Transcript Psoriasis
Psoriasis Psoriasis • • • • • • Definition and causes Types GP management Pitfalls Hospital treatments Case studies Psoriasis • Definition a chronic relapsing and remitting scaling skin disease which may appear at any age and affect any part of the skin • Prevalence 1.5-3% • Age onset 20-30y or 50-60y Psoriasis • Epidermal hyperproliferation • Vascular dilatation • Inflammatory infiltrate What causes psoriasis ? • T cell mediated autoimmune disease → increased keratinocyte proliferation • Environmental and genetic factors Psoriasis • Genetics 73% monozygotic twins concordant V 20% dizygotic twins if 1 parent affected →14/40% risk for offspring • Environmental triggers Types of psoriasis • • • • • • • Plaque Guttate Rupioid Unstable Pustular Erythrodermic ?palmo-plantar pustulosis Guttate psoriasis Pustular psoriasis Erythrodermic psoriasis Plantar pustulosis Acrodermatitis continua of Hallopeau GP Management • Time (for proper examination and to communicate with the patient) • Explanation • Information and support sources (patient.co.uk, psoriasisassociation.org.uk) • Follow-up GP Management • Emollients • Bath oils • Site-specific topical treatments Topical treatments • Vitamin D analogues Dovonex (calcipotriol) Dovobet (calcipotriol & betamethasone) Silkis (calcitriol) Curatorderm (tacalcitol) Zorac (tazarotene) • Dovonex cream and scalp application no longer available Topical treatments • Tar Carbo-dome Exorex Psoriderm Alphosyl HC Sebco Cocois Tar-based bath oils & shampoos Topical Treatments • Steroids Often in conjunction with Vit D analogue as Dovobet or separate steroid Eumovate Trimovate Scalp preparations (eumovate to dermovate strength) • BE CAREFUL (but not mean) Topical Treatments • Dithranol Dithrocream Micanol Psorin • Stains skin Has to be washed off Start and low strength and build up Topical treatments • Nails difficult potent topical steroids dovonex tazarotene systemic therapy Topical Treatments • Scalp Remove scale first Cocois or Sebco messy but effective Tar or salicylic acid shampoo Topical steroids if necessary for short periods Pitfalls • 'It's not working Doc' • It did work, but then he stopped using it and the psoriasis returned • It was too greasy/timeconsuming/smelly so he stopped using it • He wasn't applying it properly • It really didn't work Hospital Treatment • • • • • • • • Out-patient advice and support UVB PUVA Acitretin Methotrexate Ciclosporin Biologics Admission (tar, other topicals) UVB phototherapy • Suitability – age, PH skin cancer, medication, radiotherapy, photosensitive disease • X3 / week for ~6 weeks • Shield genitalia, uninvolved sites • SE burning (30%) • ↑ risk skin cancer (screen yearly if >150 treatments) PUVA • Suitability – as for UVB + CI in renal/hepatic disease, cataracts, pregnancy, children • X2 / week for ~6-8 weeks • Need eye protection for 24 h after psoralen • SE burning, nausea, itch ↑ risk skin cancer (screen yearly if >150 treatments) Systemic therapy acitretin methotrexate ciclosporin 7-20% of patients with psoriasis have arthritis Acitretin mec: affects keratinocyte differentiation CI: ? fertile women (as must avoid pregnancy for 2 years) SE: dry lips, teratogenicity, abnormal LFT, lipids, DISH Methotrexate mec: inhibits DNA synthesis by inhibiting dihydrofolate reductase → reduces proliferation of lymphocytes + keratinocytes CI: pregnancy, lactation, infection, liver/renal disease, peptic ulcers given once weekly SE: anorexia, nausea, myelosuppression, hepatotoxicity, mouth ulcers, pulmonary toxicity, oligospermia, skin cancer Interactions: NSAIDs, septrin, trimethoprim, penicillin, phenytoin Ciclosporin Mec Inhibits T cell activation CI uncontrolled HBP, malignancy, infection SE HBP, nephrotoxicity, skin cancer, other malignancy, gum hypertrophy Not recommended for long term treatment New Biologicals Anti TNF drugs infliximab etanercept Adalimumab Targeted T - cell therapy alefacept (binds CD2 & blocks LFA3) efalizumab (binds to LFA-1 & blocks ICAM-1) GP Issues • Know what your patient is on (?record as outside script on EMIS) • Know what monitoring you are responsible for • Keep a look out for myelosuppression • Don't be afraid of your local Derm department! Case Studies • Paul, age 45 • Carpet fitter • Large plaque psoriasis knees, elbows, natal cleft. Hand and nail involvement • Also has MS Case studies • Robert, age 35 • Psoriasis since teens • Lives in a hostel, alcoholic Case studies • Anne, age 15 • Recent onset guttate psoriasis • Wants skin to be clear for sister’s wedding Case studies • David, age 25 • Severe psoriasis • Has had multiple admissions, MTX, Ciclosporin, acitretin, UVB • Treatment so far has produced partial success only • Very keen to improve his skin as finds holding down a job very difficult