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Pharm 154* > Psoriasis > Flashcards

Psoriasis Flashcards

1
Q

How is skin with psoriasis different than healthy normal skin?

A

Psoriasis skin is hyperkeratotic, which means that the skin cells turn over very frequently. Every 3 days
In psoriasis, the skin may form armour in the form of silvery plaques
Normal skin turns over every 30 days

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2
Q

What is psoriasis?

A

A skin disease that causes red/silver, itchy, scaly patches.
It is most commonly found on the knees, elbows, trunk, and scalp
May occur in cycles with itching, discomfort, and sometimes pain
Two peaks of onset 20-30 and 50-60

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3
Q

What is the most common presentation of psoriasis?

A

Plaque formation
90% are of this type
It shows silver scaling on skin level

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4
Q

What are the percentages of severity for psoriasis?

A

Mild - less than 3% of the body
isolated patches on the knees, elbows, scalp, hands and feet

Moderate 3-10% of the body
appears on the arms, torso, scalp and other regions

Severe - more than 10% of the body
affects large areas of the skin
face and palms/soles considered as severe

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5
Q

How does psoriasis look like on black skin?

A

White/ or silver patches

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6
Q

What is the clinical presentation of psoriasis on the scalp?

A

Generally the same
Dry scaly, can be red and inflammatory

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7
Q

What are some characteristics of psoriasis on the scalp?

A

Lesions linger longer in this area due to skin thickness
Most difficult to treat
50-80% of patients have some degree of scalp involvement

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8
Q

What is the clinical presentation of psoriasis on the nails?

A

You will see pitting/pits on the nails
Silvery lesions possible

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9
Q

What are the less common forms of psoriasis?

A

Guttate
Pustular
Palmo-plantar
erythrodermic

We don’t treat these, we are out, beyond our scope

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10
Q

What is guttate psoriasis?

A

Less common form of psoriasis
Looks like hives, not hives because it doesn’t move

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11
Q

What is pustular psoriasis?

A

You see pus filled stuff
MD territory

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12
Q

What helps with psoriasis? What makes psoriasis worse?

A

Sunlight -> UV light therapy

Worsened by cold weather, stress, trauma

Lesions resolve without scarring

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13
Q

What is healing process for psoriasis?

A

Initially crusty, dry, and white scaling
Then, flat red patches
Finally, clear skin no condition

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14
Q

What are the causes of psoriasis?

A

Autoimmune (T-cell and TNF dysfxn)
Genetic and environmental factors (infection, trauma, some drugs)
12X the normal rate of skin cell production

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15
Q

What are the impacts of psoriasis on patients?

A

Can be physically debilitating
Social aspects
Risk factor for other diseases
Affects 1M Canadians

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16
Q

What are the tx options for psoriasis?

A

Topicals: steroid crm, moisturizers, rx retinoids, SA, coal tar
Systemic drugs:
Non biologics - methotrexate and cyclosporine
Biologics - sterlara and enbrel
Phototherapy: Narrowband UVB therapy
Broad UVB therapy
Excimer laser therapy
Psoralen +UVA (PUVA)

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17
Q

Rank the psoriasis treatments based on toxicity and effectiveness

A

Least effective and least toxic: Topical
moderate toxicity and moderate effectiveness: Photo
Most toxic and most effective: systemic

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18
Q

What are emollients?

A

They are standard dry skin products that are used between flare ups
Also known as steroid saving products
Trial-and-error in finding the best one

Central/essential to routine skin care

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19
Q

Are emollients used alone or with other products?

A

With other products such as in a combination treatment option

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20
Q

What type of dry skin products do we look for for patients with psoriasis?

A

Use the eczema grade products

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21
Q

How do emoillents work?

A

They create a barrier on the skin’s surface and coat it with oils, allowing the skin to rehydrate
Reduced dryness and irritation

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22
Q

What are Keratolytics?

A

They are agents that help by softening scales
They are very mild agents
They won’t take care of plaque

ex) Salicylic acid (OTC)

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23
Q

What is the function of a combo product with SA and a steroid? Are they OTC or Rx? Examples?

A

The SA increases the penetration of the steroid
These products are Rx.

Diprosalic, Nerisalic

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24
Q

What is tar shampoo good for? What are some of the side effects?

A

Mild cases of psoriasis on the scalp can be treated with OTC shampoos
They have anti-proliferative/ antimitotic properties
S/e: irritating, smell, folliculitis

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25
Q

What is the difference between coal tar and LCD (liquor carbonis detergens)?

A

Coal tar is the OG, leave on scalp for several minutes and use 2X per week; 1%
LCS is a dilutant of coal tar; 10%

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26
Q

What are the number one treatments for psoriasis?

A

Topical steroids and Vit D derivatives?

27
Q

Topical steroids:
Efficacy
benefit of 2 rx agents
combo with other agents
effect of dry skin lotions

A

Mainstay of therapy
only use it if the pt can afford it
Combined with dry skin lotions
Dry skin lotions decrease steroid use (steroid-sparring) and central to routine care - separate by 1 hour!

28
Q

True or false: mild potency topical steroids work for psoriasis

A

False, we need mid-potency to treat (unless for sensitive areas like the face or skin folds)

29
Q

What happens when we stop tx suddenly when using a topical steroid?

A

Pt might get a rebound flare up

there’s no evidence of tapering off, but should do it, lower or skip every second day

30
Q

What is the agent used to treat psoriasis on the face?

A

HC 1%

31
Q

True or false:
Medium and high-strength corticosteroids can be used long-term (for several months) on the face

A

False, avoid using for several months on the face

32
Q

What are the side effects of topical steroids?

A

Skin atrophy, Striae, and Telangiectasia (spider veins)
Rebound flare-ups on d/c (for the potent and strong agents)

33
Q

What are the guidelines for topical steroids?

A

No continuous use over 3 weeks
Apply thinly, don’t go crazy

34
Q

When does skin atrophy occur from steroid use?

A

When topical steroids are continuously applied to the skin even after the skin has returned to normal or normal thickness

35
Q

What additional risks are associated with using high potency agents?

A

Increased risk of cutaneous and systemic side effects

36
Q

How much skin does 1 FTU cover?

A

One palm on both sides

37
Q

How many FTU’s do you need to cover the entire chest + abdomen?

A

7 FTU’s

38
Q

What can be said about patients with moderate/severe psoriasis?

A

They are candidates from phototherapy or systemic therapy because the application of topical agents to large areas are not practical for most ppl

39
Q

What is the formulation preference for acute and chronic stage eczema? What about psoriasis?

A

Acute eczema - Lotion is better
Chronic eczema - ointments are better

Acute psoriasis - Lighter steroid (may seem like need stronger agent due to the silver and raised skin, but the skin barrier is weakened
Chronic psoriasis - stronger steroid as the skin is intact and need better penetration

40
Q

What is calcipotriol/ene?

A

It is a vitamin D analogue that is very popular for psoriasis tx
Drug of choice
Decreases skin turnover rate

effective for mild-moderate cases
not recommended for the face

41
Q

What are the max use guidelines for calcipotriol/ene?

A

100g crm
60ml scalp lotion

max weekly adult guidelines

42
Q

What are some examples of calipotriol/ene?

A

Dovonex - pure vit D
Dovobet - contains betamethasone (steroid)
Xamiol scalp gel (off the market)

43
Q

How many grams of topical medication is one FTU? Two FTUs?

A

1 FTU = 0.5 grams
2 FTUs = 1 gram

44
Q

What is special about xamiol scalp gel?

A

The manufacturer claimed that the combo drug is less irritating with minimal s/eat 52 weeks

It is the same as dovobet, but just off the market now

45
Q

What is said about using a vitamin D analogue such as dovonex and a vitamin supplement?

A

Some ppl say that you can’t use them together

ex) cholecalciferol and vitamin D - the drug interaction is that they may cause the blood calcium to increase; patient may feel dizzy, weakness, lethargy, muscle pain, headache, nausea, vomitting and seizures

46
Q

How will a doctor choose to treat scalp psoriasis?

A

A potent or very potent steroid is better than a D analogue alone
A d analogue combo is a bit better than using a steroid alone
- The combo features very low to placebo-like side effects

47
Q

What is special about clobetasol proprionate?

A

It is very expensive at 225$

48
Q

How can dovobet be formulated?

A

As a gel or as a gel contained in an applicator device
The device likely to compete with the generic version of this formulation

49
Q

What can we say about a patient using a vit d analogue with a steroid for a few months? Is this a concern?

A

This is a slight red flag, but really not because the manufacturer states that the product is safe for 1 year
However, the patient should d/c after the skin returns to normal (don’t use it permanently)

50
Q

What are the tips for scalp medications?

A

Try not to scratch the scalp
Relieve the itch by treating the psoriasis
Shampoo gently
Remove scale with care
Derms recommend using a scale softener
Try not to stress out

51
Q

How do retinoids work against psoriasis?

A

They utilize the retinoid receptor and decrease cell proliferation

52
Q

What type of psoriasis is tazorac (tazarotene) used for? What are some tips with using it?

A

mild to moderate cases
indicated for the face (because it is an ance med)
Concurrent use with a steroid is recommended - to decrease irritation
There is a pregnancy concern

53
Q

What is an example of a good tazarotene product?

A

Combo one

ex) Duobrii (halobetasol propionate + tazarotene)

54
Q

What is the expectations for improvement for Calciotriol/betamethasone dipropionate combo, Vit D analogue monotherapy, and retinoid therapy?

A

Calciotriol combo: 1 week
Vit D analogue (mono): 2 weeks
Retinoid therapy: 1-4 weeks

55
Q

What is anthralin?

A

It is a common medication for psoriasis in europe
Anti-mitotic
Not common in Canada
Quite ancient

56
Q

Explain phototherapy for psoriasis

A

historically, sent pt to mineral spas
Now, Narrow band UVB and PUVA rapidly decreases cell proliferation (UVB and UVA at certain spectrums)

57
Q

Explain narrow band UVB treatment

A

At a specific spectrum

Expose to UVB 2-3 times a week
More common over UVA due to less side effects
Can be done at home

58
Q

Explain PUVA treatment

A

PUVA is UVA and psoralen

Pt needs to go to a clinic for treatment
Requires photoactive agent oral or topical psoralen (accelerator)
Tx is v itchy and eyes can be sensitive, avoid sunlight the day after

59
Q

Is psoralen OTC or Rx in Canada?

A

Rx

60
Q

What are biologic agents?

A

They are anti-inflammatories for severe cases of psoriasis
Mostly injections and they are expensive

Serious side effects such as infections or cancers (attenuate on part of the skin, a cancer part gets activated), but safety record is growing

61
Q

What are two examples of biologic agents?

A

TNF-a and IL-23 antagonists

secukinumab (injectable), apremilast (pill)

62
Q

What is psoriatic arthritis?

A

Psoriasis and arthritis in patients
Affects 20% of psoriasis patients

Fingernails are often involved

63
Q

How do you treat psoriatic arthritis?

A

Methotrexate (anti-mitotic)
Cyclosporine (Anti-rejection med for transplants)
TNF-a blockers

64
Q

What do all of the psoriatic arthritis treatments have in common?

A

They are all serious agents with bad side effects

Biologics:
prescribed with moderate treatment not effective
can prevent further joint damage
target the parts of immune sys linked to PsA
improves pain in 3 mo and mood quickly

Pharm 154* (18 decks)

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