Pharmacotherapy

PSORIASIS

Yani Mulyani, M.Si, apt

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Komponen

Definisi

Pathofisiology

Clinical Presentation

Diagnosis

Desired outcome

Treatment

Evaluation of theurapeutic outcomes

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Definisi

• Jenis penyakit gangguan imun, yang mempengaruhi tampilan pada kulit

• Penyakit tidak menular ini ditandai oleh lesi peradangan yang ditutupi dengan keropeng putih perak dari kulit mati.

• Psoriasis disebabkan sel-sel kulit menua dalam waktu kurang dari seminggu.

• Karena tubuh tidak dapat melepaskan kulit tua secepat sel-sel baru meningkat ke permukaan, pengelupasan kulit mati menimbulkan keropeng yang berkembang di lengan, punggung, dada, siku, kaki, kuku, lipatan antara pantat, dan kulit kepala.

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Tingkatan Psoriasis

• Mild/Ringan, jika mempengaruhi kurang dari 5% dari permukaan tubuh,

• Sedang/moderat, jika 5-30% dari kulit yang terlibat, dan

• Parah/severe , jika penyakit memengaruhi lebih dari 30% dari permukaan tubuh.

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What is the genetic risk of psoriasis?

• 41% if both parents have psoriasis 14% if one parent 4% if no genetic link

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Penginduksi Psoriasis

Penyebab Diinduksi Oleh

The main climatic trigger of psoriasis is? Cold, dry weather

The primary drug triggers of psoriasis are?

ACE inhibitors Beta-blockers Chloroquine Progesterone Lithium Indomethacin Corticosteroid withdrawel

The primary infectious triggers of psoriasis are?

Streptococcal (strep throat, tonsillitis) HIV HPV (ED form)

NSAID that can improve psoriasis? Meclofenamate

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ICAM, Intracellurar ce;; adhesion molecules APCs, Antigen Presenting Cell

LFA, Leucocyte function associated type 3 Yani Mulyani - STFB

Phatofisiology

T Cell, diproduksi banyak

T cell diikat kuat oleh ICAM pada sel endhotel

Merangsang Pelepasan Antigen APC, Aktivated T CELL

Kehadiran LFA-3-CD2, Meningkat Proliferation T Cell . Saat Aktivasi T Cell, Meningkat Interleukin, Cytokines, dll,..yang menginisiasi Inflamasi di KULIT

PSORIASIS

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In which layer of the skin does psoriasis begin?

In the basal layer of the epidermis where keratinocytes form.

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Clinical Presentation

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Yani Mulyani - STFB

Yani Mulyani - STFB

Psoriasis: Clinical Presentation

Type Characteristics Plaque psoriasis Guttate psoriasis Erythrodermic psoriasis Pustular psoriasis Nail psoriasis Palmar/Plantar psoriasis Psoriatic arthritis Scalp psoriasis

Dry scaling patches (AKA common psoriasis) 75% Drop-like dots, occurs after strep or viral infection 12% Exfoliation of fine scales (total body “dandruff”), widespread, often accompanied by severe itching and pain 7% Pus-like blisters, noninfectious, fluid contains white blood cells 2% Seen on toenails and fingernails, starts as numerous pits, at times progresses to yellowing, crumbly, and thickened nail; nails may slough Erythema, thickening and peeling of the skin, blistering is often present. Can lead to disability. Inflammation, swelling, and joint destruction Plaque-type lesion

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Psoriatic Plaque

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Chronic Plaque Psoriasis

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Erythrodermic Psoriasis

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Nail changes

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Guttate Psoriasis

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Nail Changes

• In 78% of psoriatic patients

• Fingernails>Toenails

• Four changes

1. Onycholysis (= separation from nail bed)

2. Pitting*

3. Subungual debris accumulation

4. Color alterations

*Pitting rules out a fungal infection Yani Mulyani - STFB

DIAGNOSIS

Physical examination

BSA (body surface Area)

Psoriasis Area and Severity Index

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OLA Photonumeric Guidelines (overall lesion assessment)

0 = none

5 = very severe 4 = severe 3 = moderate

1 = minimal 2 = mild

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Desired Outcome

Caranya???

• Mencegah Aktivasi T Cell

• Menghambat Kerja dari Inflammatory agent

• Menurunkan Imun

• Mengurangi pembentukan Keratin

• Membuang Keratin yangg terbentuk

Outcome

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1 Leonardi, 2003; 2 Market Measures/Cozint LLP, June 2003.

Other therapies

54%

Topicals only

46%

The Majority of Moderate-Severe Psoriasis Patients Are Under-Treated

• 50% of patients with moderate or worse disease are currently untreated1

– 46% have topical therapy only

• Reason dermatologists do not use more aggressive therapies2

– Safety concerns

– Time consuming

– Cost

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Psoriasis: Treatment

• Lubrication

• Removal of scales

• Slow down lesion proliferation

• Pruritus management

• Prevent complications

• Lessen patient stress

• Season and climate

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Treatment

Non Pharmacology

Pharmacology Treatment

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Non Pharmacology

• Mengurangi stress

• Memberikan Pelembab

• Menggunakan Jenis sabun khusus

• Sunscreen

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Pharmacology Treatment

Korticosteroid

Keratolytic

Keratonycte proliferation inhibitor

Phototherapy (UV a dan UV B)

Photochemotherapy (Broadband UV B)

Systemic Therapies

BRM (biologic response modifiers)

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Algorithm Treatment Of Psoriasis Mild to Moderate

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Algorithm Treatment Of Psoriasis For Severe

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Step 1

Anthralin Calcipotriene

Coal Tar

Tazarotene Intralesional Steroid

Topical Steroid

Climatotherapy Moisturizers Keratolytics

Step 2

PUVA PUVA +Step 1 agent

Acitretin

Step 3

Methotrexate Cyclosporine

Rotational:12-24 months

of eachstep 3 agent

Supplementary

Tx

Step 4

Enbrel/Remicade/Amevive/Raptiva

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Corticosteroid

Betamethasone

Amcinonide

Triamcinolone

Fluticasone,

Dll

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Corticosteroids

Level of Potency Corticosteroid Commercial Products

Ultra-high Halobetasol propionate

Clobetasol propionate

Betamethasone dipropionate

Diflorasone diacetate

Ultravate crm/oint

Temovate crm/oint

Diprolene oint

Psorcon oint

High Halcinonide

Amcinonide

Betamethasone dipropionate

Mometasone furoate

Diflorasone diacetate

Fluocinonide

Desoximetasone

Halog crm

Cylocort oint

Diprolene AF crm

Elocon oint

Florone oint

Lidex crm,gel,oint

Topicort crm,oint,gel

Mild to high Halcinonide

Triamcinolone acetonide

Betamethasone dipropionate

Fluocinonide

Halog oint,crm,soln

Aristocort A oint

Diprosone crm

Lidex-E crm Yani Mulyani - STFB

Corticosteroids

Level of Potency Corticosteroid Commercial Products

Mild Hydrocortisone valerate

Triamcinolone acetonide

Flurandrenolide

Mometasone furoate

Fluocinolone acetonide

Westcort

Kenalog crm and oint

Cordran oint

Elocon crm

Synalar oint

Low to mild Hydrocortisone valerate

Triamcinolone acetonide

Flurandrenolide

Betamethasone dipropionate

Hydrocortisone butyrate

Flucolone acetonide

Westcort crm

Kenalog crm and oint

Cordran crm

Diprosone lotion

Locoid crm

Synalar crm

Low Alclometasone dipropionate

Betamethasone valerate

Fluocinolone acetonide

Hydrocortisone, dexamethasone,

prednisolone, methylprednisolone

Aclovate crm and oint

Valisone lotion

Synalar soln and crm

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Inhibitor keratinocyte

Calcipotriene

Tazarotene

Anthralin

Coal tar

Asam salisilat

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Phototherapy

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BRM

Adalimumab

Etanercept

Infliximab

Alefacept

Ustekinumab

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(soluble TNF receptor) Yani Mulyani - STFB