Psoriasis Therapeutics Part 2

Question 1

name the topical retinoid used is psoriasis

Answer 1

tazarotene

Question 2

how does tazarotene work in psoriasis

Answer 2

decreases inflammation and regulates the differentiation of keratinocytes

Question 3

role in therapy for tazarotene in psoriasis

Answer 3

SECOND LINE

alternative to topical CS/vitamin D analog

Question 4

true or false

tazarotene is teratogenic

Answer 4

TRUE

pregnancy category X

Question 5

in which vehicles does tazarotene come and which is preferred

Answer 5

cream and gel

cream is preferred because it is moisturizing

gel is very drying

Question 6

how often is tazarotene applied and when

Answer 6

once daily in PM to completely dry skin

start at 0.05% and may increase to 0.1% if tolerated

Question 7

how long to see improvement after using tazarotene for psoriasis every day

Answer 7

2-4 weeks

Question 8

side effects of tazarotene and pt education

Answer 8

itching, burning, irritation, erythema

PHOTOSENSITIVITY - avoid prolonged exp to sun and use SPF15 or higher

TERATOGENIC

Question 9

which therapy is actually OFF LABEL for psoriasis

Answer 9

calcineurin inhibitors

Question 10

for which psoriasis are calcineurin inhibitors effective for psoriasis and under what conditions

Answer 10

for plaque psoriasis - when occlusions used after applying them

Question 11

BLACK BOX WARNING calcineurin inhibitors

Answer 11

rare cases of lymphoma and skin malignancy

Question 12

name the 2 topical calcineurin inhibitors that can be used off label for psoriasis and which is preferred

Answer 12

pimecrolimus cream and tacrolimus ointment

TACROLIMUS OINTMENT IS PREFERRED

Question 13

how often are topical calcineurin inhibitors applied

Answer 13

2x a day

Question 14

name the topical PDE4 inhibitor used for psoriasis

Answer 14

roflumilast

Question 15

true or false

roflumilast is 1st line for psoriasis

Answer 15

FALSE

an alternative 2nd line to retinoids (topical) and topical calcineurin inhibitors

Question 16

what is a major advantage of ruflumilast over other topical therapies for psoriasis

Answer 16

it can be used in sensitive areas like in groin, thin skin, and under armpit (intertriginous)

better tolerated than the other topical therapies

Question 17

roflumilast is used for treatment of what kind of psoriasis

Answer 17

plaque

Question 18

how often is roflumilast applied and it is indicated for what age

Answer 18

over 12

every day for ~12 weeks

Question 19

is roflumilast a cream or ointment

Answer 19

cream

Question 20

ADRs of roflumilast

are they common

Answer 20

GI adverse events, application site reactions

GI adverse events very rare and likely not from topical therapy. also, it’s a cream so it doesn’t penetrate as much as an ointment would

Question 21

topical aryl hydrocarbon receptor modulating agent used in psoriasis

Answer 21

Tapinarof

Question 22

how does Tapinarof work to help plaque psoriasis

Answer 22

modulates helper t cell type 17 (Th17) cytokines like IL-17A and IL-17F

normalizes the skin barrier and has antioxidant activity

Question 23

how often is Tapinarof applied?
name some ADR

Answer 23

every day

contact derm, headache, folliculitis

Question 24

Tapinarof is like _____ line treatment for plaque psoriasis

Answer 24

3rd

Question 25

what drug class was originally used to treat plaque psoriasis? give 4 examples

Answer 25

keratolytics they eat away at the plaque and dead skin. promote "desquamation" of the thick scales and break them down salicylic acid glycolic acid urea lactic acid

Question 26

keratolytics should not be applied to which areas

Answer 26

genitals, mucous membranes, skin that is healthy

Question 27

why are tars and anthralin not really preferred for psoriasis treatment

Answer 27

they're sticky and smell bad also, for anthralin, you have to apply it and then wash it off - it's an extra step involved

Question 28

which psoriasis treatment must be applied in a downward, 1 direction motion

Answer 28

tars - crude coal tars

Question 29

keratolytic side effects

Answer 29

contact derm tenderness at app site

Question 30

phototherapy vs photochemotherapy

Answer 30

start at phototherapy UVA for mod-severe plaque psoriasis if not working, add the photoactive drug to enahnce efficacy (psoralen/oxsoralen) 2 hours b4 with food or milk to help absorb

Question 31

true or false phototherapy is used in combination with topical and systemic therapies

Answer 31

true

Question 32

name the ORAL retinoid for psoriasis it is a _____ derivative

Answer 32

Acitretin vitamin A

Question 33

is Acitretin teratogenic

Answer 33

YES have to wait 3yrs after dicontinuing b4 becoming pregnant

Question 34

how can you remember the AE/monitoring parameters of Acitretin

Answer 34

same as isotretinoin monitor lipids, esp triglycerides, liver function, glucose dries you out - dry lips, nose, eyes, skin, itching, alopecia

Question 35

explain how to counsel a patient starting acitretin

Answer 35

obviously don't get pregnant, but also take with food to increase absorption and avoid alcohol for 2 months even after discontinuing

Question 36

what class is cyclosporine

Answer 36

a SYSTEMIC calcineurin inhibitor for SEVERE psoriasis lowest effective dose used

Question 37

around how long to see psoriasis improvements when using cyclosporine

Answer 37

4 weeks

Question 38

cyclosporine is CONTRAINDICATED with.....

Answer 38

PUVA

Question 39

big concerns with cyclosporine

Answer 39

has many drug interactions, renal toxicity and HTN, hypertriglyceridemia, headaches have to monitor blood levels, renal function, and lipid profile - LOT of toxicities

Question 40

which is typically used more often for psoriasis - cyclosporin or methotrexate?

Answer 40

methotrexate

Question 41

methotrexate is typically useful for pts with what kind of psoriasis

Answer 41

PSORIATIC ARTHRITIS

Question 42

some monitoring parameters for MTX

Answer 42

CBC, liver and renal fxn, chest XRAY TERATOGENIC

Question 43

side effects MTX

Answer 43

nausea, pulmonary toxic, megaloblastic anemia, pancytopenia (low RBS, WBC, AND PLATELETS)

Question 44

What is apremilast

Answer 44

ORAL small molecule PDE4 inhibitor (NOT a biologic) use in mod-severe plaque psoriasis (arouns3-10% BSA - not really for severe) in pts who are candidates for systemic therapy

Question 45

pt education for apremilast

Answer 45

don't crush or chew, report signs of infection or signs of depression

Question 46

when are biologics used in psoriasis

Answer 46

for SEVERE psoriasis - greater than 10% BSA when systemic treatment is needed but methotrexate/cyclosporine are not tolerated or effective

Question 47

a patient has persistent psoriasis that relapses quickly when taken off of therapy what is a treatment option to consider?

Answer 47

biologics

Question 48

if a pt has psoriatic arthritis, who should they consult before starting biologic therapy

Answer 48

a rheumatologist

Question 49

name 2 advantages of biologics over MTX/cyclosporine

Answer 49

-less toxic to liver, kidneys, and bone marrow -work quicker and are more efficacious

Question 50

cons of biologics vs MTX/cyclosporine

Answer 50

increased risk of infections and tb reactivation exacerbate CSF injection reactions demyelinating diseases