DERM 11: Psoriasis Flashcards
(107 cards)
1
Q
Describe the appearance of psoriasis. (3)
A
- well-demarcated
- symmetric
- erythematous plaques with overlying silvery scale
2
Q
What is the age epidemiology of psoriasis?
A
any age
- 75% before age 40
- peak onset at age 20-30, and 50-60
3
Q
What is the etiology of psoriasis?
A
genetic factors + environmental influences trigger T-lymphocyte-mediated immune response that forms initial skin lesions
4
Q
What is the pathophysiology of psoriasis?
A
- disorder of immune system (trigger +/-)
- inappropriate activation of T helper and dendritic cells that move into dermis and epidermis
- excess production of cytokines (TNF-alpha) by T cells and keratinocytes
- inflammation of skin and other organs
- widened blood vessels (angiogenesis)
- WBC and inflammatory cytokine accumulation
- abnormal + accelerated multiplication of keratinocytes – causes clinical presentation + other comorbidities
5
Q
What are the risk factors for psoriasis? (8)
A
- trauma – injury to skin
- stress
- season changes
- medications
- lifestyle – smoking, alcohol
- hereditary
- metabolism – obesity
- infections
6
Q
What medications are risk factors for psoriasis? (9)
A
- lithium
- antimalarials – chloroquine, hydroxychloroquine
- beta blockers – propranolol, atenolol
- antibiotics
- NSAIDs
- ACE inhibitors
- interferons
- terbinafine
- benzodiazepines
7
Q
What are the comorbidities of psoriasis? (5)
A
- psoriatic arthritis – most common
- CV disease and diabetes – metabolic syndrome, MI, stroke, T2DM
- GI
- malignancy – non-Hodgkin lymphoma, cutaneous T cell lymphoma, melanoma, non-melanoma
- psychiatric – depression, anxiety, etc.
8
Q
Describe the clinical presentation of psoriatic arthritis. (4)
A
- entire digit swollen
- affects small/large joints
- oligoarticular or polyarticular
- may affect axial skeleton (inflammatory back pain)
9
Q
Describe the relationship between psoriasis and psoriatic arthritis.
A
no correlation in the severity of each condition
10
Q
Describe the relationship between treatment for psoriasis and psoriatic arthritis.
A
- immunomodulating treatments for psoriasis are useful for psoriatic arthritis
- NSAIDs for joint symptoms may exacerbate psoriasis
11
Q
What are the phenotypic classifications of psoriasis? (5)
A
- plaque (psoriasis vulgaris)
- generalized pustular psoriasis
- guttate (post-infection)
- annular
- erythrodermic (medical emergency)
12
Q
Describe the characteristics of the lesions/plaques of plaque psoriasis (psoriasis vulgaris).
A
- well-demarcated
- symmetric
- erythematous
- red/violet + overlying silvery flaking scale (some bleeding)
- ≥ 0.5 cm diameter
- may be itchy or painful
- single lesions at predisposed W
13
Q
Describe the locations of the lesions/plaques of plaque psoriasis (psoriasis vulgaris).
A
- develop at sites of trauma or injury (Koebner phenomenon)
- flexural and/or intertriginous (inverse psoriasis)
- nail
- scalp
- palm and/or soles (palmar plantar psoriasis)
14
Q
What assessment methods are used to determine disease category? (2)
A
objective evaluation of extent and symptoms (BSA, PASI, PGA)
+
subjective evaluation of QOL impact (DLQI, SF-36 health survey)
15
Q
What is considered mild psoriasis?
A
< 3% of BSA
- isolated patches on knees, elbows, scalp, hands, feet
16
Q
What is considered moderate psoriasis?
A
3-10% of BSA
- arms, torso, scalp
17
Q
What is considered severe psoriasis?
A
> 10% of BSA
- large areas of skin
- face and palms/soles may be considered severe
18
Q
What assessments measure clinical outcomes? (3)
A
- body surface area (BSA)
- psoriasis area and severity index (PASI)
- physician global scale (PGA)
19
Q
What assessments measure QOL outcomes? (2)
A
- dermatology life quality index (DLQI)
- SF-36 (short form) health survey
20
Q
What non-skin related conditions should be considered in psoriasis treatment?
A
hepatic and/or renal dysfunction
21
Q
What are the two phases of psoriasis treatment?
A
- induction: first 6-24 weeks
- maintenance: beyond 24 weeks
22
Q
What is considered successful psoriasis therapy? (2)
A
- at 3 months (post-induction phase): BSA < 3% or ≥ 75% improvement of baseline BSA
- at 6 months (maintenance phase): BSA ≤ 1%
23
Q
What sunscreen SPF is recommended as a non-pharmacological measure?
A
SPF 30+
24
Q
Describe the therapeutic algorithm for mild to moderate psoriasis.
A
start with topical agent
- if inadequate/ineffective: topical + phototherapy
- if inadequate/ineffective again: topical + systemic
always use moisturizers, continue therapy if controlled, step down to lowest doses/potencies that maintain control
25
Describe the therapeutic algorithm for moderate to severe psoriasis.
start with systemic agent (ie. methotrexate) +/- topical or phototherapy
note: consider biologic if comorbidities (ie. PsA)
- if inadequate/ineffective: more potent systemic or biologic (or less commonly 2+ systemics rotating) +/- topical
- if inadequate/ineffective again: biologic (if not already used) +/- other agents
always use moisturizers, continue therapy if controlled, step down to lowest doses/potencies that maintain control
26
What topical agents are used to treat psoriasis? (7)
- topical corticosteroids
- vitamin D analogues – calcitriol, calcipotriol
- retinoids – tazarotene
- calcineurin inhibitors – tacrolimus, pimecrolimus
- anthralin
- salicylic acid
- coal tar
27
What is a fingertip unit (FTU)?
- 1 FTU = 500 mg = 2% BSA = hand (front and back)
- 15 FTU = 7500 mg = 30% BSA = trunk (front and back)
28
Topical Corticosteroids
What is the duration of treatment?
- limit to BID for 4 weeks, can be up to 12 weeks
- > 12 weeks under physician supervision
29
Topical Corticosteroids
How is treatment tapered?
- reduce to every other day → 2x per week → discontinue if possible
- can combine with corticosteroid-sparing agents to help taper
30
Topical Corticosteroids
What are the side effects?
- topical: skin atrophy, striae, folliculitis, telangiectasia, purpura
- systemic: HPA axis suppression
- tachyphylaxis (loss of effectiveness)
31
Vitamin D Analogues – Calcitriol, Calcipotriol
What is it used for? (4)
- first-line topical for mild plaque psoriasis
- first-line topical for moderately severe scalp psoriasis
- first-line for nail psoriasis in combination with corticosteroid
- used for facial psoriasis in combination with hydrocortisone
32
Vitamin D Analogues – Calcitriol, Calcipotriol
How should vitamin D analogues and corticosteroid combination therapy be spread apart?
for 3-52 weeks:
- vitamin D analogue: BID on weekdays
- corticosteroids (high potency): BID on weekends
33
Vitamin D Analogues – Calcitriol, Calcipotriol
What can decrease concentration on skin?
UVA
- apply after photography to avoid inactivation by UVA and blocking UVB radiation
34
Vitamin D Analogues – Calcitriol, Calcipotriol
What are the side effects?
- topical: (improves with use) burning, pruritis, edema, peeling, dryness, erythema
- systemic: hypercalcemia (rare)
35
Retinoids – Tazarotene
What is it used for?
2nd-line for palmar-plantar psoriasis and nail psoriasis
- tazarotene 0.1% cream + clobetasol 0.05% cream under occlusion for 12 weeks
36
Retinoids – Tazarotene
What is the treatment duration?
8-12 weeks for mild to moderate psoriasis
- 50% improvement at 12 weeks
37
Retinoids – Tazarotene
How does combination therapy with topical corticosteroids affect outcome of therapy?
- increase efficacy
- decrease irritation
38
Retinoids – Tazarotene
How does combination therapy with NB-UVB affect outcome of therapy?
- increase efficacy by reducing UV radiation needed
39
Retinoids – Tazarotene
What are the side effects?
- topical: erythema, burning, pruritis (high concentration) – use cream, or lower concentration, or combination with clobetasol
40
Retinoids – Tazarotene
Is it safe for pregnancy?
avoid (teratogenic)
41
Anthralin (Dithranol)
What is the dose and duration of treatment?
SCAT: short acting anthralin therapy
- start at 0.1%
- short contact: 5-10 min of cream during first week
- gradually increase to 30 min or as tolerated
- can be used up to 2 hr once daily
42
Anthralin (Dithranol)
What are the side effects?
- topical: skin irritation and staining
43
Salicylic Acid
What is it used for?
- in combination with other Rx for scalp psoriasis
- in combination with other Rx for plaque psoriasis
- in combination with topical corticosteroid enhances steroid penetration
44
Salicylic Acid
What should it not be used with?
- inactivates calcipotriol
- UVB phototherapy decreases efficacy – apply after
45
Salicylic Acid
What are the side effects?
- topical: skin irritation if left for too long, weakens/breaks hair shafts, temporary hair loss
- systemic: salicylate toxicity in renal or hepatic disease with high BSA (> 20%)
46
Salicylic Acid
Is it safe for children?
avoid
47
Coal Tar
What does it do?
relieves itching, scaling, flaking, redness, irritation – but limited efficacy
48
Coal Tar
What are the directions for use?
- scalp: apply 3-12 before shampooing
- body: apply hs
49
Coal Tar
What are the side effects?
- topical: irritate, redden, dry skin, folliculitis, acne, sunlight sensitivity (use sunscreen)
- systemic: cancer at very high concentrations
- stains clothing and light hair
- unpleasant odour
50
Calcineurin Inhibitors – Tacrolimus, Pimecrolimus
What is the indication for use?
off-label use in psoriasis
- for facial and intertriginous/inverse psoriasis (thinner skins)
51
Calcineurin Inhibitors – Tacrolimus, Pimecrolimus
What is it used in combination with?
tacrolimus + salicylic acid 6% for 12 weeks
- plaque psoriasis steroid-sparing agents for prolonged use (> 4 weeks)
52
Calcineurin Inhibitors – Tacrolimus, Pimecrolimus
What are the side effects?
- topical: burning, pruritus
- systemic: (theoretical) – ↑ risk of lymphoma
- avoid moist skin and continued use
53
Scalp Psoriasis
What is the topical treatment (products + duration)?
Products: corticosteroids +/- vitamin D analogues
- gel, solution, foams
- coal tar and/or salicylic acid for mild scalp psoriasis prior to Rx application can increase penetration
Duration: minimum 4 weeks
54
Nail Psoriasis
What is the topical treatment (products + duration)?
Products
- corticosteroid
- topical vitamin D analogues + betamethasone dipropionate
- tazarotene 0.1% cream + clobetasol 0.05% cream
Duration: 12 weeks (not >) for under occlusion
55
Facial Psoriasis
What is the topical treatment (products + duration)?
Products
- off-label use of 0.1% tacrolimus
- hydrocortisone 1% cream
Duration: up to 8 weeks, long-term can be considered
56
Intertriginous Psoriasis
What is the topical treatment (products + duration)?
Products
- off-label use of 0.1% tacrolimus
- hydrocortisone 1% cream
Duration: up to 8 weeks, long-term can be considered
57
Plaque Psoriasis
What is the topical treatment (products + duration)?
Products
- vitamin D derivatives
- tazarotene
- coal tar
- anthralin
- any of the above in combination with corticosteroids and other topicals
Duration: up to 4 weeks
58
Palmar Psoriasis
What is the topical treatment (products + duration)?
Products
- medium to very high potency corticosteroids
- vitamin D analogues
- topical tazarotene – especially useful
- coal tar or salicylic acid under occlusion
Duration: 4-8 weeks
59
Phototherapy
What is it used for?
moderate to severe psoriasis
- especially if unresponsive to topicals
60
Phototherapy
What is UVA therapy?
given with photosensitizer (oral psoralens) to enhance efficacy
- aka PUVA photochemotherapy with oral methoxypsoralen and UVA light
- NOT in pregnancy
61
Phototherapy
What is UVB therapy?
given as photochemotherapy with topicals (coal tar, anthralin)
- broadband or narrowband (first-line)
- CAN use in children, pregnancy
62
Phototherapy
What is the frequency of treatment?
3 times per week for 3 months initially
63
Phototherapy
Compare the efficacy of different types of treatment.
PUVA > NB-UVB > BB-UVB
64
Phototherapy
What are emollients?
prevent evaporation from deep layers of skin
- apply topically 1-3 times per day
65
Phototherapy
What are the side effects?
- erythema, pruritus, xerosis, blistering, hyperpigmentation (especially higher doses)
- PUVA: squamous cell carcinoma is dose-related, oral psoralen may cause nausea, vomiting, headache, sensitivity to UV light
66
Phototherapy
What are the contraindications?
- history of melanoma or non-melanoma skin cancers
- using tetracyclines
67
What non-biologic systemic agents are used to treat psoriasis? (5)
- acitretin
- cyclosporine
- methotrexate
- apremilast
- deucravacitinib
68
Systemic: Non-Biologic
What is the recommended therapy for moderate to severe psoriasis?
topical calcipotriene + methotrexate
- lower cumulative dose of methotrexate and increased time in remission after methotrexate is discontinued
69
Acitretin (Soriatane)
What is it used for?
- mostly adjunct – enhance efficacy, lower doses, reduce side effects
- severe psoriasis (adults)
- in combination with topical calcipotriol or phototherapy
70
Acitretin (Soriatane)
What is the dose?
25-50 mg/day
- lower doses may be used
71
Acitretin (Soriatane)
What are the side effects?
hypervitaminosis A, hyperlipidemia, hepatotoxicity, GI intolerance
- mucocutaneous dryness of eyes, nasal and oral mucosa, chapped lips, cheilitis, epistaxis, xerosis, brittle nails, burning and sticky skin
- ophthalmologic – photosensitivity, decreased colour vision, impaired night vision
- hepatitis, jaundice
72
Acitretin (Soriatane)
What are the contraindications? (3)
- stop 3 years before pregnancy
- no blood donations during or 1 year after use
- avoid alcohol during and 2 months after
73
Methotrexate
What is it used for?
severe, recalcitrant, disabling psoriasis – if unresponsive to other therapies
74
Methotrexate
What is the dose?
7.5-25 mg once weekly
- increase by 2.5 mg every 2-4 weeks until response (do not exceed 30 mg weekly)
75
Methotrexate
What are the side effects?
myelosuppression, hepatotoxicity, nausea, vomiting, stomatitis, malaise, headaches, pulmonary toxicity
76
Methotrexate
What are the contraindications? (2)
- stop at least 3 months before pregnancy
- avoid if breastfeeding
77
Cyclosporine (Neoral)
What is it used for?
- severe, recalcitrant plaque psoriasis (non-immunocompromised adults) if unresponsive to other systemic therapies
- PsA
- other (pustular, nail)
78
Cyclosporine (Neoral)
What is the dose?
2.5-4 mg/kg/day in two divided dose
- dose may be reduced
79
Cyclosporine (Neoral)
What are the side effects?
hypertension, elevated lipids, GI intolerance, headache, gingival hyperplasia, hair growth
- cumulative renal toxicityt
80
Cyclosporine (Neoral)
What are the contraindications?
- long-term therapy not recommended due to risk of malignancy (SCC, non-melanoma)
- no live vaccines
- significant drug interactions with Ca2+ channel blockers, diuretics, macrolide antibiotics, SSRIs, antifungals, grapefruit juice
81
Apremilast (Otezla)
What is it used for?
- plamar-plantar psoriasis
- scalp psoriasis
- PsA
- moderate to severe plaque psoriasis if candidate for phototherapy or systemic therapy
82
Apremilast (Otezla)
What is the dose?
- day 1: 10mg AM
- day 2: 10mg BID
- day 3: 10mg/20mg
- day 4: 20mg/20mg
- day 5: 20mg/30mg
- 30mg BID after
83
Apremilast (Otezla)
What are the side effects?
diarrhea, nausea, headaches, upper respiratory tract infection, weight loss, depression
84
Apremilast (Otezla)
What are the contraindications? (2)
- stop > 2 days before pregnancy
- avoid while breastfeeding
85
What biologic systemic agents are used to treat psoriasis? (5)
TNF Alpha Inhibitors:
- etanercept (Enbrel): PsO (plaque psoriasis), PsA (psoriatic arthritis)
- adalimumab (Humira): PsO, PsA
- infliximab (Remicade): PsO, PsA
inhibitors of IL-17 pathway:
- secukinumab (Cosentyx): PsO, PsA
inhibitors of IL-12/23 pathway and cytokines:
- ustekinumab (Stelara): PsO, PsA
86
Systemic: Biologic
What is it used for?
- moderate to severe psoriasis
- when other therapies are inadequate or contraindicated
- in combination with traditional systemic therapy for PsA
87
Systemic: Biologic
What is it contraindicated in?
- active, serious infections
- screen for TB and hepatitis
- avoid live vaccines
88
Systemic: Biologic
Compare the efficacy of the different biologics.
infliximab > ustekinumab > adalimumab > etanercept
89
Systemic: Biologic
How long does it take to see effects?
up to 12 weeks, depending on the product
90
TNF-Alpha Inhibitors
What is it used for?
- psoriasis
- PsA
- other inflammatory conditions
91
TNF-Alpha Inhibitors
What are the safety points?
- TB lowest with etanercept, and highest with infliximab
- infliximab associated with hepatosplenic T-cell lymphomas (rare but fatal), cholecystitis, and autoimmune hepatitis
92
TNF-Alpha Inhibitors
What are the side effects?
- infection: URTI, TB reactivation, sepsis, opportunistic infections
- worsening autoimmune disease: MS or drug-induced lupus-like syndromes
- malignancies: lymphoma
- worsening CHF (NYHA III/IV)
93
TNF-Alpha Inhibitors
What is it contraindicated in?
- active TB
- live vaccines
94
Ustekinumab
What is it used for?
effective in difficult-to-treat areas
- hand and foot (palmar-plantar plaque or pustular)
- nail psoriasis
- scalp psoriasis
95
Ustekinumab
What are the side effects?
- upper respiratory infection, headache, fatigue, pruritis, back pain, injection site reactions, arthralgia, nasopharyngitis
- severe: fungal, tubercular, viral infections and cancers
96
Secukinumab
What are the side effects?
nasopharyngitis, URTI, headache, diarrhea
97
What is the treatment algorithm for healthy adult men with chronic plaque psoriasis (> 5% of BSA) and no PsA?
topical:
- corticosteroid
- calcipotriol
- calcipotriol-steroid combination
if UV therapy available:
- UVB phototherapy (NB or BB) alone
- UVB phototherapy + acitretin
- PUVA
- UVB phototherapy + methotrexate
if UV therapy not available:
- first-line is non-biologic: acitretin, methotrexate, apremilast, cyclosporine
- biologic: etanercept, adalimumab, infliximab, secukinumab, ustekinumab
second-line:
- acitretin + biologic
- methotrexate + biologic
- UVB + biologic
98
What are the main combination therapies? (5)
- TCS + vitamin D3 analogue
- retinoids + phototherapy
- cyclosporine + calcipotriol/betamethasone dipropionate
- methotrexate + UVB
- methotrexate + UVA
99
Combination Therapy
Describe the efficacy of TCS + vitamin D3 analogue.
- effective and safe – may be steroid-sparing
- less skin irritation than monotherapy
- effective for severe psoriasis
100
Combination Therapy
Describe the efficacy of retinoids + phototherapy.
- significant enhancement in UVB efficacy and fewer treatment sessions (but retinoids can increase photosensitivity)
- UVB doses may need reduction to prevent burning
- acitretin with UVB or PUVA shows better efficacy than monotherapy
101
Combination Therapy
Describe the efficacy of cyclosporine + calcipotriol/betamethasone dipropionate.
- superior to cyclosporine alone
- should not be used with PUVA due to reduced efficacy and cancer risk
102
Combination Therapy
Describe the efficacy of methotrexate + UVB.
- synergistic effect in combination
103
Combination Therapy
Describe the efficacy of methotrexate + UVA.
- methotrexate used effectively with biologics (etanercept, infliximab, adalimumab, ustekinumab)
- methotrexate with biologics ↓ formation of anti-biologic antibodies and ↑ biologic trough levels
104
What is the standard treatment for psoriasis in children?
topical
- first-line: calcipotriol (vitamin D3 analogue with corticosteroid-sparing function) +/- TCS – minimal S/E
- topical calcineurin inhibitors recommended as first-line for psoriasis of face, genitalia, body folds
105
What is the treatment for moderate to severe psoriasis in children?
systemic
- methotrexate
- etanercept
- adalimumab
- infliximab
- ustekinumab
106
What is the mainstay treatment for psoriasis in pregnancy?
topical corticosteroids – low to moderate potency preferred
107
What treatments are contraindicated in pregnancy? (3)
- salicylic acid – avoid during breastfeeding
- anthralin and coal tar – potential options for 2nd and 3rd trimester
- TNF-alpha (certolizumab pegol) – minimal to no placental transfer during 3rd trimester
