乾癬乾癬乾癬乾癬

行政院衛生署台北醫院行政院衛生署台北醫院行政院衛生署台北醫院行政院衛生署台北醫院

皮膚科皮膚科 鍾沛霖鍾沛霖

CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATIONNonpustular PsoriasisNonpustular PsoriasisNonpustular PsoriasisNonpustular Psoriasis

Psoriasis vulgaris (including guttate type)Psoriasis vulgaris (including guttate type)h dh dPsoriatic erythrodermaPsoriatic erythroderma

Pustular PsoriasisPustular PsoriasisPustular psoriasis of von ZumbuschPustular psoriasis of von ZumbuschPustular psoriasis of von ZumbuschPustular psoriasis of von ZumbuschPalmoplantar pustulosisPalmoplantar pustulosisAcordermatitis continuaAcordermatitis continuaAcordermatitis continuaAcordermatitis continuaImpetigo herpetiformisImpetigo herpetiformis

EPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGYEPIDEMIOLOGY

Onset : 2 peak pattern (22.5 and 55 y/o)Onset : 2 peak pattern (22.5 and 55 y/o)Prevalence : about 1 5~2% of populationPrevalence : about 1 5~2% of populationPrevalence : about 1.5 2% of populationPrevalence : about 1.5 2% of populationM:F about equalM:F about equalHereditary : PolygenicHereditary : Polygenic

Incidence 8% when 1 of parents infectedIncidence 8% when 1 of parents infectedIncidence 8% when 1 of parents infectedIncidence 8% when 1 of parents infectedIncidence 41% when both of parents infectedIncidence 41% when both of parents infectedHLAHLA B13 B17 B 57 C 6 l t dB13 B17 B 57 C 6 l t dHLAHLA--B13,B17,Bw57,Cw6 relatedB13,B17,Bw57,Cw6 related

PATHOGENESISPATHOGENESISPATHOGENESISPATHOGENESIS

Cell cycle of keratinocytesCell cycle of keratinocytes311 Hr 311 Hr 36 Hr36 Hr33 3636

Keratinization disorder?Keratinization disorder?

Immune response / TImmune response / THH11--cell relatedcell relatedImmune response / TImmune response / THH11 cell relatedcell relatedAutoreactive immune responseAutoreactive immune response真皮的發炎反應誘發表皮改變真皮的發炎反應誘發表皮改變真皮的發炎反應誘發表皮改變真皮的發炎反應誘發表皮改變

HISTORYHISTORYHISTORYHISTORY

History : usually indolent, acute onset History : usually indolent, acute onset sometimessometimesSymptoms : Itching sometimesSymptoms : Itching sometimesA th l i th itiA th l i th itiArthralgia, arthritisArthralgia, arthritisFever, chillness, acute illness appearanceFever, chillness, acute illness appearanceFever, chillness, acute illness appearance Fever, chillness, acute illness appearance in pustular psoriasis of von Zumbuschin pustular psoriasis of von Zumbusch

HISTORYHISTORYProvocation factorsProvocation factors

Physical trauma (KoebnerPhysical trauma (Koebner’’s phenomenon)s phenomenon)Physical trauma (KoebnerPhysical trauma (Koebner’’s phenomenon)s phenomenon)InfectionInfectionPsychological / PressurePsychological / PressureCli t / SCli t / SClimate / Sun exposureClimate / Sun exposureSystemic steroidSystemic steroidyyOral LithiumOral Lithium

l f bl f b bl kbl kAntimalaria, inteferon, betaAntimalaria, inteferon, beta--blockersblockersAlcohol ? Smoking ?Alcohol ? Smoking ?Alcohol ? Smoking ?Alcohol ? Smoking ?

Laboratory examinationsLaboratory examinations

D t th lD t th lDermatopathologyDermatopathologyRheumatology studies ifRheumatology studies ifRheumatology studies if Rheumatology studies if indicatedindicatedHIV ?HIV ?

Clinical appearanceClinical appearanceClinical appearanceClinical appearancePlaque lesions on knee elbowPlaque lesions on knee elbowPlaque lesions on knee, elbow, Plaque lesions on knee, elbow, buttock, extensor side of extremities, buttock, extensor side of extremities, scalpscalpscalpscalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsGenital lesionsGenital lesionsGenital lesions Genital lesions Inverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermaAcute generalized pustular psoriasisAcute generalized pustular psoriasisAcute generalized pustular psoriasisAcute generalized pustular psoriasisPustulosis palmoplantarisPustulosis palmoplantaris

Clinical appearanceClinical appearanceClinical appearanceClinical appearance

Pl l i k lb b kPl l i k lb b kPlaque lesions on knee, elbow, buttock, Plaque lesions on knee, elbow, buttock, extensor side of extremities, scalpextensor side of extremities, scalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsPsoriatic nailsPsoriatic nailsGenital lesions Genital lesions Inverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermaErythrodermaErythrodermaAcute generalized pustular psoriasisAcute generalized pustular psoriasisP t l i l l t iP t l i l l t iPustulosis palmoplantarisPustulosis palmoplantaris

Clinical appearanceClinical appearanceClinical appearanceClinical appearance

Pl l i k lb b kPl l i k lb b kPlaque lesions on knee, elbow, buttock, Plaque lesions on knee, elbow, buttock, extensor side of extremities, scalpextensor side of extremities, scalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsPsoriatic nailsPsoriatic nailsGenital lesions Genital lesions Inverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermaErythrodermaErythrodermaAcute generalized pustular psoriasisAcute generalized pustular psoriasisP t l i l l t iP t l i l l t iPustulosis palmoplantarisPustulosis palmoplantaris

Clinical appearanceClinical appearanceClinical appearanceClinical appearance

Pl l i k lb b kPl l i k lb b kPlaque lesions on knee, elbow, buttock, Plaque lesions on knee, elbow, buttock, extensor side of extremities, scalpextensor side of extremities, scalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsPsoriatic nailsPsoriatic nailsGenital lesionsGenital lesionsInverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermaErythrodermaErythrodermaAcute generalized pustular psoriasisAcute generalized pustular psoriasisP t l i l l t iP t l i l l t iPustulosis palmoplantarisPustulosis palmoplantaris

Clinical appearanceClinical appearanceClinical appearanceClinical appearance

Pl l i k lb b kPl l i k lb b kPlaque lesions on knee, elbow, buttock, Plaque lesions on knee, elbow, buttock, extensor side of extremities, scalpextensor side of extremities, scalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsPsoriatic nailsPsoriatic nailsGenital lesions Genital lesions Inverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermaErythrodermaErythrodermaAcute generalized pustular psoriasisAcute generalized pustular psoriasisP t l i l l t iP t l i l l t iPustulosis palmoplantarisPustulosis palmoplantaris

Clinical appearanceClinical appearanceClinical appearanceClinical appearance

Pl l i k lb b kPl l i k lb b kPlaque lesions on knee, elbow, buttock, Plaque lesions on knee, elbow, buttock, extensor side of extremities, scalpextensor side of extremities, scalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsPsoriatic nailsPsoriatic nailsGenital lesions Genital lesions

llInverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermaErythrodermaErythrodermaAcute generalized pustular psoriasisAcute generalized pustular psoriasisP t l i l l t iP t l i l l t iPustulosis palmoplantarisPustulosis palmoplantaris

Clinical appearanceClinical appearanceClinical appearanceClinical appearance

Pl l i k lb b kPl l i k lb b kPlaque lesions on knee, elbow, buttock, Plaque lesions on knee, elbow, buttock, extensor side of extremities, scalpextensor side of extremities, scalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsPsoriatic nailsPsoriatic nailsGenital lesions Genital lesions

llInverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermayyAcute generalized pustular psoriasisAcute generalized pustular psoriasisP t l i l l t iP t l i l l t iPustulosis palmoplantarisPustulosis palmoplantaris

Clinical appearanceClinical appearanceClinical appearanceClinical appearance

Pl l i k lb b kPl l i k lb b kPlaque lesions on knee, elbow, buttock, Plaque lesions on knee, elbow, buttock, extensor side of extremities, scalpextensor side of extremities, scalpGuttate type lesionsGuttate type lesionsPsoriatic nailsPsoriatic nailsPsoriatic nailsPsoriatic nailsGenital lesions Genital lesions

llInverse pattern lesionsInverse pattern lesionsErythrodermaErythrodermayyAcute generalized pustular psoriasisAcute generalized pustular psoriasisP st losis palmoplanta isP st losis palmoplanta isPustulosis palmoplantarisPustulosis palmoplantaris

Differential diagnosisDifferential diagnosisDifferential diagnosisDifferential diagnosis

MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENT

ddConsiderationsConsiderationsAgeAgeAgeAgeSubtypeSubtypeInvolved area Involved area Previous therapyPrevious therapyPrevious therapyPrevious therapyUnderlined diseasesUnderlined diseases

MANAGEMENT (I)MANAGEMENT (I)MANAGEMENT (I)MANAGEMENT (I)

Localized disease; <5% or 10%Localized disease; <5% or 10%Localized disease; <5% or 10%Localized disease; <5% or 10%Topical corticosteroid (with or without Topical corticosteroid (with or without p (p (occlusion)occlusion)Topical Calcipotriol / CalcitriolTopical Calcipotriol / CalcitriolTopical Calcipotriol / CalcitriolTopical Calcipotriol / CalcitriolTopical TazaroteneTopical TazaroteneTopical anthralinTopical anthralinTarTarTarTarIntralesional triamcinolone acetonideIntralesional triamcinolone acetonide

MANAGEMENT (II)MANAGEMENT (II)MANAGEMENT (II)MANAGEMENT (II)

Etretinate / AcitretinEtretinate / Acitretin//Methetrexate : 2.5~5mg every 12Hr Methetrexate : 2.5~5mg every 12Hr x 3 times per weekx 3 times per weekx 3 times per weekx 3 times per weekCyclosporin A : 3~5 mg/kg/dayCyclosporin A : 3~5 mg/kg/dayBiologic therapies Biologic therapies

MANAGEMENT (III)MANAGEMENT (III)MANAGEMENT (III)MANAGEMENT (III)

UVB phototherapy (311nm)UVB phototherapy (311nm)UVB phototherapy (311nm)UVB phototherapy (311nm)PUVAPUVA

Oral or topical PUVAOral or topical PUVA

ReRe--UVB, ReUVB, Re--PUVAPUVAReRe UVB, ReUVB, Re PUVAPUVADay care center / Day care center / 浸泡療法浸泡療法 (Tar)(Tar)

Biologic therapiesBiologic therapiesBiologic therapiesBiologic therapies

具有藥理作用的蛋白質具有藥理作用的蛋白質 //具有藥理作用的蛋白質具有藥理作用的蛋白質 //從人或動物直接萃取而得從人或動物直接萃取而得從人或動物直接萃取而得從人或動物直接萃取而得

Etanercept (Enbrel /Etanercept (Enbrel /恩博恩博 ))Etanercept (Enbrel /Etanercept (Enbrel /恩博恩博 ))

Made from the fusion of 2 Made from the fusion of 2 naturally occurring TNF naturally occurring TNF receptorsreceptorsreceptors receptors Binding to TNF renders the Binding to TNF renders the bound TNF biologicallybound TNF biologicallybound TNF biologically bound TNF biologically inactive, resulting in inactive, resulting in significant reduction in significant reduction in inflammatory activity inflammatory activity Approved for the treatment of Approved for the treatment of rheumatoid arthritis and rheumatoid arthritis and psoriatic arthritis psoriatic arthritis

Alefacept (Amevive /Alefacept (Amevive /愛美麗愛美麗 ))Alefacept (Amevive /Alefacept (Amevive /愛美麗愛美麗 ))

A fusion protein A fusion protein composed of LFAcomposed of LFA--3 3 protein and human IgG1 protein and human IgG1 Fc domains Fc domains

Binds to CD2 onBinds to CD2 onBinds to CD2 on Binds to CD2 on memorymemory--effector T effector T lymphocytes, inhibitinglymphocytes, inhibitinglymphocytes, inhibiting lymphocytes, inhibiting their activation and their activation and reducing their numberreducing their numberreducing their number reducing their number

Efalizumab (Raptiva /Efalizumab (Raptiva /瑞體膚瑞體膚))Efalizumab (Raptiva /Efalizumab (Raptiva /瑞體膚瑞體膚))

A humanized monoclonal antibody A humanized monoclonal antibody against the CD11a (CD11a :a subunit ofagainst the CD11a (CD11a :a subunit ofagainst the CD11a (CD11a :a subunit of against the CD11a (CD11a :a subunit of LFALFA--1) 1) The binding of this drug to CD11a on T The binding of this drug to CD11a on T cells blocks the interaction between cells blocks the interaction between LFALFA--1 and ICAM1 and ICAM--11Block TBlock T cell migration into the skincell migration into the skinBlock TBlock T--cell migration into the skincell migration into the skin

Infliximab (Remicade)Infliximab (Remicade)Infliximab (Remicade)Infliximab (Remicade)

Chimeric (mouseChimeric (mouse--h )h )human) human) immunoglobulin G immunoglobulin G

bb l 1l 1subsub--class 1 class 1 monoclonal antibody monoclonal antibody th t bi d t TNFth t bi d t TNFthat binds to TNFthat binds to TNF--ααApproved for CrohnApproved for Crohn’’s s disease / RAdisease / RA

Adalimumab (Himura /Adalimumab (Himura / 復邁))Adalimumab (Himura / Adalimumab (Himura / 復邁))

H l lH l lHuman monoclonal Human monoclonal antibody against TNFantibody against TNF--

/ Th thi d TNF/ Th thi d TNFα / The third TNF α / The third TNF inhibitorinhibitorFor RA / Psoriatic For RA / Psoriatic arthritis / Ankylosing arthritis / Ankylosing spondylitis / Crohnspondylitis / Crohn’’s s disease / Plaque disease / Plaque psoriasispsoriasis

Summary of available biotherapiesSummary of available biotherapiesy py pAgentAgent Mechanism of ActionMechanism of Action AdministrationAdministration

InfliximabInfliximab TNFTNF--α inhibitorα inhibitor IV infusion IV infusion (>120 min)(>120 min)(>120 min)(>120 min)

EtanerceptEtanercept TNFTNF--α inhibitorα inhibitor SC twice SC twice weeklyweeklyweeklyweekly

EfalizumabEfalizumab Inhibits TInhibits T--cell cell SC twice SC twice activation, migrationactivation, migration weeklyweekly

AlefaceptAlefacept Reduces memoryReduces memory-- IV/IM push IV/IM push pp yyeffector T cells.effector T cells.

pponce weeklyonce weekly

AdalimumabAdalimumab TNFTNF--α inhibitorα inhibitor SC biweeklySC biweeklyAdalimumabAdalimumab TNFTNF α inhibitorα inhibitor SC biweeklySC biweekly

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