precautions: severe
extensive psoriasis, generalised pustular psoriasis, guttate psoriasis, erythrodermic exfoliative psoriasis; facial use; skin fold use; occlusion;
excessive, prolonged use; use in children. Monitor serum calcium and renal function prior to therapy and then three monthly; max weekly
dose, see dosage. No experience with: continuous use for greater than 1 year in adults, sunlight and UV light, impaired renal or hepatic
function, pregnancy (category B1), lactation. Adverse Effects: Local irritation, photosensitivity, pigmentation changes, hypercalcaemia
(excessive use). Dosage and Administration: In adults, twice daily on affected areas, reduce frequency according to response; maximum
dosage 100g/week of cream or 60mL of scalp solution; total calcipotriol should not exceed 5mg/week; reinstate on recurrence.
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DAIVONEX® PBS Information: 30g cream and 30mL scalp solution. Restricted benefit.
Treatment of chronic stable plaque-type psoriasis vulgaris. Refer to PBS Schedule for full information.
Please review Product Information before prescribing.
MINIMUM PRODUCT INFORMATION
Minimum Product Information: DAIVOBET® 50/500 Ointment. 50mcg/g calcipotriol / 500mcg/g betamethasone dipropionate. Indication:
Once daily topical treatment of plaque-type psoriasis vulgaris amenable to topical therapy. Contraindications: Allergic sensitisation to any
constituent of DAIVOBET® ointment; disorders of calcium metabolism; viral skin lesions, fungal / bacterial skin infections, parasitic infections,
skin manifestations related to tuberculosis or syphilis, perioral dermatitis, acne vulgaris, atrophic skin, striae atrophicae, fragile skin veins,
ichthyosis, acne rosacea, ulceration, wounds, perianal / genital pruritus; erythrodermic, exfoliative and pustular psoriasis; severe renal or
hepatic insufficiency; ophthalmic use. Precautions: For external use only; avoid application to scalp, face, mouth or eyes; treatment of >30% of
body surface area; monitor serum calcium and renal function; concurrent treatment with other steroids; application to large areas of damaged
skin, occlusive dressings, application to mucous membranes or in skin folds; avoid long term treatment of face and genitals; infected lesions;
generalised pustular psoriasis; sunlight / UV exposure; pregnancy category B1; lactation; children below 18 years of age; renal or hepatic
impairment; HPA axis suppression with excessive prolonged use of topical corticosteroids; risk of rebound when discontinuing long-term
corticosteroids. Recommended treatment period is 4 weeks under medical supervision, for up to 52 weeks. There is clinical trial experience
with intermittent 4 weekly cycles of DAIVOBET® ointment and calcipotriol alone used between treatment cycles. Adverse Effects: Pruritus,
rash, burning sensation, skin pain or irritation, dermatitis, erythema, exacerbation of psoriasis, folliculitis, application site pigment changes,
hypercalcaemia, hypercalciuria, photosensitivity, allergic and hypersensitivity reactions including very rare cases of angioedema and facial
oedema. Local reactions, especially during prolonged application include skin atroph elangiectasia, folliculitis, hypertrichosis, perioral
dermatitis, allergic contact dermatitis, depigmentation, colloid milia and generalised pustular psoriasis. Adrenocorticol suppression,
hypercalcaemia, cataract, infections and increase in intra-ocular pressure can occur, especially after long term treatment. Risk of rebound
when discontinuing long term treatment with corticosteroids. Dosage and Administration: Apply topically to the affected area once daily.
Maximum 15g ointment per day. Maximum 100g of ointment per week. Treated area should be no more than 30% body surface. Treatment
should be intermittent for up to 1 year; treatment should be limited to 4 week periods with calcipotriol used alone for 1 month between periods
of DAIVOBET® use as needed.
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DAIVOBET® PBS Information: Restricted benefit. Treatment of chronic stable
plaque-typepsoriasis vulgaris in a patient who is not adequately controlled with either
calcipotriol or potent topical corticosteroid monotherapy.
Please review Product Information before prescribing.
Product Information is available from CSL Biotherapies Pty Ltd ABN 66 120 398 067, 45 Poplar Road, Parkville, 3052. DAIVOBET® and
DAIVONEX® are registered trademarks of licensor, LEO Pharma, Ballerup, Denmark. DAIVOBET® and DAIVONEX® are distributed by
CSL Biotherapies Pty Ltd under licence from LEO Pharma. ® Thinking Australia is a registered trademark of CSL Limited, Australia. 8713.
Thank you
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