PSORIASIS ETIOPATOGENESIS AND

PHARMACOTHERAPY

BY

VINEETHA B MENONPHARM.D (PB)

FIRST YEARJSS COLLEGE OF PHARMACY,

MYSORE

Apr 19, 2023 1

INTRODUCTION

EPIDEMIOLOGY

AETIOLOGY

PATHOGENESIS

DIAGNOSIS

CLINICAL FEATURES

TREATMENTApr 19, 2023 2

CONTENTS

INTRODUCTION

• Psoriasis is a chronic inflammatory condition that may affect the skin and joints

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• EPIDEMIOLOGY

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• 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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EPIDEMIOLOGY

• AETIOLOGY

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AETIOLOGY

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• PATHOGENESIS

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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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• Large number of inflammatory cells are present in all layers of the skin- granulocytes are predominant and form micro-abscessess in the epidermis

• Langerhan cells and lymphocytes are also increased

• Main abnormality is the increased epidermal cell turn over

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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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2. Epithelial cells themselves produce cytokines which promote proliferation of epithelial cells and attract lymphocytes

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• DIAGNOSIS

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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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Rete pegs are the epithelial extensions that project into the underlying connective tissue

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• CLINICAL FEATURES

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CLINICAL FEATURES

• Typical psoriatic lesion is red, scaly, sharply demarcated plaque

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• It can be on any size and can affect any part of the body

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• 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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• Different patterns of psoriasis are:1. Guttate psoriasis2. Chronic plaque psoriasis3. Psoriasis of scalp4. Psoriasis of nails5. Psoriasis of palms and soles6. Flexural psoriasis7. Erythrodermic and generalized pustular

psoriasis8. Psoriatic arthropathy

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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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CHRONIC PLAQUE PSORIASIS

Medium and large plaques occur on the limb and trunk

Very persistent

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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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PSORIASIS OF THE NAILS

Pitting, onycholysis and hyperkeratosis under the nail

Very resistant

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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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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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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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PSORIATIC ARTHROPATHY

Occurs in 5% of the patients with psoriasis

Similar to RA, but RF is negative

Different patterns:1. Distal Arthritis2. Large Joint Involvement3. Spodilitis/ Sacroiliitis

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• TREATMENT

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TREATMENTAimed at controlling the current attack and not curing, and does not influence future progress of the disease

TOPICAL THERAPY1. Emolients2. Topical Steroids3. Dithranol4. Coal Tar5. Salicylic Acid6. Vitamin D Analogues7. UVB

SYSTEMIC THERAPY1. PUVA2. Cytotoxic Drugs3. Immunosuppressant

Drugs4. Acitretin5. Photodynamic

Therapy6. Systemic Steroids

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TOPICAL THERAPY

1. EMOLIENTS

• Used alone in very mild cases

• Used along with other therapies for moderate to severe disease

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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 discontinuedApr 19, 2023 32

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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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5. SALICYLIC ACID

• Useful to remove the scales

• Used in preparation for other treatment

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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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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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SYSTEMIC THERAPY1. PUVA

• Used for the treatment of moderate to severe chronic plaque psoriasis

• PSORALENS: drugs that are activated by UVA (320-400nm), 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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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 cancerApr 19, 2023 39

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 bleedingApr 19, 2023 40

• HYDROXYCARBAMIDE

• It should be used continuously as relapse

will occur when the drug is stopped

• Causes bone marrow depression

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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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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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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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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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THANKYOU