1. PSORIASIS
ETIOPATOGENESIS AND PHARMACOTHERAPY
BY
VINEETHA B MENON
PHARM.D (PB)
FIRST YEAR
JSS COLLEGE OF PHARMACY,
MYSORE
Feb 1, 2014
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2. CONTENTS
 INTRODUCTION
 EPIDEMIOLOGY
 AETIOLOGY
 PATHOGENESIS
 DIAGNOSIS
 CLINICAL FEATURES
 TREATMENT
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3. INTRODUCTION
• Psoriasis is a chronic inflammatory
condition that may affect the skin and
joints
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4. • EPIDEMIOLOGY
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5. EPIDEMIOLOGY
• Psoriasis affects both sexes equally
• Can occur at any age, although it most
commonly appears for the first time
between the ages of 15 and 25 years
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6. • AETIOLOGY
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7. AETIOLOGY
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8. • PATHOGENESIS
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9. PATHOGENESIS
•Many changes
occur in the skin
•Epidermis –
Acanthosis,
Parakeratosis
•Dermis –
capillaries are
dilated, twisted,
closer to the
surface of the skin
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10. • Large number of inflammatory cells are
present in all layers of the skingranulocytes are predominant and form
micro-abscessess in the epidermis
• Langerhan cells and lymphocytes are also
increased
• Main abnormality is
epidermal cell turn over
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the
increased
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11. Two hypothesis:
1. Hyperproliferation may be due to
immunological response. Cytokines
released by lymphocytes and langerhan
cells may further stimulate the
inflammatory
cells
which
cause
epidermal cell turn over at an increased
rate
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12. 2. Epithelial cells themselves produce
cytokines which promote proliferation
of
epithelial
cells
and
attract
lymphocytes
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13. • DIAGNOSIS
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14. DIAGNOSIS
• A diagnosis of psoriasis is usually based on the
appearance of the skin
• There are no special blood tests or diagnostic
procedures
• Skin biopsy, may be needed to rule out other
disorders and to confirm the diagnosis
• Skin from a biopsy will show clubbed rete pegs, if
positive for psoriasis
• Another sign of psoriasis is that when the plaques
are scraped, one can see pinpoint bleeding from
the skin below
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15. Rete pegs are
the
epithelial
extensions that
project into the
underlying
connective tissue
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16. • CLINICAL FEATURES
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17. CLINICAL FEATURES
• Typical psoriatic lesion
is red, scaly, sharply
demarcated plaque
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18. • It can be on any
size and can affect
any part of the
body
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19. • The scales are silvery and easily scraped
off revealing tiny bleed points
• Psoriasis is not typically itchy, but it can
cause itching when severely inflammed
and rapidly spreading to the palms and
soles
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20. • Different patterns of psoriasis are:
1.
2.
3.
4.
5.
6.
7.
Guttate psoriasis
Chronic plaque psoriasis
Psoriasis of scalp
Psoriasis of nails
Psoriasis of palms and soles
Flexural psoriasis
Erythrodermic and generalized pustular
psoriasis
8. Psoriatic arthropathy
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21. GUTTATE
PSORIASIS
Multiple small plaques are
seen all over the body
Mainly seen in children
after streptococcal sore
throat
Self limiting after a few
weeks
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22. CHRONIC PLAQUE
PSORIASIS
Medium and large plaques
occur on the limb and trunk
Very persistent
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23. PSORIASIS OF THE
SCALP
May occur as demarcated
plaques or may involve the
entire scalp extending to the
hairline
Scales are white, thick and
chalky
Hair loss will occur if the
scalp is thickly scaled
Recover if the scales are
cleared and kept under
control
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24. PSORIASIS OF THE
NAILS
Pitting, onycholysis and
hyperkeratosis under the
nail
Very resistant
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25. PSORIASIS OF THE
PALMS AN SOLES
Sharp demarcation of the
involved areas
Affected areas are inflammed
and scaly and may contain
sterile pustules of large pin
head size. These pustules dry
up and form brown macules
Affected skin becomes
hyperatotic and fissuring
Secondary infection with
itching and pain are common
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26. FLEXURAL PSORIASIS
Psoriasis occurs in the axillae,
submammary areas, groin and
genitalia
Demarcation is present, but
the affected areas are glazy
rather than scaly and is bright
red in color
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27. ERYTHRODERMIC AND
GENERALIZED
PUSTULAR PSORIASIS
Severe and life threatening condition
Uncommon
Whole skin surface is involved and
highly inflammed and the patient is
sick
Pustules are sterile and coalesce to
form sheets of pus
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28. PSORIATIC
ARTHROPATHY
Occurs in 5% of the patients with
psoriasis
Similar to RA, but RF is negative
Different patterns:
1.
2.
3.
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Distal Arthritis
Large Joint Involvement
Spodilitis/ Sacroiliitis
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29. • TREATMENT
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30. TREATMENT
Aimed at controlling the current attack and not curing,
and does not influence future progress of the disease
TOPICAL THERAPY
1. Emolients
2. Topical Steroids
3. Dithranol
4. Coal Tar
5. Salicylic Acid
6. Vitamin D Analogues
7. UVB
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SYSTEMIC THERAPY
1. PUVA
2. Cytotoxic Drugs
3. Immunosuppressant
Drugs
4. Acitretin
5. Photodynamic Therapy
6. Systemic Steroids
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31. TOPICAL THERAPY
1. EMOLIENTS
•
Used alone in very mild cases
•
Used along with other therapies for moderate to
severe disease
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32. 2. TOPICAL STEROIDS
•
Most useful for acutely inflammed psoriasis
•
Mild steroids are used on face and flexures
•
Potent
steroids
are
used on hands
and
feet; in
combination with Clioquinol or Salicylic acid
•
Aq. and alcoholic solutions cause stinging and burning,
thus usually ointments, creams and mousse are prefered
•
Use of potent steroids on large areas of psoriasis may
cause rebound flare when discontinued
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33. Feb 1, 2014
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34. 4. COAL TAR
• Used in combination with emolients, topical steroids,
and salicylic acid
• Used for guttate psoriasis, psoriasis of the scalp, and
localized pustular psoriasis of the palms and soles
• Efficiency of coal tar is enhanced when used with
UVB
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35. 5. SALICYLIC ACID
• Useful to remove the scales
• Used in preparation for other treatment
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36. 6. VITAMIN D ANALOGUES
• Efficacy of topical vit D analogues is enhanced when
used in combination with topical steroids and UVB
• Calciptriol & Tacalcitol
• Calciptriol is more effective than coal tar and
dithranol. It cannot be used on face.
• Tacalcitol is used for once daily treatment of chronic
plaque psoriasis. It can be used on the face
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37. 7. UVB
• Short
wavelength
ultraviolet
light
is
used
in
combination with coal tar or dithranol
• Narrow band UVB is more effective
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38. SYSTEMIC THERAPY
1. PUVA
•
Used for the treatment of moderate to severe chronic
plaque psoriasis
•
PSORALENS: drugs that are activated by UVA (320400nm), to interfere with the DNA synthesis and reduce
the epidermal cell turn over
•
Eg: 5-methoxy psoralen & 8-methoxy psoralen
•
Can be administered orally or it can be applied topically
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39. The time of exposure is calculated
based upon the previous light
testing and the time interval is
increased if tolerated by the patient
as the treatment progresses
Treatment is given twice weekly for
6 weeks
Unless the disease is severe,
maintenance dose is avoided to
minimize the long term side effects
Adverse effects: Nausea, pruritis,
dry skin, aging of the skin,
melanoma and non-melanoma skin
cancer
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40. 2. CYTOTOXIC DRUGS
•
Methotrexate & hydroxycarbamide
• METHOTREXATE
•
Most effective in the treatment of psoriatic arthritis
•
Test dose- 2.5 mg
•
Then 30 mg weekly
•
Side effects: nausea, fatigue, GI bleeding
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41. • HYDROXYCARBAMIDE
• It should be used continuously as relapse will
occur when the drug is stopped
• Causes bone marrow depression
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42. 3. IMMUNOSUPPRESSANT DRUGS
• CICLOSPORIN
•
Severe psoriasis
•
Dose is 2-5 mg/kg/day
•
Relapse may occur when the drug is stopped but
intermittent therapy is preferred to maintenance
therapy
•
Avoid sun over exposure, PUVA & UVB therapy
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43. 4. ACITRETIN
•
Used for severe resistant psoriasis, acute pustular
psoriasis, and palmoplantar psoriasis
•
Has teratogenic effect
•
Re-PUVA therapy: acitretin + PUVA
•
It causes bone maturation abnormality, LFT and
serum lipid levels
•
Causes dry skin and hair loss
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44. 5. PHOTODYNAMIC THERAPY
•
5-aminolaevullinic acid (ALA) causes local
accumulation of proto porphyrin 9 which is activated
by irradiation with visible light and causes tissue
destruction
•
Used for localized plaque psoriasis
•
Causes burning sensation at the site of treatment
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45. 6. SYSTEMIC STEROIDS
• Not commonly used
• May be used for the management of life threatening
erythroderma
• Systemic steroids or their withdrawal may itself
provoke acute generalised pustular psoriasis
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46. Feb 1, 2014
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47. THANK
YOU
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