Psoriasis

• Psoriasis is a chronic relapsing disease of the skin characterized by variable clinical features. • The lesions are erythro-squamous –

• The vasculature – erythema
• Increased scale formation • Clinical presentation varies from few localized patches to generalized skin involvement.
Sales Training

Definition
• Psoriasis is a common, chronic, relapsing, inflammatory skin disorder with a strong genetic basis, characterized by circular-to-oval red plaques that usually exhibit silvery white scaling.

Sales Training

Psoriasis
• Common locations are elbows, knees & scalp. • 5% have arthritis. • Onset, at any age, most commonly

teens-twenties.
Sales Training

Psoriasis • Impacts QOL. Sales Training . difficult to truly get psoriasis under control. • May be some gender differences. women may suffer more when afflicted. aggressive therapies are withheld.

6% of psoriatics which significantly affects QOL Sales Training J Dermatol. 2001 Aug.Psoriasis • Complete remission of disease was experienced by 35% of patients • Prevalence of depression were 23.3% in psoriatics which significantly affects Quality of Life (QOL) • Sleep disturbance was seen in 56. 28(8):419-23 .

Sales Training . alcohol consumption. stress & skin trauma (Koebnerization: Areas frequently rubbed or damaged can sometimes lead to plaques of psoriasis). worse in winter. • Negatively affected by cigarette smoking.Psoriasis • Severity tends to wax & wane.

3% of the total dermatology out- patients • Mean age of onset was lower in females • More than half of the patients were in 3rd to 4th decade of life • 17.India • Account for 2.Incidence .34% have involvement of palms and/or soles • Most of men with palm/plantar involvement were in regular manual labor Sales Training J Dermatol. 24(4):230-4 . 1997 Apr.

Sales Training . • Histopathological hallmark features that include:- • Hyperproliferation of epidermal keratinocytes • Hyperkeratosis • Infiltration of immunocytes along with angiogenesis. with resultant typical thickening and scaling of the erythematous skin.Pathophysiology • Psoriatic skin exhibits pathological changes in most of cutaneous cell types.

• There is accompanied by altered differentiation Sales Training . • So keratinocytes need only 3 to 5 days in order to move from the basal layer to the cornified layer (instead of the normal 28 to 30 days).Pathophysiology • Mitotic activity of basal keratinocytes is increased by as much as a factor of 50 in psoriatic skin.

and most other cells of the human body. are the proteins present on the surface of the white blood cell. which allow the body to recognize self versus nonself. • Biomedical defects • Immuno-pathology Sales Training .Etiological Factors • Trigger Factors • Genetic Factors – HLA (Human leukocyte antigen) association Human leukocyte antigens.

Anti-malarials. ACE inhibitors.Trigger Factors • ENVIRONMENTAL • Physical Trauma • Infections • Stress • Drugs : Beta blockers. Oral contraceptives Sales Training .

Sales Training . Associations and exacerbations can be unpredictable. • NSAIDS work by causing a build up of the inflammatory mediator. and may occur months after the medication is first taken.• Lithium is believed to act by enhancing the release of inflammatory mediators from neutrophils • Beta-blockers by decreasing cyclic adenosine monophosphate and cyclic (AMP)-dependent protein kinase. arachinoidonic acid. • Anti-malarials are also associated but for unknown reasons.

Trigger Factors • Alcohol • Hyperglycemia • Climate Sales Training .

Biomedical Defects in Psoriatic scales • Alterations in levels of cyclic neucleotides • Higher amounts of polyamines and arachidonic acid • Increased protease activity • Expression of antigens associated with hyperproliferation Sales Training .

Immunopathology • Presence of numerous T cells in lesions • Cytokine profile of TH1 mediated disease • Immune dependent expression of adhesion molecules on keratinocytes • Absence of association with TH2 mediated disorders – AD & Urticaria • Antipsoriatic effects of immunobiologicals which reduce T cell activation & infiltration. Sales Training .

Sales Training .Immunological abnormalities • Abnormal leucocyte function • Altered lymphokine secretion • Free radical generation Pathogenesis remains unclear. All the above could be secondary rather than the cause. as none are the primary defect in psoriasis.

moderate and severe psoriasis Mild Moderate Severe Disease does not alter the patient‟s QOL Disease alters the patient‟s QOL Disease alters the patient‟s QOL Disease does not have a satisfactory response to treatments that have minimal risks Minimal impact of The patient expects disease and may not therapy will improve require treatment QOL Treatments have no known serious risks (eg class 5 topical corticosteroids) Therapies used have minimal risks (ie may be inconvenient.Classification of psoriasis Quality of – life – based definitions of mild. expensive. timeconsuming Sales Training and less than totally effective) Patients are willing to accept lifealtering side-effects to achieve less disease or no disease .

Classification of psoriasis
Mild Moderate Severe

Generally <2% of body surface area is involved

Generally 2% to 10% of body surface area is involved

Sales Training

• Generally >10% of body surface area is involved • Other factors: – Patients attitude about disease – Location of disease (eg, face, hands, fingernails feet, genitals) – Symptoms (eg pain, tightness, bleeding or severe itching) – Arthralgias/arthritis

Clinical Classification
Non Pustular • Psoriasis vulgaris • Psoriatic erythroderma Pustular • Generalized pustular psoriasis • Pustulosis palmaris & plantaris • Guttate psoriasis • Annular pustular psoriasis • Impetigo herpetiformis
Sales Training

Clinical features
• Well defined, erythematous, scaly papules and plaques of varying sizes
• Koebner phenomenon suggest acute, eruptive or florid (Having bright deep red colour) progression • Auspitz sign (If one removes the white scale of psoriasis, one may see punctate bleeding points) • Negative Koebner phenomenon (absence of lesions at the pressure sites) • Psoriatic leucoderma ( hypopigmentation after Sales Training healing)

Psoriasis: Types • Plaque type (Psoriasis vulgaris): Most common. • Guttate psoriasis: Abrupt onset small patches spread widely. Sales Training . round to oval raised patches of scaly red skin. Typically occurs after being infected with a strep throat.

Fingernails & toenails can be involved in any type resulting in pits. thickening & yellowish & brown discoloration. Sales Training .Psoriasis: Types • Hand / foot psoriasis: Effects mainly hands & feet.

Psoriasis: Types Plaque psoriasis Guttate psoriasis Sales Training .

Resistant psoriatic plaques over the buttock & posterior thighs Sales Training .

Resistant plaque-type psoriasis on the elbows Sales Training .

Psoriasis: Types • Scalp psoriasis: Approximately 50% of psoriasis sufferers are affected by this condition. Sales Training . Appears on scalp as reddened bumps with silvery scales.

Most often appears in armpit. Sales Training . groin area. under breasts & in other skin folds.Psoriasis: Types • Inverse psoriasis: Smooth inflamed scores (lesions) without apparent scaling characterize this form. Lesions are easily irritated by rubbing & sweating.

Psoriasis: Types Scalp psoriasis Inverse (Flexural) psoriasis Sales Training .

• Hand/foot psoriasis: Effects mainly hands & feet. This condition is very difficult to treat. Nail may become thickened & yellowed. Nails crumble easily & may become loosened & detach from nail bed. Sales Training .Psoriasis: Types • Nail psoriasis: Pits of various size & shape appear in nail. Both fingernails & toenails may be affected.

Psoriasis: Types • Erythrodermic psoriasis: Entire body covered with thin red scales. Sales Training .

Psoriasis: Types Erythrodermic psoriasis Sales Training .

including face. trunk and extremities • Erythema is most prominent but scaling is less • There may be generalized exfoliation Ann Derm Venereol Suppl. 1989.Erythrodermic psoriasis • Generalized form of disease • Affecting all body sites.146:69-71 Sales Training .

24% of erythroderma • 90% or more body area involved • Either gradual progression or sudden explosive course (due to various factors) • Nose sign (absence of lesions on the nose) • Metabolic effects dictate the course and outcome Sales Training .Exfoliative psoriasis • Accounts for 16 .

• Pustular psoriasis: Involves small pustules scattered on red plaques. Sales Training .

Psoriasis: Types Pustular psoriasis Sales Training .

generalized eruption of sterile pustules • May be accompanied with erythroderma • Disseminated over trunk and extremities • Accompanied by systemic symptoms like fever Sales Training .Generalized pustular psoriasis • Acute variant of psoriasis • Sudden.

Generalized pustular psoriasis Sales Training .

Localized pustular • Also called as Pustulosis of palmaris & plantaris • Affecting palms and soles predominantly • May affect trunk Sales Training .

Localized pustular Sales Training .

Sometimes require hospitalization.Erythrodermic & pustular psoriasis are serious can be accompanied by systemic symptoms fever & illness. skin can’t retain enough body heat or fluids. Sales Training .

The course of psoriasis is unpredictable. It has a tendency to „recur‟ and „persist‟ Aggravation Relieving • Secondary infection • Drugs – Beta Blockers – Lithium – Antimalarials – Terbinafine – Steroids – Lipid lowering drug – gemfibrozil • Homeopathy Sales Training • Irritant oils • Antibiotics • Oil massages • Change of medications. .

previous Rx and age of patient. • Accept the disease and live with it. systemic or combination. Sales Training . severity. • Tendency for each remedy to loose its effectiveness gradually. duration. • Topical. • Treatment methods vary accordingly to site.General Management • Counseling.

• Provide “Substantial” improvement – complete clearing is possible. • Provide better safety – minimize significant side effects.Goals of Therapy • Provide durable remission period. • Provide maintenance therapy after initial improvement. which is realistic with available therapies & occurs in 40 % of patients. Sales Training .

Sales Training .Methods to achieve goals of Therapy • Monotherapy – Use of a single agent. considering “Benefits – Efficacy / Safety / Patient compliance / Economy” when selecting among various therapies to combine with one another. • Combination therapy may improve effectiveness & allow some of the therapies associated with toxicity to be utilised at lower doses.

but potentially more toxic agents to clear psoriasis initally. switching different treatment types every few years (1-2 yrs) after which an alternative therapy is used.Methods to achieve goals of Therapy • Concept of “Rotational therapy” has evolved that is. This strategy may minimize long term toxicity with any given therapy & decrease resistance to that therapy. • “ Sequential therapy” – Use of stronger. followed by use of weaker. less toxic agent Sales Training to maintain control. .

Avoidance of Triggers • Medical • Surgical • Laser Topical.Psoriasis Therapy • General Emollients. Systemic Shave Technique 308 nm Excimer Laser Sales Training .

lotion. ointments or gels).Psoriasis: Therapy • Depends on location & BSA covered. • Four categories: Steroids. • Common topical treatment are steroids Sales Training . retinoids (vitamin A derivatives) & tar preparation (cream. vitamin D derivatives.

Psoriasis: Therapy Psoriasis Severity Surface involvement Treatment Mild <2% Topical Moderate 2 to 10% Topical or UV or oral Severe > 10% UV & or Oral Sales Training .

“the ladder of psoriasis therapy” • Step 3 • Step 2 • Step 1 Sales Training .

Step 1 – Topical Therapy Topical Corticosteroids Coal tar Anthralin Salicylic acid Calcitriol. Tacalcitol Tazarotene Topical Methotrexate Tacrolimus. Calcipotriol. Sales Training Pimecrolimus .

Step 2 .Phototherapy PUVA (Psoralen + UVA) UVB – Broad Band UVB – Narrow Band Sales Training .

Sulfasalazine Hydroxyurea Azathioprine Mycofenolate mofetil Sales Training .Step 3 – Systemic therapy Retinoids Methotrexate Cyclosporin Dapsone.

 Widespread disease cannot be managed.  All require lengthy treatment to give relief that is often temporary.  Poor compliance.Limitations of current therapies Topical agents:  None are predictably effective. Sales Training .

Sales Training .Limitations of current therapies Treatment Topical steroids Drawbacks Temporary relief (tolerance occurs). Intralesional Only for limited areas. brief remissions. less effective with continued use. atrophy and telangiectasia occur with continued use. atrophy and steroids telangiectasia occur at injection site.

Limitations of current therapies Treatment Anthralin Drawbacks Purple-brown staining. Sales Training . irritating. careful application (only to plaque) required.

Sales Training . gels & lotions appropriate for hair bearing areas. • Topical steroids are best used in conjunction with one of the newer topical medicines for treatment.Psoriasis: Therapy • Vehicle makes a difference in potency. ointments being strongest. • Calcipotriene & Tazarotene.

hypercalcemia & messier. Sales Training . calcipotriol : Daivonex ointment (Crosslands) Advantages are few long term side effects & does not “lose its potency” over time. skin irritation. works slowly as monotherapy. burning .Psoriasis: Therapy • Vitamin D derivative. Disadvantages are. expensive.

• Tar: Ionax-T solution (Ranbaxy). Works best when paired with topical steroids. moderately effective. folliculitis. photosensitisation & dark staining. Sales Training .Psoriasis: Therapy • Tazarotene: Does a good job with thick plaques of psoriasis. odour. contact dermatitis.

• Receive treatments in dermatologist‟s office by trained personnel. . Sales Training • Sunburn reaction can ensure.Psoriasis: Therapy Ultraviolet • Patients on UVB & PUVA have to take a UV sensitizing oral medicine (a type of psoralen) or apply a topical psoralen before being exposed to UVA.

Sales Training . • Increased risk of skin cancer. • Particularly PUVA can damage eyes.Psoriasis: Therapy Ultraviolet • Needs to be given 2-3 times/week over a period of 2-3 mths.

but without requiring ingestion of a sun-sensitizing medication. . • Requires more precision & some testing Sales Training before beginning treatment. • Also hope is that it may be less cancer causing than PUVA.Psoriasis: Therapy Ultraviolet • Last few years narrow band UV has come with advantage of being similar in effectiveness to PUVA.

stored in human tissues for at least 3 years. depending on the dosage. decreasing rapidity with which psoriatic skin is made. usually 25-50mg / day. modulate tissue metabolism. Training .Psoriasis: Therapy • Acitretin (retinoid). possiblySales longer. • Cannot be taken by women of childbearing years. Systemic • Taken once or twice a day.

Psoriasis: Therapy Systemic • Isotretinoin. photosensitivity & elevations in blood TG as well as liver enzymes. • Side effects of systemic retinoids are dry lips. main drawback isn‟t quite as effective as acitretin could be combined with UVB or PUVA. hand stickiness. Sales Training . hair loss.

decreases metabolism in overactive cells. • Given in lower dosages than used for cancer. taken orally 1-2 days of week. Zexate Tab & Inj (Dabur) anticancer drug.Psoriasis: Therapy Systemic • Methotrexate. Sales Training . Oncotrex Tab & Inj (Sun). Trixilem Tab & Inj (Elder).

Psoriasis: Therapy Systemic • Main drawback. Sales Training . susceptibility to infection. • Anemia. • Intermittent liver biopsies are necessary. severe liver damage that can‟t reliably be ascertained by blood tests. mouth or stomach ulcers & hair loss.

Psoriasis: Therapy Systemic • Other side effects are bone marrow depression. thrombocytopenia. lung toxicity & nephrotoxicity. Sales Training . leukopenia. megaloblasic anemia.

• Taken orally. Sandimmun Neoral Cap & Inj (Novartis). expensive than methotrexate. dosages 2. Sales Training . • Discovery that it could treat psoriasis led to the breakthrough knowledge that psoriasis was an autoimmune disease. immunosuppressive agent. Zymmune Inj (Zydus).5-5 mg/kg (150-400 mg/day for average size adults).Psoriasis: Therapy Systemic • Cyclosporine. Imusporin Cap (Cipla).

less toxic therapy. pustular or erythrodermic psoriasis). suitable for people with very severe forms of psoriasis (e. Sales Training . • Used to get severe psoriasis under control then switch to another.Psoriasis: Therapy Systemic • Cyclosporine. highly effective & probably works faster than any other anti-psoriasis medication available.g.

Psoriasis: Therapy Systemic • Cyclosporine. hemolytic anemia. • Long-term therapy necessitates 24 hour urine specimens & possibly kidney biopsies. long-term. Bilirubinemia Sales Training . hypertension & kidney damage. low-dose therapy has also been advocated. • Main problem. leukopenia. • Other side effects are thrombocytopenia.

Psoriasis: Therapy • Even though psoriasis is chronic & eventually reoccurs. multiple treatment regimens & disease free intervals are a “Welcome relief” to those who suffer. • Concept of “Rotational therapy” & “ Sequential therapy” has evolved over the years. Sales Training .