Psoriasis Jurnal

sorlasls hLLp//emedlclnemedscapecom/arLlcle/1943419overvlew
age 1 of 24 10/19/2011 846M

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O Lhor !effrey MefferL Mu Clef LdlLor 8oberL L C'ConnorMu MP more
DpdaLed Sep 23 2011
8ackground
sorlasls ls a chronlc nonconLaglos mlLlsysLem lnflammaLory dlsorder aLlenLs wlLh
psorlasls have a geneLlc predlsposlLlon for Lhe lllness whlch mosL commonly manlfesLs lLself on
Lhe skln of Lhe elbows knees scalp lmbosacral areas lnLerglLeal clefLs and glans penls 1he
[olnLs are also affecLed by psorlasls ln p Lo 30 of paLlenLs wlLh Lhe dlsease (See
aLhophyslology and LLlology)
sorlasls has a Lendency Lo wax and wane wlLh flares relaLed Lo sysLemlc or envlronmenLal
facLors lncldlng llfe sLress evenLs and lnfecLlon lL lmpacLs qallLy of llfe and poLenLlally long
Lerm srvlval 1here shold be a hlgher cllnlcal ssplclon for depresslon ln Lhe paLlenL wlLh
psorlasls (See rognosls)
MlLlple Lypes of psorlasls are ldenLlfled wlLh plaqeLype psorlasls also known as dlscold
psorlasls belng Lhe mosL common Lype laqe psorlasls sally presenLs wlLh plaqes on Lhe
scalp Lrnk and llmbs (see Lhe lmage below) 1hese plaqes appear as focal ralsed lnflamed
edemaLos leslons covered wlLh sllverywhlLe mlcaceos" scales (See Cllnlcal resenLaLlon)
sorlasls plcLres laqe psorlasls ls mosL common on Lhe
exLensor srfaces of Lhe knees and elbows ConLrlbLed by 8andy ark Mu
Cclar slgns occr ln approxlmaLely 10 of psorlasls paLlenLs and Lhey are more common ln
men Lhan ln women aLlenLs wlLh oclar flndlngs almosL always have psorlaLlc skln dlsease
however lL ls rare for Lhe eye Lo become lnvolved before Lhe skln
1 2 3

age 2 of 24 10/19/2011 846M

1he dlagnosls of psorlasls ls cllnlcal (See Workp) ManagemenL of psorlasls may lnvolve Loplcal
or sysLemlc medlcaLlons llghL Lherapy sLress redcLlon cllmaLoLherapy and varlos ad[ncLs
sch as snshlne molsLrlzers and sallcyllc acld (See 1reaLmenL and ManagemenL)
lor more lnformaLlon see Lhe followlng
O LLaLe sorlasls
O -all sorlasls
O laqe sorlasls
O sLlar sorlasls
O sorlaLlc rLhrlLls
O lmaglng of sorlaLlc rLhrlLls
O arapsorlasls
athophys|o|ogy
sorlasls ls a complex mlLlfacLorlal dlsease LhaL appears Lo be lnflenced by geneLlc and
lmmnemedlaLed componenLs 1hls ls spporLed by Lhe sccessfl LreaLmenL of psorlasls wlLh
lmmnemedlaLlng blologlc medlcaLlons
1he paLhogenesls of Lhls dlsease ls noL compleLely ndersLood MlLlple Lheorles exlsL
regardlng Lrlggers of Lhe dlsease process lncldlng an lnfecLlos eplsode LramaLlc lnslL and
sLressfl llfe evenL ln many paLlenLs no obvlos Lrlgger exlsLs aL all Powever once Lrlggered
Lhere appears Lo be sbsLanLlal lekocyLe recrlLmenL Lo Lhe dermls and epldermls reslLlng ln
Lhe characLerlsLlc psorlaLlc plaqes
Speclflcally Lhe epldermls ls lnfllLraLed by a large nmber of acLlvaLed 1 cells whlch appear Lo
be capable of lndclng keraLlnocyLe prollferaLlon 1hls ls spporLed by hlsLologlc examlnaLlon
and lmmnohlsLochemlcal sLalnlng of psorlaLlc plaqes reveallng large poplaLlons of 1 cells
wlLhln Lhe psorlasls leslons Cne reporL calclaLed LhaL a paLlenL wlLh 20 body srface area
affecLed wlLh psorlasls leslons has arond 8 bllllon blood clrclaLlng 1 cells compared wlLh
approxlmaLely 20 bllllon 1 cells locaLed ln Lhe dermls and epldermls of psorlasls plaqes
4

DlLlmaLely a rampedp dereglaLed lnflammaLory process enses wlLh a large prodcLlon of
varlos cyLoklnes (eg Lmor necrosls facLor 1-l lnLerferongamma lnLerlekln12)
Many of Lhe cllnlcal feaLres of psorlasls are explalned by Lhe large prodcLlon of sch
medlaLors lnLeresLlngly elevaLed levels of 1-l speclflcally are fond Lo correlaLe wlLh flares
of psorlasls
Cne sLdy adds frLher spporL LhaL 1cell hyperacLlvlLy and Lhe reslLlng prolnflammaLory
medlaLors (ln Lhls case lL17/23) play a ma[or role ln Lhe paLhogenesls of psorlasls
3

age 3 of 24 10/19/2011 846M

key flndlngs ln Lhe affecLed skln of paLlenLs wlLh psorlasls lnclde vasclar engorgemenL de Lo
sperflclal blood vessel dllaLlon and alLered epldermal cell cycle Lpldermal hyperplasla leads Lo
an acceleraLed cell Lrnover raLe (from 23 d Lo 33 d) leadlng Lo lmproper cell maLraLlon
Cells LhaL normally lose Lhelr nclel ln Lhe sLraLm granlosm reLaln Lhelr nclel a condlLlon
known as parakeraLosls ln addlLlon Lo parakeraLosls affecLed epldermal cells fall Lo release
adeqaLe levels of llplds whlch normally cemenL adheslons of corneocyLes SbseqenLly
poorly adherenL sLraLm cornem ls formed leadlng Lo Lhe flaklng scaly presenLaLlon of
psorlasls leslons Lhe srface of whlch ofLen resembles sllver scales
Con[ncLlval lmpresslon cyLology demonsLraLed a hlgher lncldence of sqamos meLaplasla
neLrophll clmplng and nclear chromaLln changes ln paLlenLs wlLh psorlasls
6 7

Lt|o|ogy
sorlasls lnvolves hyperprollferaLlon of Lhe keraLlnocyLes ln Lhe epldermls wlLh an lncrease ln
Lhe epldermal cell Lrnover raLe (See aLhophyslology) 1he case of Lhe loss of conLrol of
keraLlnocyLe Lrnover ls nknown Powever envlronmenLal geneLlc and lmmnologlc facLors
appear Lo play a role
Lnv|ronmenta| factors
Many facLors besldes sLress have also been observed Lo Lrlgger exacerbaLlons lncldlng cold
Lrama lnfecLlons (eg sLrepLococcal sLaphylococcal hman lmmnodeflclency vlrs) alcohol
and drgs (eg lodldes sLerold wlLhdrawal asplrln llLhlm beLablockers boLllnm
anLlmalarlals) PoL weaLher snllghL and pregnancy may be beneflclal alLhogh Lhe laLLer ls
noL nlversal ercelved sLress can exacerbaLe psorlasls Some aLhors sggesL LhaL psorlasls ls
a sLressrelaLed dlsease and offer flndlngs of lncreased concenLraLlons of neroLransmlLLers ln
psorlaLlc plaqes
Genet|c factors
aLlenLs wlLh psorlasls have a geneLlc predlsposlLlon for Lhe dlsease 1he gene locs ls
deLermlned 1he Lrlggerlng evenL may be nknown ln mosL cases bL lL ls llkely lmmnologlc
1he flrsL leslon commonly appears afLer an pper resplraLory lnfecLlon
sorlasls ls assoclaLed wlLh cerLaln hman lekocyLe anLlgen (PL) alleles parLlclarly hman
lekocyLe anLlgen Cw6 (PLCw6) ln some famllles psorlasls ls an aLosomal domlnanL LralL
mlLlcenLer meLaanalysls conflrmed LhaL deleLlon of 2 laLe cornlfled envelope (LCL) genes
lcJc and lcJ8 ls a common geneLlc facLor for sscepLlblllLy Lo psorlasls ln dlfferenL
poplaLlons
8

age 4 of 24 10/19/2011 846M

CbeslLy ls anoLher facLor assoclaLed wlLh psorlasls WheLher lL ls relaLed Lo welghL alone
geneLlc predlsposlLlon Lo obeslLy or a comblnaLlon of Lhe 2 ls noL cerLaln CnseL or worsenlng
of psorlasls wlLh welghL galn and/or lmprovemenL wlLh welghL loss ls observed
Immuno|og|c factors
Lvldence sggesLs LhaL psorlasls ls an aLolmmne dlsease SLdles show hlgh levels of dermal
and clrclaLlng 1-l 1reaLmenL wlLh 1-l lnhlblLors ls ofLen sccessfl sorlaLlc leslons are
assoclaLed wlLh lncreased acLlvlLy of 1 cells ln Lhe nderlylng skln
sorlasls ls relaLed Lo excess 1cell acLlvlLy LxperlmenLal models can be lndced by sLlmlaLlon
wlLh sLrepLococcal speranLlgen whlch crossreacLs wlLh dermal collagen 1hls small pepLlde
has been shown Lo case lncreased acLlvlLy among 1 cells ln paLlenLs wlLh psorlasls bL noL ln
conLrol grops Some of Lhe newer drgs sed Lo LreaL severe psorlasls dlrecLly modlfy Lhe
fncLlon of lymphocyLes
lso of slgnlflcance ls LhaL 23 of Lhose wlLh Plv develop worsenlng psorlasls wlLh decreaslng
Cu4 conLs 1hls ls paradoxlcal ln LhaL Lhe leadlng hypoLhesls on Lhe paLhogenesls of psorlasls
spporLs 1cell hyperacLlvlLy and LreaLmenLs geared Lo redce 1cell conLs help redce
psorlasls severlLy 1hls flndlng ls posslbly explalned by a decrease ln Cu4 1 cells whlch leads Lo
overacLlvlLy of Cu8 1 cells whlch drlves Lhe worsenlng psorlasls 1he Plv genome may drlve
keraLlnocyLe prollferaLlon dlrecLly
Plv assoclaLed wlLh opporLnlsLlc lnfecLlons may see lncreased freqency of speranLlgen
exposre leadlng Lo slmllar cascades as above menLloned
LLaLe psorlasls ofLen appears followlng cerLaln lmmnologlcally acLlve evenLs sch as
sLrepLococcal pharynglLls cessaLlon of sLerold Lherapy and se of anLlmalarlal drgs
Lp|dem|o|ogy
ccordlng Lo Lhe -aLlonal lnsLlLLes of PealLh (-lP) approxlmaLely 22 of Lhe DnlLed SLaLes
poplaLlon has psorlasls lnLernaLlonally Lhe lncldence of psorlasls varles dramaLlcally sLdy
of 26000 SoLh merlcan lndlans dld noL reveal a slngle case of psorlasls whereas ln Lhe
laeroe lslands an lncldence of 28 was observed Cverall approxlmaLely 23 of people are
affecLed by psorlasls worldwlde sorlasls can begln aL any age pproxlmaLely 1013 of new
cases begln ln chlldren yonger Lhan 10 years 1he medlan age aL onseL ls 28 years
sorlasls appears Lo be sllghLly more prevalenL among women Lhan among men however men
are LhoghL Lo be more llkely Lo experlence Lhe oclar dlsease sorlasls ls sllghLly more
common ln women Lhan ln men
age S of 24 10/19/2011 846M

1he lncldence of psorlasls ls dependenL on Lhe cllmaLe and geneLlc herlLage of Lhe poplaLlon lL
ls less common ln Lhe Lroplcs and ln darksklnned persons sorlasls prevalence ln frlcan
merlcans ls 13 compared wlLh 23 ln whlLes
9

rognos|s
lLhogh psorlasls ls sally benlgn lL ls a llfelong lllness wlLh remlsslons and exacerbaLlons and
ls someLlmes refracLory Lo LreaLmenL lL progresses Lo arLhrlLls ln aboL 10 of cases boL 17
33 of paLlenLs experlence remlsslons of varylng lengLhs
Mlld psorlasls does noL appear Lo lncrease rlsk of deaLh
10
Powever men wlLh severe psorlasls
dled 33 years earller compared wlLh men wlLhoL Lhe dlsease Women wlLh severe psorlasls
dled 44 years earller compared wlLh women wlLhoL Lhe dlsease
10

sorlasls ls assoclaLed wlLh cardlovasclar dlsease smoklng alcohol meLabollc syndrome
lymphoma depresslon slclde poLenLlally harmfl drg and llghL Lheraples and posslbly
melanoma and nonmelanoma skln cancers
sysLemaLlc revlew of 90 sLdles conflrmed LhaL paLlenLs wlLh psorlasls had a hlgher rlsk of
lschemlc hearL dlsease sLroke and perlpheral arLerlal dlsease bL also a greaLer prevalence of
rlsk facLors for cardlovasclar dlsease compared wlLh conLrols 1he aLhors conclded LhaL
large prospecLlve sLdles wlLh longLerm followp are reqlred Lo deLermlne wheLher psorlasls
ls an lndependenL rlsk facLor for vasclar dlsease or ls merely assoclaLed wlLh known rlsk
facLors
11

sorlasls can slgnlflcanLly lnflence a person's qallLy of llfe Cne sLdy sggesLs LhaL Lhe
physlcal and menLal dlsablllLy experlenced wlLh Lhls dlsease was comparable or ln excess of LhaL
fond ln paLlenLs wlLh oLher chronlc lllnesses sch as cancer arLhrlLls hyperLenslon hearL
dlsease dlabeLes and depresslon
12
sLdy by krd eL al frLher spporLs Lhe noLlon LhaL
psorlasls lmpacLs qallLy of llfe and poLenLlally longLerm srvlval
13
1here shold be a hlgher
cllnlcal ssplclon for depresslon ln Lhe paLlenL wlLh psorlasls
SLdles show LhaL psorlasls of Lhe palms and soles Lend Lo have greaLer lmpacL on Lhe paLlenL's
qallLy of llfe compared Lo Lhose wlLh more exLenslve psorlaLlc lnvolvemenL noL lnvolvlng Lhe
palms and soles
14 13

at|ent Lducat|on
ury eye and lLs manlfesLaLlons may be presenL voldlng drylng condlLlons and slng lbrlcanLs
can be effecLlve aLlenL recognlLlon of Lhese sympLoms ls vlLal for effecLlve early LreaLmenL of
Lhls dlsease MosL cases of psorlasls can be conLrolled aL a Lolerable level wlLh Lhe reglar
appllcaLlon of care measres
age 6 of 24 10/19/2011 846M

lor paLlenL edcaLlon resorces see Lhe sorlasls CenLer as well as sorlasls WhaL ls
sorlasls? 1ypes of sorlasls -all sorlasls and DndersLandlng sorlasls MedlcaLlons
n|story
SympLoms of psorlasls may lnclde Lhe followlng
O Worsenlng of a longLerm eryLhemaLos scaly area
O Sdden onseL of many small areas of scaly redness
O 8ecenL sLrepLococcal LhroaL lnfecLlon vlral lnfecLlon lmmnlzaLlon se of anLlmalarlal
drg or Lrama
O lamlly hlsLory of slmllar skln condlLlon
O aln (especlally ln eryLhrodermlc psorlasls and ln some cases of LramaLlzed plaqes or
ln Lhe [olnLs affecLed by psorlaLlc arLhrlLls)
O rrlLs (especlally ln erpLlve gLLaLe psorlasls)
O febrlle (excepL ln psLlar or eryLhrodermlc psorlasls ln whlch Lhe paLlenL may have
hlgh fever)
O uysLrophlc nalls
O LongLerm rash wlLh recenL presenLaLlon of [olnL paln
O !olnL paln wlLhoL any vlslble skln flndlngs
1he skln almosL always ls affecLed before Lhe eyes Cclar flndlngs occr ln approxlmaLely 10
of paLlenLs 1he mosL common oclar sympLoms are redness and Learlng de Lo con[ncLlvlLls
or blepharlLls
1he nonoclar sympLoms are relaLed Lo rash and psorlaLlc arLhrlLls 1he rash can be
ncomforLable or even palnfl sorlaLlc arLhrlLls can case sLlffness paln Lhrobblng swelllng
or Lenderness of Lhe [olnLs 1he dlsLal [olnLs sch as Lhe flngers Loes wrlsLs knees and ankles
are mosL ofLen affecLed
hys|ca| Lxam|nat|on
llndlngs on physlcal examlnaLlon depend on Lhe Lype of psorlasls presenL
1he mosL common skln manlfesLaLlons are scallng eryLhemaLos macles paples and
plaqes 1yplcally Lhe macles are seen flrsL and Lhese progress Lo maclopaples and
lLlmaLely welldemarcaLed noncoherenL sllvery plaqes overlylng a glossy homogeneos
eryLhema 1he area of skln lnvolvemenL varles wlLh Lhe form of psorlasls
Chronlc sLaLlonary psorlasls (psorlasls vlgarls) ls Lhe mosL common Lype of psorlasls 1hls
lnvolves Lhe scalp exLensor srfaces genlLals mblllcs and lmbosacral and reLroarlclar
reglons
age 7 of 24 10/19/2011 846M

laqe psorlasls ls characLerlzed by ralsed lnflamed leslons covered wlLh a sllvery whlLe scale
1he scale may be scraped away Lo reveal lnflamed skln beneaLh 1hls ls mosL common on Lhe
exLensor srfaces of Lhe knees elbows scalp and Lrnk
LLaLe psorlasls presenLs as small salmonplnk paples 110 mm ln dlameLer predomlnaLely
on Lhe Lrnk Lhe leslons may be scaly (see Lhe lmage below) lL freqenLly appears sddenly 2
3 weeks afLer an pper resplraLory lnfecLlon (D8l) wlLh grop beLahemolyLlc sLrepLococcl
sorlasls plcLres LLaLe psorlasls erpLed ln Lhls paLlenL afLer
Loplcal sLerold Lherapy was wlLhdrawn drlng a pregnancy ConLrlbLed by 8andy ark Mu
lnverse psorlasls occrs on Lhe flexral srfaces armplL groln nder Lhe breasL and ln Lhe skln
folds lL ls characLerlzed by smooLh lnflamed leslons wlLhoL scallng de Lo Lhe molsL naLre of
Lhe area where Lhls Lype of psorlasls ls locaLed
sLlar psorlasls presenLs as sLerlle psLles appearlng on Lhe palms and soles or dlffsely
over Lhe body sLlar psorlasls may cycle Lhrogh eryLhema psLles Lhen scallng 1he
dlffse varlanL ls Lermed von Zmbsch varlanL whlch ls accompanled by fever and lnLense lll
feellng ln addlLlon Lo Lhe wldespread psLles crodermaLlLls conLlna of Pallopea ls
consldered a form of psLlar psorlasls LhaL affecLs Lhe hands and feeL lL may prove reslsLanL Lo
Loplcal and oLher Lheraples
LryLhrodermlc psorlasls presenLs as generallzed eryLhema paln lLchlng and flne scallng
varlos psLlar forms also exlsL lL Lyplcally encompasses nearly Lhe enLlre body srface area lL
may be accompanled by fever chllls hypoLhermla and dehydraLlon secondary Lo Lhe large
body srface area lnvolvemenL aLlenLs wlLh severe psLlar or eryLhrodermlc psorlasls may
reqlre hosplLal admlsslon for meLabollc and paln managemenL Clder paLlenLs wlLh
eryLhrodermlc psorlasls may experlence cardlac lnsLablllLy and hypoLenslon de Lo masslve
vasclar shnLlng ln Lhe skln
Scalp psorlasls affecLs approxlmaLely 30 of paLlenLs lL presenLs as eryLhemaLos ralsed
plaqes wlLh sllvery whlLe scales on Lhe scalp
-all psorlasls may case plLs on Lhe nalls whlch ofLen become Lhlckened and yellowlsh ln color
-alls may separaLe from Lhe nall bed sorlaLlc nalls may be lndlsLlnglshable from fngal nalls
and aL Lhe same Llme may be more prone Lo developlng onychomycosls becase of Lhe nall
separaLlon and sbngal debrls
age 8 of 24 10/19/2011 846M

sorlaLlc arLhrlLls affecLs approxlmaLely 1030 of Lhose wlLh skln sympLoms 1he arLhrlLls ls
sally ln Lhe hands and feeL and occaslonally Lhe large [olnLs lL prodces sLlffness paln and
progresslve [olnL damage
Cral psorlasls may presenL wlLh whlLlsh leslons on Lhe oral mcosa whlch may appear Lo
change ln severlLy dally lL may also presenL as severe chellosls wlLh exLenslon onLo Lhe
srrondlng skln crosslng Lhe vermllllon border eographlc Longe ls consldered by many Lo
be an oral form of psorlasls
LrpLlve psorlasls lnvolves Lhe pper Lrnk and pper exLremlLles MosL ofLen lL ls seen ln
yonger paLlenLs
Ccu|ar Man|festat|ons
ln addlLlon Lo skln manlfesLaLlons psorlasls may also affecL Lhe lld con[ncLlva or cornea and
glve rlse Lo oclar manlfesLaLlons lncldlng ecLroplon and Lrlchlasls con[ncLlvlLls and
con[ncLlval hyperemla and corneal dryness wlLh pncLaLe keraLlLls and corneal melL
16 17

8lepharlLls ls Lhe mosL common oclar flndlng ln psorlasls LryLhema edema and psorlaLlc
plaqes may develop and Lhey can reslL ln madarosls clcaLrlclal ecLroplon Lrlchlasls and even
loss of Lhe lld Llsse
chronlc nonspeclflc con[ncLlvlLls ls falrly common lL sally occrs ln assoclaLlon wlLh eyelld
margln lnvolvemenL sorlaLlc plaqes can exLend from Lhe lld onLo Lhe con[ncLlva Chronlc
con[ncLlvlLls can lead Lo symblepharon keraLocon[ncLlvlLls slcca and Lrlchlasls -odlar
eplsclerlLls and llmbal leslons resembllng phlycLenles also can be seen
Corneal dlsease ls relaLlvely rare MosL ofLen lL ls secondary Lo lld or con[ncLlval
compllcaLlons sch as dryness Lrlchlasls or exposre 1he mosL common flndlng ls pncLaLe
keraLlLls lllamenLs eplLhellal Lhlckenlng recrrenL eroslons vasclarlzaLlon lceraLlon and
scarrlng can occr 1he vasclarlzaLlon Lends Lo be sperflclal perlpheral and lnLerpalpebral or
lnferlor 8arely perlpheral lnfllLraLlon and melLlng can occr ln Lhe absence of Lrlchlasls and
exposre
18

ln one case recrrenL nasolacrlmal dcL occlslon was observed presmably cased by
washlng of Lhe scales lnLo Lhe lacrlmal sac
Dsally anLerlor velLls can be seen ln assoclaLlon wlLh psorlaLlc arLhrlLls cLe psorlaLlc
velLls Lends Lo be bllaLeral prolonged and more severe Lhan nonpsorlaLlc cases
19 20

Comp||cat|ons
CompllcaLlons of psorlasls may lnclde Lhe followlng
age 9 of 24 10/19/2011 846M

O Secondary lnfecLlons
O osslble lncreased rlsk of lymphoma
O osslble lncreased rlsk of cardlovasclar and lschemlc hearL dlsease
O sorlaLlc arLhrlLls
O MlLral valve prolapse

D|agnost|c Cons|derat|ons
CondlLlons Lo be consldered lnclde Lhe followlng
O Seborrhelc dermaLlLls
O ulaper dermaLlLls
O Cnychomycosls
O Sqamos cell carclnoma
O -mmlar eczema
O Llchen plans
O Llchen slmplex chronlcs
O Mycosls fngoldes
O Sbcorneal psLlosls
O sLlar erpLlons
D|fferent|a|s
O dlL 8lepharlLls
O Loplc uermaLlLls
O Loplc keraLocon[ncLlvlLls
O ConLacL uermaLlLls
O ury Lye Syndrome
O oL and sedogoL
O lLyrlasls lba
O lLyrlasls 8osea
O 8eacLlve rLhrlLls
O Slcca keraLocon[ncLlvlLls
O Syphllls
O 1lnea
Approach Cons|derat|ons
1he dlagnosls of psorlasls ls cllnlcal 1he dlfferenLlaLlon of psorlaLlc arLhrlLls from rhemaLold
arLhrlLls and goL can be faclllLaLed by Lhe absence of Lhe Lyplcal laboraLory flndlngs of Lhose
condlLlons
age 10 of 24 10/19/2011 846M

Lab Stud|es
LaboraLory sLdles and flndlngs for paLlenLs wlLh psorlasls may lnclde Lhe followlng
O 1esL reslL for rhemaLold facLor (8l) ls negaLlve
O LryLhrocyLe sedlmenLaLlon raLe (LS8) ls sally normal (excepL ln psLlar and
eryLhrodermlc psorlasls)
O Drlc acld level may be elevaLed ln psorlasls (especlally ln psLlar psorlasls) caslng
confslon wlLh goL ln psorlaLlc arLhrlLls
O llld from psLles ls sLerlle wlLh neLrophlllc lnfllLraLe
O erform fngal sLdles (1hls ls especlally lmporLanL ln cases of hand and fooL psorlasls
LhaL seem Lo be worsenlng wlLh Lhe se of Loplcal sLerolds)
lf sLarLlng sysLemlc Lheraples sch as lmmnologlcal lnhlblLors conslder obLalnlng basellne
laboraLory sLdles (le compleLe blood conL C8C blood rea nlLrogen 8D-/creaLlnlne llver
fncLlon LesLs Ll1s hepaLlLls panel Lberclosls 18 screenlng)
Cther 1ests
lLhogh mosL cases of psorlasls are dlagnosed cllnlcally some parLlclarly Lhe psLlar forms
can be dlfflclL Lo recognlze ln Lhese cases dermaLologlc blopsy can be sed Lo make dlagnosls
8lopsy of Lhe skln leslon may reveal basal cell hyperplasla prollferaLlon of sbepldermal
vasclaLre absence of normal cell maLraLlon and keraLlnlzaLlon large nmber of acLlvaLed
1 cells are presenL ln Lhe epldermls Leslons from oLher lnflammaLory condlLlons may be rbbed
and scraLched nLll Lhey develop psorlaslform hlsLologlcal changes
8adlographs of affecLed [olnLs can be helpfl ln dlfferenLlaLlng Lypes of arLhrlLls !olnL xrays can
faclllLaLe Lhe dlagnosls of psorlaLlc arLhrlLls 8one scans can ldenLlfy [olnL lnvolvemenL early
Con[ncLlval lmpresslon cyLology has demonsLraLed an lncreased lncldence of sqamos
meLaplasla neLrophll clmplng and snakellke chromaLln
When Lhe scales are removed small dropleLs of blood appear wlLhln a few seconds Lhls ls
known as Lhe splLz slgn
Approach Cons|derat|ons
ManagemenL of psorlasls may lnvolve drgs llghL Lherapy sLress redcLlon cllmaLoLherapy
and varlos ad[ncLs sch as snshlne molsLrlzers and sallcyllc acld
1he merlcan cademy of uermaLology (u) ls developlng a serles of recommendaLlons nder
Lhe mbrella LlLle ColJelloes of cote fot tbe Moooqemeot of lsotlosls ooJ lsotlotlc Attbtltls
1he mosL recenL addlLlon was SecLlon 6 (pbllshed onllne ln -ovember 2010 ln prlnL 2011) ll
age 11 of 24 10/19/2011 846M

6 secLlons are avallable onllne aL Lhe u webslLe
21 22 23 24 23
SecLlon 6 of Lhe u gldellne
recommends LhaL psorlasls LreaLmenL be personallzed for each paLlenL's cllnlcal slLaLlon and
dlscsses examples of Lhls approach Lo LreaLmenL
23

1reatment of Sk|n Les|ons
aLlenLs wlLh gLLaLe eryLhrodermlc or psLlar psorlasls may presenL Lo Lhe emergency
deparLmenL ln each of Lhese cases resLoraLlon of Lhe barrler fncLlon of Lhe skln ls of prlme
concern 1hls can be performed wlLh cleanlng and bandaglng
laqe and scalp leslons are freqenLly enconLered ln paLlenLs seeklng care for oLher
problems and lnlLlal LreaLmenL of Lhe leslons shold be offered
1he slmplesL LreaLmenL of psorlasls ls dally sn exposre sea baLhlng Loplcal molsLrlzers and
relaxaLlon MolsLrlzers sch as peLrolaLm [elly are helpfl ually appllcaLlon of molsLrlzlng
cream Lo Lhe affecLed area ls lnexpenslve and sccessfl ad[ncL Lo psorlasls LreaLmenL
ppllcaLlon lmmedlaLely afLer a baLh or shower helps Lo mlnlmlze lLchlng and Lenderness
SecLlon 3 (2009) of Lhe u gldellne dlscsses Loplcal agenLs and recommends Lhelr se
ad[ncLlvely bL noL as monoLherapy lf Lhe dlsease ls exLenslve or recalclLranL
22

-onprescrlpLlon Lar preparaLlons are avallable and have LherapeLlc sccess especlally when
sed ln con[ncLlon wlLh Loplcal corLlcosLerolds Lhe newer foams are less messy preparaLlons
Lhan some of Lhe older ones nLhralln Loplcal corLlcosLerolds sallcyllc acld phenollc
componds and calclpoLrlene (a vlLamln u analog) also may be effecLlve SysLemlc
corLlcosLerolds are generally lneffecLlve and Lhey can slgnlflcanLly exacerbaLe Lhe dlsease pon
wlLhdrawal ComblnaLlon Lherapy wlLh a vlLamln u analog (calclpoLrlol and calclpoLrlene) or a
reLlnold sch as LazaroLene and a Loplcal corLlcosLerold ls more effecLlve Lhan Lherapy wlLh
elLher agenL alone
26
CaLmeal baLhs may be helpfl
Solar or lLravloleL radlaLlon may be helpfl varlos lLravloleL llghL LreaLmenLs are sed
mosL commonly psoralenlLravloleL (Dv) Lherapy mong phoLoLherapy opLlons SecLlon
3 (2010) of Lhe u gldellne glves Lhe hlghesL recommendaLlon Lo oral Dv or a comblnaLlon
of Dv and Loplcal agenLs
24
soralen ls a phoLosenslLlzer LhaL ls lngesLed prlor Lo llghL
exposre Dv LreaLmenL reslLs ln con[ncLlval hyperemla and dry eye parLlclarly lf sn
proLecLlon ls noL sed WlLh proper eye proLecLlon Lhere does noL appear Lo be a rlsk of
caLaracL soralens for elLher Loplcal (baLh) or sysLemlc se may occaslonally be dlfflclL Lo
obLaln becase of sLocklng shorLages
ccordlng Lo Lhe u gldellnes Dv can reslL ln long remlsslons bL longLerm se of Dv
ln Cacaslans may lncrease Lhe rlsk of sqamos cell carclnoma and posslbly mallgnanL
melanoma
21 24

-arrowband lLravloleL 8 (Dv8) Lherapy has always been accepLed as a good LreaLmenL
modallLy of psorlasls and Lhe u gldellnes recommend lL over broadband (Dv) alLhogh
age 12 of 24 10/19/2011 846M

boLh are less effecLlve Lhan Dv
21 24
s wlLh Dv Lhe gldellnes also recommend
LreaLmenL wlLh comblnaLlons of Dv8 and Loplc or sysLemlc agenLs
24
Powever a sLdy by
keaney and klrsner glves ob[ecLlve reasonlng for Lhe beneflL of narrowband Dv Lherapy by
showlng decreases ln 1 cells dendrlLlc cells and lnLerleklns wlLhln responslve psorlaLlc plaqes
compared wlLh plaqes LhaL dld noL respond Lo Lherapy
3
LaLe psorlasls may prove
especlally responslve Lo phoLoLherapy 1heraples sch as Dv8 and Dv have low efflcacy for
Lhe LreaLmenL of nall psorlasls becase of Lhe blockage of Lhe Dv radlaLlon by Lhe lnLervenlng
nall plaLe
27

aLlenLs wlLh psorlasls shold avold ln[ry Lo skln lncldlng snbrn and oLher physlcal Lrama
as Lhese areas may develop psorlasls 1he appearance of psorlaLlc leslons ln prevlosly
nlnvolved areas afLer lrrlLaLlon or Lrama ls known as Lhe kbner phenomenon aLlenLs wlLh
psorlasls shold also avold drgs known Lo worsen Lhe problem (eg chloroqlne beLablockers
asplrln or oLher -Slus)
ln severe cases reLlnolds (aclLreLln) meLhoLrexaLe cyclosporlne 6Lhloganlne azaLhloprlne a
blologlc or hydroxyrea may be sed 8eLlnolds have been reporLed Lo case dry eye
blepharlLls corneal opaclLles caLaracLs and decreased nlghL vlslon
28 29
ll of Lhese may be
assoclaLed wlLh gasLrolnLesLlnal lnLolerance hepaLlc damage (aclLreLln 6Lhloganlne
azaLhloprlne meLhoLrexaLe) marrow sppresslon (6Lhloganlne meLhoLrexaLe azaLhloprlne
hydroxyrea) or renal damage (cyclosporlne) 1he se of Lhese sysLemlc medlcaLlons wlLh
approprlaLe safeLy conslderaLlons ls spporLed by SecLlon 4 (2009) of Lhe u gldellnes
23

ln addlLlon sysLemlc reLlnolds and hydroxyrea may lnLerfere wlLh proper wond heallng and
elecLlve procedres lncldlng denLal srgery whlch are besL performed before Lhe sLarL of Lhe
medlcaLlons clLreLln appears more effecLlve Lhan lsoLreLlnoln ln psorlasls and does noL
reqlre enrollmenL ln Lhe lledge program Cn Lhe oLher hand Lhere ls a 3year pregnancy
prohlblLlon afLer lLs se and many wlll noL se Lhls medlcaLlon ln any paLlenL capable of ever
becomlng pregnanL ComblnaLlon Lheraples sch as a blologlc pls anoLher lmmnosppresslve
medlcaLlon have been sed wlLh good effecL bL daLa deLalllng Lhe safesL way Lo do Lhls are
scanL ll of Lhe sysLemlc medlcaLlons excepL aclLreLln may lncrease Lhe rlsk of lnfecLlon
brpLly sLopplng sLerold Lherapy ln psorlasls or addlng known lrrlLanL drgs can reslL ln Lhe
sdden worsenlng of psorlasls or appearance of a new form Commonly Lhls new form ls
gLLaLe psorlasls whlch ls mch more severe and cosmeLlcally problemaLlc Lhan Lhe preexlsLlng
plaqe Lype lL may also presenL wlLh a more LhreaLenlng psLlar or eryLhrodermlc psorlaLlc
flare
1he se of blologlc agenLs (proLelns wlLh pharmacologlc acLlvlLy) ls dlscssed ln SecLlon 1 (2008)
and revlewed wlLh pdaLed safeLy lnformaLlon ln SecLlon 6 of Lhe u gldellnes 1he u
recommends a seL of basellne laboraLory sLdles before sLarLlng LreaLmenL wlLh a blologlc
agenL Lo ensre any nderlylng condlLlons or rlsk facLors are ndersLood
21 23

age 13 of 24 10/19/2011 846M

Many of Lhe Lheraples for psorlasls manlplaLe Lhe fncLlon of Lhe lmmne sysLem and expose
Lhe paLlenL Lo rlsk of severe lnfecLlons whlle blnLlng Lhe body's response ln Lhese paLlenLs
flndlngs sggesLlve of mlnor lnfecLlons msL be Laken serlosly and Lhe rlsk verss Lhe beneflL
of conLlnlng Lhe drg ln Lhe face of Lhe lnfecLlon msL be welghed
1reatment of Ccu|ar Comp||cat|ons
keraLocon[ncLlvlLls slcca can be LreaLed wlLh oclar lbrlcanLs and pncLal occlslon 1rlchlasls
and clcaLrlclal ecLroplon sally reqlre srglcal LreaLmenL Con[ncLlval corneal and anLerlor
chamber lnflammaLlon can be LreaLed wlLh Loplcal corLlcosLerolds -onsLeroldal anLl
lnflammaLory agenLs or oral corLlcosLerolds are occaslonally necessary WheLher sysLemlc
lmmnosppresslon ls effecLlve for oclar dlsease ls noL clear
Corneal melLlng lnflammaLlon and vasclarlzaLlon can be dlfflclL Lo LreaL bandage conLacL
lens may reLard Lhe melLlng 1oplcal corLlcosLerolds can conLrol Lhe lnfllLraLlon and delay Lhe
vasclarlzaLlon ln some cases progresslon can occr ln splLe of Lhese LreaLmenLs and can lead
Lo Lhe need for lamellar or peneLraLlng keraLoplasLy
Consu|tat|ons
sorlasls ls a chronlc problem and conslLaLlon for followp wlLh a dermaLologlsL or a
rhemaLologlsL ls approprlaLe Close followp ls necessary Lo deslgn an opLlmal LreaLmenL plan
ln accordance wlLh Lhe severlLy of dlsease
SeverlLy of psorlasls can be classlfled as follows
O Mlld Less Lhan 2 of Lhe body ls affecLed
O ModeraLe lrom 310 of Lhe body ls affecLed
O Severe More Lhan 10 of Lhe body ls affecLed
Cf noLe Lhe palm of Lhe paLlenL's hand ls eqal Lo 1 body srface area
ueLermlnlng Lhe severlLy of psorlasls reqlres comblnlng ob[ecLlve measres sch as body
srface area lnvolvemenL dlsease locaLlon sympLoms and presence of psorlaLlc arLhrlLls wlLh
sb[ecLlve measres sch as Lhe physlcal flnanclal and emoLlonal lmpacL of Lhe dlsease
aLlenLs wlLh lnfecLlos dlseases and psorlasls may be slng drgs LhaL modlfy lmmnologlc
response and render Lhem lmmnocompromlsed lnvesLlgaLlon lnLo Lhe Lype of Lherapy ls
lmporLanL and lf sch an agenL ls ldenLlfled referral and close followp ls needed
Med|cat|on Summary
age 14 of 24 10/19/2011 846M

Many drgs LhaL affecL Lhe raLe of skln cell prodcLlon are sed ln psorlasls Lherapy alone or ln
comblnaLlon wlLh llghL Lherapy sLress redcLlon and cllmaLoLherapy d[ncLs Lo LreaLmenL
lnclde snshlne molsLrlzers and sallcyllc acld as a scaleremovlng agenL enerally Lhese
Lheraples are sed for paLlenLs wlLh less Lhan 20 of body srface area lnvolved nless Lhe
leslons are physlcally soclally or economlcally dlsabllng
1reaLmenLs for more advanced psorlasls lnclde narrowband lLravloleL 8 (Dv8) llghL psoralen
wlLh lLravloleL (Dv) llghL reLlnolds (eg lsoLreLlnoln ccLane Claravls aclLreLln
SorlaLane) meLhoLrexaLe (parLlclarly for arLhrlLls) cyclosporlne (-eoral Sandlmmne)
lnfllxlmab (8emlcade) eLanercepL (Lnbrel) adallmmab (Pmlra) and alefacepL (mevlve)
1he u gldellnes recommend LreaLmenL wlLh meLhoLrexaLe cyclosporlne and aclLreLln wlLh
conslderaLlon of Lhe conLralndlcaLlons and drg lnLeracLlons noLed ln Lhe dlscsslon of each
medlcaLlon below
23

1op|ca| Cort|costero|ds
C|ass Summary
1oplcal corLlcosLerolds are sed Lo redce plaqe formaLlon 1hese agenLs have anLl
lnflammaLory effecLs and may case profond and varled meLabollc acLlvlLles ln addlLlon Lhey
modlfy Lhe body's lmmne response Lo dlverse sLlmll
Several examples are provlded bL no Loplcal corLlcosLerolds are sperlor ln efflcacy or adverse
effecLs Lo oLhers ln Lhe same class Some formlaLlons sch as foams and solLlons are easler Lo
se ln Lhe scalp Lhan elLher creams or olnLmenLs paLlenL who has been dolng well on a
Loplcal sLerold who beglns Lo have worsenlng especlally wlLh lLchlng shold be evalaLed for
elLher a concomlLanL fngal lnfecLlon or Lhe developmenL of allerglc conLacL dermaLlLls Lo a
sLerold or vehlcle componenL
vlew fll drg lnformaLlon
1r|amc|no|one aceton|de (Ar|stocort kena|og) 002S01 cream

1rlamclnolone LreaLs lnflammaLory dermaLosls responslve Lo sLerolds lL decreases
lnflammaLlon by sppresslng mlgraLlon of polymorphonclear lekocyLes and reverslng
caplllary permeablllLy lL has mlld poLency and ls Lhe flrsL drg of cholce for mosL paLlenLs
8etamethasone (D|pro|ene D|prosone) 002S01 cream
age 1S of 24 10/19/2011 846M

8eLameLhasone LreaLs lnflammaLory dermaLosls responslve Lo sLerolds lL decreases
lnflammaLlon by sppresslng mlgraLlon of polymorphonclear lekocyLes and reverslng
caplllary permeablllLy lL ls a poLenL Loplcal sLerold and ls Lhe drg of cholce lf psorlasls ls
reslsLanL Lo mllder forms
Cphtha|m|c Cort|costero|ds
C|ass Summary
CphLhalmlc corLlcosLerolds LreaL con[ncLlval corneal and anLerlor chamber lnflammaLlon
1hese agenLs help conLrol lnfllLraLlon and delay vasclarlzaLlon
redn|so|one acetate 1 ophtha|m|c (red Iorte)

rednlsolone decreases lnflammaLlon by sppresslng mlgraLlon of polymorphonclear
lekocyLes and reverslng lncreased caplllary permeablllLy
ln cases of bacLerlal lnfecLlons concomlLanL se of anLllnfecLlve agenLs ls mandaLory lf slgns
and sympLoms do noL lmprove afLer 2 days reevalaLe paLlenL uoslng may be redced bL
advlse paLlenLs noL Lo dlsconLlne Lherapy premaLrely
Dexamethasone 01 ophtha|m|c

uexameLhasone ls sed for varlos allerglc and lnflammaLory dlseases lL decreases
lnflammaLlon by sppresslng mlgraLlon of polymorphonclear lekocyLes and redclng caplllary
permeablllLy
Coa| 1ar
C|ass Summary
Coal Lar ls an lnexpenslve LreaLmenL LhaL ls avallable over Lhe conLer ln shampoos loLlons
creams or foam for se ln wldespread areas of lnvolvemenL lL ls parLlclarly sefl ln halr
bearlng areas Some recenL research has shown Lhe 1 concenLraLlon may be sperlor ln
conLrol of leslons Lo more concenLraLed preparaLlons 1ar preparaLlons may be especlally sefl
age 16 of 24 10/19/2011 846M

when comblned wlLh Loplcal corLlcosLerolds 1hls may be accompllshed by applylng Lhe
prodcLs seqenLlally or when avallable obLalnlng Lhem from a compondlng pharmacy
Coa| tar 0S33 (DnS 1ar Doctar 1herap|ex 1)

Coal Lar ls anLlprrlLlc and anLlbacLerlal and lnhlblLs dereglaLed epldermal prollferaLlon and
dermal lnfllLraLlon lL does noL ln[re Lhe normal skln when applled wldely and lL enhances Lhe
seflness of phoLoLherapy lL generally ls sed as a secondllne drg Lherapy de Lo messy
appllcaLlon excepL for shampoos whlch may be sed and rlnsed aL once
kerato|yt|c Agents
C|ass Summary
keraLolyLlc agenLs are sed Lo remove scale Lo smooLh Lhe skln and Lo LreaL hyperkeraLosls
8emovlng Lhe Lhlck scale allows Loplcal corLlcosLerolds and oLher Loplcal medlcaLlons Lo beLLer
reach Lhe LargeL Llsses and achleve beLLer reslLs 1hls ls especlally lmporLanL on Lhe scalp
Many overLheconLer preparaLlons can be sed for Lhls mosL of whlch conLaln sallcyllc acld
LacLlc acld ammonlm lacLaLe and rea are oLher lngredlenLs LhaL may be applled before or aL
Lhe same Llme as oLher Loplcal medlcaLlons Drea preparaLlons sLronger Lhan 30 reqlre a
prescrlpLlon a varleLy of creams loLlons and foams are avallable for Lhls Many fooL creams"
conLaln comblnaLlons of keraLolyLlcs and may be applled Lo any area of Lhe body needlng scale
removal
nLhralln ls also consldered Lo be ln Lhe anLlpsorlaLlc LherapeLlc class
Anthra||n 011 (Dr|thocreme AnthraDerm)

nLhralln redces Lhe raLe of cell prollferaLlon lLs chemlcally redclng properLles may also
pseL Lhe oxldaLlve meLabollc processes frLher redclng epldermal mlLosls lL ls noL Lhe flrsL or
second drg of cholce de Lo lrrlLaLlon problems of normal skln srrondlng leslons and
sLalnlng of Lhe skln
V|tam|n D Ana|ogs
C|ass Summary
age 17 of 24 10/19/2011 846M

vlLamln u analogs are sed ln paLlenLs wlLh leslons reslsLanL Lo Loplcal Lherapy or wlLh leslons
on Lhe face or exposed areas where Lhlnnlng of Lhe skln wold pose cosmeLlc problems 1hese
come as olnLmenLs solLlons and foams 1he laLLer 2 are especlally sefl for scalp LreaLmenLs
Ca|c|tr|o| (Vect|ca|) C|ntment

CalclLrlol ls a Loplcal vlLamln u analog slmllar Lo calclpoLrlene bL seems Lo be less lrrlLaLlng ln
senslLlve areas of skln
Ca|c|potr|ene (Dovonex Sor||ux)

CalclpoLrlene ls a synLheLlc vlLamln u3 analog LhaL reglaLes skln cell prodcLlon and
developmenL lL ls sed ln Lhe LreaLmenL of moderaLe plaqe psorlasls 1hls LreaLmenL does noL
case longLerm skln Lhlnnlng or sysLemlc effecLs Sorllx ls a newer foam verslon of Lhls
medlcaLlon
Ca|c|potr|ene and betamethasone top|ca| o|ntment (1ac|onex)

CalclpoLrlene ls a synLheLlc vlLamln u3 analog LhaL reglaLes skln cell prodcLlon and
developmenL lL lnhlblLs epldermal prollferaLlon promoLes keraLlnocyLe dlfferenLlaLlon and has
lmmnosppresslve effecLs on lymphold cells 8eLameLhasone ls a corLlcosLerold LhaL
decreases lnflammaLlon by sppresslng mlgraLlon of polymorphonclear lekocyLes and
reverslng caplllary permeablllLy 1he comblnaLlon ls avallable as a Loplcal olnLmenL and as a
scalp solLlon conLalnlng calclpoLrlene 0003 and beLameLhasone dlproplonaLe 0064
1he prodcL ls qlLe expenslve and Lhe same reslLs may be obLalned by slng a generlc
corLlcosLerold seqenLlally ln comblnaLlon wlLh one of Lhe oLher vlLamln u analog prodcLs
1op|ca| ket|no|ds
C|ass Summary
age 18 of 24 10/19/2011 846M

qeos gel formlaLlons are odorless and colorless and no longLerm skln damage has been
noLed wlLh Loplcal reLlnolds 1here ls also no LhreaL of worsenlng lf Lhe Lherapy ls wlLhdrawn as
wlLh sLerolds 1hese drgs shold noL be sed ln women lf pregnancy ls a posslblllLy
1azarotene (1azorac) aqueous ge| and cream 00S and 01

1azaroLene ls a reLlnold prodrg LhaL ls converLed Lo lLs acLlve form ln Lhe body and modlaLes
dlfferenLlaLlon and prollferaLlon of eplLhellal Llsse and perhaps has anLllnflammaLory and
lmmnomodlaLory acLlvlLles lL may be Lhe drg of cholce for Lhose wlLh faclal leslons who are
noL aL rlsk of pregnancy
1azaroLene alLhogh Loplcal ls a caLegory x medlcaLlon 1oplcal LreLlnoln ls of less se ln
psorlaLlc paLlenLs sLraLegy LhaL may be Lrled ln paLlenLs who experlence naccepLable
lrrlLaLlon ls Lo se shorL conLacL Llmes 1here are several proLocols bL Lhe leasL lrrlLaLlng ls Lo
apply Lhe medlcaLlon for 1320 mln and Lhen wash off 1he LoLal Llme on may be lncreased by
1320 mlnLes every few weeks nLll cllnlcal efflcacy or adverse cLaneos effecLs are seen
1hls shorLconLacL meLhod may be especlally sefl when one ls slng lL ln skln folds bL ls less
effecLlve for Lhe plaqe wlLh very Lhlck scale
Ant|metabo||tes
C|ass Summary
nLlmeLabollLes lnhlblL cell growLh and prollferaLlon
Methotrexate (1rexa||)

MeLhoLrexaLe lnhlblLs dlhydrofollc acld redcLase ulhydrofolaLes msL be redced Lo
LeLrahydrofolaLes by Lhls enzyme before Lhey can be Llllzed as carrlers of onecarbon grops ln
Lhe synLhesls of ncleoLldes and LhymldylaLe SbseqenLly meLhoLrexaLe lnLerferes wlLh u-
synLhesls repalr and celllar repllcaLlon cLlvely prollferaLlng Llsses are ln general more
senslLlve Lo Lhls effecL of meLhoLrexaLe
Immunomodu|ators
age 19 of 24 10/19/2011 846M

C|ass Summary
lmmnomodlaLors reglaLe key facLors responslble for lnflammaLory response
1acro||mus top|ca| 01 (rotop|c)

1oplcal Lacrollms has been sed ln Lhe pasL for managemenL of refracLory aLoplc dermaLlLls
Powever mlLlple sLdles have shown effecLlveness wlLh psorlasls affecLlng lnLerLrlglnos
reglons as well as Lhe face enerally lL seems Lo be effecLlve ln Lhlnsklnned areas Powever lL
has become somewhaL of a secondllne agenL glven oLher sLdles showlng Loplcal sLerolds may
be more effecLlve and poLenLlal serlos dlsease assoclaLlon
Cyc|ospor|ne (Sand|mmune Neora|)

Cyclosporlne ls an 11amlno acld cycllc pepLlde and naLral prodcL of fngl lL acLs on 1cell
repllcaLlon and acLlvlLy
Cyclosporlne ls a speclflc modlaLor of 1cell fncLlon and an agenL LhaL depresses cell
medlaLed lmmne responses by lnhlblLlng helper 1cell fncLlon referenLlal and reverslble
lnhlblLlon of 1 lymphocyLes ln Lhe 0 or 1 phase of cell cycle ls sggesLed 1he drg blnds Lo
cyclophllln an lnLracelllar proLeln whlch ln Lrn prevenLs formaLlon of lnLerlekln (lL)2 and
Lhe sbseqenL recrlLmenL of acLlvaLed 1 cells
Cyclosporlne has aboL 30 bloavallablllLy bL Lhere ls marked lnLerlndlvldal varlablllLy lL
speclflcally lnhlblLs 1lymphocyLe fncLlon wlLh mlnlmal acLlvlLy agalnsL 8 cells Maxlmm
sppresslon of 1lymphocyLe prollferaLlon reqlres LhaL Lhe drg be presenL drlng flrsL 24 h of
anLlgenlc exposre
Cyclosporlne sppresses some hmoral lmmnlLy and Lo a greaLer exLenL cellmedlaLed
lmmne reacLlons (eg delayed hypersenslLlvlLy allografL re[ecLlon experlmenLal allerglc
encephalomyellLls and grafL verss hosL dlsease) for a varleLy of organs
Cyclosporlne ls sed ln exLenslve dlsease refracLory Lo oLher LreaLmenLs especlally when sed
aL 3 mg/kg/d 8emlsslon ls sally rapld wlLh Lhls Lherapy however skln leslons Lend Lo recr
wlLhln days Lo weeks afLer LreaLmenL ls sLopped (alLhogh paLlenLs do noL sally have Lhe
age 20 of 24 10/19/2011 846M

severe rebond LhaL paLlenLs wlLhdrawlng from Lherapy may have) MalnLenance Lherapy (3
mg/kg/d) sally ls reqlred wlLh lower doses of Lhls drg
A|efacept (Amev|ve)

lefacepL ls a recomblnanL dlmerlc fslon proLeln LhaL blnds Lo Cu2 on memoryeffecLor 1
lymphocyLes Lhereby lnhlblLlng Lhe acLlvaLlon of Lhese cells and redclng Lhe nmber of Lhese
cells lL ls lndlcaLed for moderaLe Lo severe psorlasls 1hls drg sally ls admlnlsLered
lnLramsclarly
Ustek|numab (Ste|ara)

DsLeklnmab ls a hman monoclonal anLlbody dlrecLed agalnsL lL12 and lL23 Lhereby
lnLerferlng wlLh 1cell dlfferenLlaLlon and acLlvaLlon and sbseqenL cyLoklne cascades lL ls
lndlcaLed for moderaLeLosevere plaqe psorlasls
1umor Necros|s Iactor Inh|b|tors
C|ass Summary
1hese agenLs neLrallze Lhe effecLs of Lmor necrosls facLor (1-l)
Inf||x|mab (kem|cade)

lnfllxlmab ls a chlmerlc anLlbody LhaL blnds boLh Lhe solble and Lransmembrane 1-l
molecles Lhereby neLrallzlng Lhe effecLs of 1-l lL ls lndlcaLed for chronlc severe (le
exLenslve and/or dlsabllng) plaqe psorlasls ln adlLs who are candldaLes for sysLemlc Lherapy
and when oLher sysLemlc Lheraples are medlcally less approprlaLe lL ls also lndlcaLed Lo redce
slgns and sympLoms and Lo lmprove physlcal fncLlon of paLlenLs wlLh psorlaLlc arLhrlLls
Screen paLlenLs for Lberclosls (18) and hepaLlLls 8 as reacLlvaLlon of boLh lllnesses ls
assoclaLed wlLh 1-l lnhlblLors
age 21 of 24 10/19/2011 846M

1hls drg ls dellvered by lnfslon only
Ltanercept (Lnbre|)

LLanercepL ls a recomblnanL hman 1-l recepLor proLeln fsed wlLh Lhe lc porLlon of lg1
LhaL blnds Lo solble and membranebond 1-l Lhereby neLrallzlng Lhe effecLs of 1-l lL
ls lndlcaLed for moderaLeLosevere psorlasls and moderaLeLosevere psorlaLlc arLhrlLls Screen
paLlenLs for 18 and hepaLlLls 8 as reacLlvaLlon of boLh lllnesses ls assoclaLed wlLh 1-l
lnhlblLors
Ada||mumab (num|ra)

dallmmab ls a flly hman anLl1-l monoclonal anLlbody lL blnds speclflcally Lo solble
and membranebond 1-l Lhereby neLrallzlng Lhe effecLs of 1-l lL ls sed Lo LreaL
moderaLeLosevere psorlasls and moderaLeLosevere psorlaLlc arLhrlLls Screen paLlenLs for 18
and hepaLlLls 8 as reacLlvaLlon of boLh lllnesses ls assoclaLed wlLh 1-l lnhlblLors
Art|f|c|a| 1ears
C|ass Summary
rLlflclal Lears are sed Lo LreaL dry eye lrrlLaLlon Many Lypes of arLlflclal Lears are avallable
over Lhe conLer ln mlld cases preserved Lears can be sed ln severe cases only
nonpreserved Lears shold be sed reserved Lears lnclde en1eal 8efresh 1ears and 1ears
-aLrale ll -onpreserved Lears lnclde 8efresh 8efresh ls CcCoaL 8lon and Pypo 1ears
l
Art|f|c|a| tears

age 22 of 24 10/19/2011 846M

rLlflclal Lears conLaln Lhe eqlvalenL of 09 -aCl and are sed Lo malnLaln oclar LonlclLy
1hey acL Lo sLablllze and Lhlcken precorneal Lear fllm and prolong Lear fllm breakp Llme whlch
occrs wlLh dry eye sLaLes
In[ectab|e Cort|costero|ds
C|ass Summary
lnLramsclar corLlcosLerolds are noL recommended for Lhe managemenL of psorlasls becase
of Lhe rlsk of flare pon wlLhdrawal Cn Lhe oLher hand lsolaLed plaqes may be ln[ecLed
lnLraleslonally as may Lhe nall maLrlx ln cases of severe psorlaLlc nalls
1r|amc|no|one 10 mg]mL

lor lnflammaLory dermaLosls responslve Lo sLerolds decreases lnflammaLlon by sppresslng
mlgraLlon of polymorphonclear lekocyLes and reverslng caplllary permeablllLy Many oLher
Loplcal sLerolds also are avallable
Dp Lo 04 mL may be ln[ecLed afLer rlng block lnLo Lhe nall bed and maLrlx Lo lmprove psorlaLlc
dysLrophy 8eslLs may be long lasLlng bL more Lhan one LreaLmenL may be reqlred

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4 kreger ! 8owcock sorlasls paLhophyslology crrenL concepLs of paLhogenesls
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3 keaney 1C klrsner 8S -ew lnslghLs lnLo Lhe mechanlsm of narrowband Dv8 Lherapy
for psorlasls I lovest etmotol -ov 2010130(11)2334 Medllne
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cyLology and Learfllm changes ln paLlenLs wlLh psorlasls cotoeo Sep 199918(3)3448
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8 8lvelraMnoz L Pe SM Lscaramls eL al MeLanalysls Conflrms Lhe LCL3C_LCL38
ueleLlon as a 8lsk lacLor for sorlasls ln Several LLhnlc rops and llnds lnLeracLlon wlLh
PLCw6 I lovest etmotol May 2011131(3)11039 Medllne
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psorlasls ln frlcan merlcans reslLs from a poplaLlonbased sLdy I Am AcoJ
etmotol !an 200332(1)236 Medllne
10elfand !M 1roxel 8 Lewls !u krd Sk Shln u8 Wang x eL al 1he rlsk of morLallLy ln
paLlenLs wlLh psorlasls reslLs from a poplaLlonbased sLdy Atcb etmotol uec
2007143(12)14939 Medllne
11aLel 8v Shelllng ML rodanovlch S lederman u klrsner 8S sorlasls and vasclar
dlseaserlsk facLors and oLcomes a sysLemaLlc revlew of Lhe llLeraLre I Ceo loteto
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1)4017 Medllne
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g 2010146(8)8913 Medllne lll 1exL
14eLLey 8alkrlshnan 8 8app S8 llelscher 8 leldman S8 aLlenLs wlLh palmoplanLar
psorlasls have more physlcal dlsablllLy and dlscomforL Lhan paLlenLs wlLh oLher forms of
psorlasls lmpllcaLlons for cllnlcal pracLlce I Am AcoJ etmotol g 200349(2)2713
Medllne
13Sampogna l 1abolll S SderfeldL 8 xLells 8 paro D benl u Measrlng qallLy of
llfe of paLlenLs wlLh dlfferenL cllnlcal Lypes of psorlasls slng Lhe Sl36 8t I etmotol
May 2006134(3)8449 Medllne
16CaLsaroCaLsarl kaLambs 1heodorpoylos CphLhalmologlcal manlfesLaLlons ln
paLlenLs wlLh psorlasls ln Acto etm veoeteol (5tock) 64 1984337339
17Pynh - CervanLesCasLaneda 8 8haL allagher M! losLer CS 8lologlc response
modlfler Lherapy for psorlaLlc oclar lnflammaLory dlsease col lmmoool loflomm
May!n 200816(3)8993 Medllne
18Moadel k erry Pu uonnenfeld Lu Zagelbam 8 lngraham P! sorlaLlc corneal
abscess Am I pbtbolmol !n 1993119(6)8001 Medllne
19urranl k losLer CS sorlaLlc velLls a dlsLlncL cllnlcal enLlLy? Am I pbtbolmol !an
2003139(1)10611 Medllne
201akahashl P SglLa S Shlmlz - Mochlzkl M hlgh vlral load of LpsLeln8arr vlrs
u- ln oclar fllds ln an PL827negaLlve acLe anLerlor velLls paLlenL wlLh psorlasls
Ipo I pbtbolmol Marpr 200832(2)1368 Medllne
21ldellne MenLer oLLlleb leldman S8 van voorhees S Leonardl CL ordon
k8 eL al ldellnes of care for Lhe managemenL of psorlasls and psorlaLlc arLhrlLls
SecLlon 1 Cvervlew of psorlasls and gldellnes of care for Lhe LreaLmenL of psorlasls
wlLh blologlcs I Am AcoJ etmotol May 200838(3)82630 Medllne
22ldellne MenLer korman -! LlmeLs C leldman S8 elfand !M ordon k8 eL al
ldellnes of care for Lhe managemenL of psorlasls and psorlaLlc arLhrlLls SecLlon 3
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ldellnes of care for Lhe managemenL and LreaLmenL of psorlasls wlLh Loplcal
Lheraples I Am AcoJ etmotol pr 200960(4)64339 Medllne
ldellnes of care for Lhe managemenL of psorlasls and psorlaLlc arLhrlLls secLlon 4
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sysLemlc agenLs I Am AcoJ etmotol Sep 200961(3)43183 Medllne
ldellnes of care for Lhe LreaLmenL of psorlasls wlLh phoLoLherapy and
phoLochemoLherapy I Am AcoJ etmotol !an 201062(1)11433 Medllne
ldellnes of care for Lhe LreaLmenL of psorlasls and psorlaLlc arLhrlLls Casebased
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2011Medllne
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plaqe psorlasls cocbtooe otobose 5yst kev pr 13 2009Cu003028 Medllne
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Pman Cadaverlc llngernall laLe Atcb etmotol pr 2011147(4)43941 Medllne
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sorlasls hLLp//emedlclnemedscapecom/arLlcle/1943419overvlew

age 1 of 24 10/19/2011 846M

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