Psoriasi dalla diagnosi agli approcci clinici

PSORIASIS

Diagnosis and management

OVERVIEW 2

5. Case studies

4. Managing psoriasis

3. Diagnosing psoriasis

2. Clinical presentation

1. Epidemiology and pathophysiology

WHAT IS PSORIASIS? 3

– Inflammatory and

hyperplastic disease of

skin1

– Characterised by

erythema and elevated

scaly plaques1

– Chronic, relapsing

condition

– Course of disease often

unpredictable

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

5

19

21

29

31

71

79

94

0 20 40 60 80 100

Other

Fatigue

Burning sensation

Bleeding

Tightness of skin

Skin redness

Itching

Scaling

Percentage of respondents (n = 17,425)

SYMPTOMS OF PSORIASIS

Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.

4

Most frequently experienced symptoms

SOCIAL IMPACT OF PSORIASIS

40

48

57

0 10 20 30 40 50 60

Percentage of respondents with severe psoriasis (n = 502)


5

Psoriasis mistaken for

other disease

Trouble receiving

equal treatment in

service establishments

(e.g. hair salons,

public pools)

Psoriasis mistaken

as contagious

PSORIASIS AFFECTS

EMOTIONAL STATE

54

75

81

88

0 20 40 60 80 100

Depression

Feelings of unattractiveness

Feelings of embarrassment

Concern that disease would worsen

Percentage of 18-to-34-year-old respondents with severe psoriasis (n not reported)


6

EPIDEMIOLOGY

• Common skin disorder

• Prevalence variable: ~ 0.3–2.5%1

• Prevalence equal in males and females2

• Estimated incidence: ~ 60 per 100,000 per year3

1. Plunkett A et al. Australas J Dermatol 1998; 39: 225–232. 2. Griffiths CEM et al. In: Burns T et al., eds. Rook’s textbook of dermatology.

8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Bell LM et al. Arch Dermatol 1991; 127: 1184–7.

7

AGE OF ONSET

• Mean age: ~ 23–37 years1

• Current theory:

2 distinct peaks with possible genetic associations1

– Early onset (16–22 years)2

• More severe and extensive

• More likely to have affected first-degree family member

– Late onset (57–60 years)2

• Milder form

• Affected first-degree family members nearly absent

1. Plunkett A et al. Australas J Dermatol 1998; 39: 225-232. 2. Henseler T et al. J Am Acad Dermatol 1985; 13:450-6.

8

GENETIC INFLUENCE

• Evidence suggests strong

genetic association

– Studies of monozygotic twins show concordance

for psoriasis (e.g. 64% in a Danish Study)1

– Multiple susceptibility loci have been identified2

• Disease expression – likely result of genetic and environmental factors2

1.Brandup F et al. Acta Dermato-Vernerol 1982; 62L: 229–36. 2. Barker J. Clin Exp Dermatol 2001; 26(4): 321–5.

9

COMMON TRIGGER FACTORS

FOR PSORIASIS1

• Infections (e.g. streptococcal, viral)

• Skin trauma (Koebner phenomenon)

• Psychological stress

• Drugs (e.g. lithium, beta blockers)

• Sunburn

• Metabolic factors (e.g. calcium deficiency)

• Hormonal factors (e.g. pregnancy)


10

PSORIASIS IS A T-CELL MEDIATED,

AUTOIMMUNE DISEASE1

• Current hypothesis:

– Unknown skin antigens stimulate immune response

• Antigen-specific memory T-cells are primary mediators

– Leads to impaired differentiation and

hyperproliferation of keratinocytes

1. Lee M et al. Australas J Dermatol 2006; 47: 151–9.

11

CLINICAL PRESENTATION:

CLASSIC PSORIASIS 12

– Well-defined and sharply

demarcated1,2

– Round/oval-shaped

lesions1,3

– Usually symmetrical1,3

– Erythematous, raised

plaques1–3

– Covered by white, silvery

scales1–3

1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology.

2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

COMMON SITES

AFFECTED BY PSORIASIS 13

• Can affect any part

of the body –

typically scalp,

elbow, knees and

sacrum1

• Extent of disease

varies

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

TYPES OF PSORIASIS

• Chronic plaque

• Guttate

• Flexural

• Erythrodermic

• Pustular

– Localised and generalised

• Local forms

– Palmoplantar

– Scalp

– Nail (psoriatic

onychodystrophy)

14

1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Rossi S, ed. Australian medicines

handbook. Adelaide: AMH, 2010.

CHRONIC PLAQUE PSORIASIS 15

– Most common type –

affects approximately

85%1

– Features pink, well-defined

plaques with silvery scale2

– Lesions may be single or

numerous2

– Plaques may involve large

areas of skin2

– Classically affects elbows,

knees, buttocks and scalp3

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Dermatology Expert Group. Therapeutic guidelines:

dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –

dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.





GUTTATE PSORIASIS 20

– Numerous and small

lesions – ~ 1 cm

diameter1,2,3

– Pink with less scale than

plaque psoriasis1

– Commonly found on trunk

and proximal limbs1,3

– Typically seen in

individuals < 30 years4

– Often preceded by an

upper respiratory tract

streptococcal infection1,2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A

et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –

dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 4. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

FLEXURAL PSORIASIS 21

– Lesions in skin folds1

– Particularly groin, gluteal

cleft, axillae and

submammary regions

– Often minimal or absent

scaling1,2

– May cause diagnostic

difficulty when genital or

perianal region is affected

in isolation

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Schon

MP et al. N Engl J Med 2005; 352(18): 1899–912.

ERYTHRODERMIC PSORIASIS 22

– Generalised erythema

covering entire skin

surface1,2

– May evolve slowly from

chronic plaque psoriasis or

appear as eruptive

phenomenon1,3

– Patients may become

febrile, hypo/hyperthermic

and dehydrated3

– Complications include

cardiac failure, infections,

malabsorption and

anaemia1

– Relatively uncommon

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller

PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

PUSTULAR PSORIASIS 23

– Two forms:

• Localised form

• More common1,2

• Presents as deep-seated

lesions with multiple small

pustules on palms and

soles1,2

• Generalised form

• Uncommon3

• Associated with fever and

widespread pustules

across inflamed body

surface3

1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Griffiths CEM et al. Psoriasis. In: Burns T et al., eds. Rook’s

textbook of dermatology. 8th ed. UK: Blackwell Publishing Ltd, 2010. 3. Menter A et al. J Am Acad Dermatol 2008; 58(5): 826–50.

PALMOPLANTAR PSORIASIS1 24

– Can be hyperkeratotic or

pustular

– May mimic dermatitis –

look for psoriatic

manifestations elsewhere

to aid diagnosis

– Possibly aggravated by

trauma


SCALP PSORIASIS 25

– Varies from minor scaling

with erythema to thick

hyperkeratotic plaques1,2

– May extend beyond

hairline1,2

– Patient scratching may

produce asymmetric

plaques2


et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

NAIL PSORIASIS1 26

– May be present in patients

with any type of psoriasis

– Can take several forms:

• Pitting: discrete, well-

circumscribed depressions

on nail surface

• Subungual hyperkeratosis:

silvery white crusting under

free edge of nail with some

thickening of nail plate

• Onycholysis: nail separates

from nail bed at free edge

• ‘Oil-drop sign’: pink/red

colour change on nail

surface


NAIL PSORIASIS

27

NAIL PSORIASIS 28

NAIL PSORIASIS 29

PSORIATIC ARTHRITIS 30

– Approximately 5–20%

have associated arthritis1

– Five major patterns of

psoriatic arthritis:2

• Distal interphalangeal

involvement

• Symmetrical polyarthritis

• Psoriatic

spondylarthropathy

• Arthritis mutilans

• Oligoarticular,

asymmetrical arthritis

– Clinical expressions

often overlap2

1. Schon MP et al. N Engl J Med 2005; 352(18): 1899–912. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

DIAGNOSING PSORIASIS

• Other dermatological disorders

can resemble psoriasis

• Diagnosed clinically according to appearance,

distribution, history of lesions and family history

• Important to consider non-cutaneous

complications1

1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials –dermatology. 2nd ed. Sydney:

Australasian Medical Publishing Company, 2005.

31

DIFFERENTIAL DIAGNOSIS1,2

• Localised

patches/plaques – Tinea

– Eczema

– Superficial basal cell

carcinoma and Bowen’s

disease

– Seborrhoeic dermatitis

– Cutaneous T-cell lymphoma

(mycosis fungoides)

• Guttate – Pityriasis rosea

– Drug eruption

– Secondary syphilis

• Flexural – Tinea

– Eczema

– Candidiasis


• Erythrodermic – Eczema


– Pityriasis rubra pilaris

– Lichen planus

– Drug

• Palmoplantar – Tinea

32

1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd ed.

Oxford: Health Press, 2004.

LOCALISED PATCHES/PLAQUES 33

– Tinea corporis1

• Affects body

• Lacks symmetrical

lesions

• Presence of peripheral

scale and central

clearing


Tinea coporis Psoriasis


– Discoid eczema1

• Individualised patches

more pruritic than

psoriasis

• Lack silvery scale

• Less vivid colour than

psoriasis


Discoid eczema Psoriasis


– Superficial basal cell

carcinoma/Bowen’s

disease1,2

• Asymmetrical lesions,

either single or few in

number

• Perform biopsy if

lesions resistant to

topical psoriasis

treatment, or to

confirm diagnosis

1. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003. 2. Menter A et al. Fast facts: psoriasis. 2nd

ed. Oxford: Health Press, 2004.

Bowen’s disease Psoriasis



• Characterised by yellowish

scaling and erythema1

– Localised to many of the same

areas as psoriasis

• Diffuse scaling differs from

sharply defined psoriasis

plaques2

• Affects furrows of face

(facial psoriasis is generally

restricted to hairline)1

1. Marks R et al. Dermatology within the pharmacy. Australia: Department of Dermatology, St

Vincent’s Hospital, 1998. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press,

2004.

Dermatitis

Psoriasis



(mycosis fungoides)

• Red, discoid lesions1

• Asymmetrical and less scaly

than psoriasis1

• Lesions may present with fine

atrophy and be resistant to

antipsoriatic therapy2

• Biopsy to confirm diagnosis

1. Fry L. An atlas of psoriasis. Spain: Taylor & Francis, 2004. 2. Menter A

et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

Mycosis fungoides

Psoriasis


– Pityriasis rosea1

• Difficult to distinguish from

acute guttate psoriasis

• Presents first as single

large patch, progresses to

a truncal rash of multiple

red scaly plaques

(‘Christmas tree’

distribution)

• Resolves over 8–12 weeks

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press,

2004.

< Psoriasis ^ Pityriasis rosea


– Secondary syphilis

• Search for characteristic

primary syphilitic lesion,

lymphadenopathy, and

lesions of face, palm and

soles1

• Conduct serology and skin

biopsies to confirm1,2

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health

Press, 2004. 2. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd

ed. Melbourne: Blackwell Publishing, 2003.

< Psoriasis ^ Secondary syphilis


– Tinea cruris1

• Affects groin area

• Characterised by central

clearing with advancing edge

• Non-silvery lesion with fine

scale, particularly at

periphery

• Lesion frequently extends

more on left side


< Psoriasis ^ Tinea cruris


– Atopic eczema1,2

• Often associated with

asthma and hay fever

• Lacks classic psoriatic nail

involvement and sharply

demarcated scaly plaques


2. Fischer, G. How to treat: atopic dermatitis. Australian Doctor. 16 April 2010: 29–36.

< Psoriasis ^ Atopic eczema


– Candidiasis1,2

• Characteristic peripheral

pustules and scaling differ

to psoriasis

• Yeast cultures are

diagnostic

– Seborrhoeic dermatitis2

1. Van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne: Blackwell Publishing, 2003.


Flexural psoriasis

PALMOPLANTAR PSORIASIS 43

– Tinea manum1

• Ringworm of hands

• Fine powdery scale,

particularly involving palms

and palmar creases

• Usually asymmetrical


Tinea corporis

Psoriasis


– Hand and foot eczema

• Hyperkeratotic forms

difficult to distinguish from

psoriasis1,2

• Biopsies can assist

diagnosis1

• Look for history of atopy, a

lack of psoriasis elsewhere

on body, and evidence of

eczema elsewhere on skin1


2. van de Kerkhof P, ed. Textbook of psoriasis. 2nd ed. Melbourne:

Blackwell Publishing, 2003.

Eczema

Psoriasis


– Pompholyx of palms and

soles (dishydrotic

eczema)1

• Presents as clear vesicles

– contrast to white/yellow

pustules in pustular

psoriasis

• Accompanied by intense

pruritus


Eczema

Psoriasis

DETERMINING PSORIASIS SEVERITY

• Psoriasis Area and Severity Index (PASI)1

– Score indicates severity of disease at a given time

– Single number that considers severity of lesions and extent of disease

across four major body sites (head, trunk, upper limbs and lower limbs)

– Score ranges from 0 (no disease) to 72 (maximal disease)

1. Dubertret L. Psoriasis from clinic to therapy. France: Med’com, 2005.

46

MANAGING PSORIASIS

• Before starting treatment

– Establish relationship of trust with patient1

– Provide patient with information

• Emphasise benign nature of disease2,3

• Explain that psoriasis tends to be chronic and recurrent2,3

1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,

2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.


47

MANAGING PSORIASIS

• Determine clinical setting before

selecting treatment, considering

– Disease pattern, severity and extent1,2

– Sites of disease2

– Coexistent medical conditions1

– Patient’s perception of disease severity1

– Time commitments and treatment expense1,2

– Previous treatments for psoriasis1


dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009.

48

MANAGING PSORIASIS

• Goals of management

– Tailor management to individual and address both medical and

psychological aspects1–3

– Improve quality of life3

– Achieve long-term remission and disease control3

– Minimise drug toxicity3

– Evaluate and monitor efficacy and suitability of individual treatments3

– Remain flexible and respond to changing needs1–3

1.Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,

2005. 2. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 3.

Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.

49

TREATMENT OPTIONS FOR PSORIASIS

• Stepwise approach is advised1

• Treatments include:1,2,3

– General measures and topical therapy

– Phototherapy

– Systemic and biological therapies

• Combination therapies may

reduce toxicity and improve outcomes2

1. Weller PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company,

2005. 2. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Dermatology Expert Group. Therapeutic guidelines:


50

TREATING PSORIASIS:

GENERAL MEASURES1,2

• Reduce/eliminate potential trigger factors:

– Stress

– Smoking

– Alcohol

– Trauma

– Drugs

– Infections



51

TOPICAL THERAPIES

• Approximately 70% of patients with

mild-to-moderate psoriasis can be managed

with topical therapies alone1

• Tailor to needs of patient2

• Potency, delivery vehicle and patient

motivation may affect compliance1

• Application may be time-consuming for patients1



52

TOPICAL THERAPIES:

EMOLLIENTS

• Include aqueous cream, sorbolene cream, white

soft paraffin and wool fats1

• Regular use can:

– alleviate pruritus2

– reduce scale2

– enhance penetration of concomitant topical therapy2

– hydrate dry and cracked skin3

• Soap should be avoided4

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et

al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Rossi S, ed. Australian medicines handbook. Adelaide: AMH, 2010. 4. Weller

PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

53

TOPICAL THERAPIES:

KERATOLYTICS

• Over-the-counter products include:1

– Salicylic acid

– Urea

• Help dissolve keratin to soften

and lift psoriasis scales1,2

• May enhance penetration of other actives1



54

TOPICAL THERAPIES:

COAL TAR

• Help reduce inflammation and pruritus1

• May induce longer remissions2

• Use limited by distinctive smell

and ability to stain clothing and skin1,2

• May cause local skin irritation2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Weller

PA. Psoriasis. In: Marks R, ed. MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005.

55

TOPICAL THERAPIES:

DITHRANOL

• Anti-proliferative properties1

• Particularly effective in thick plaque psoriasis1

• Initiate therapy at very low concentrations

– can burn skin2

• Not suitable for face, flexures or genitals1,3

• Stains clothes permanently

and skin temporarily1,2,3

1. Dermatology Expert Group. Therapeutic Guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Menter A et

al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Weller PA. Psoriasis. In: Marks R,ed. MJA practice essentials – dermatology. 2nd

ed. Sydney: Australasian Medical Publishing Company, 2005.

56

TOPICAL THERAPIES:

TAZAROTENE

• Topical synthetic retinoid1,2

• For treatment of chronic plaque psoriasis1,2

• Applied once daily in evening1,2

• Commonly causes local irritation1,2

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009. 2. Zorac

Product Information, 30 March 2007.

57

TOPICAL THERAPIES:

CORTICOSTEROIDS

• Possess anti-inflammatory, antiproliferative and

immunomodulatory properties1,2

• Reduce superficial inflammation within plaques3

• Potency choice depends on disease severity,

location and patient preference2


et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009.

58

TOPICAL THERAPIES:

CORTICOSTEROIDS

• Adverse effects associated

with long-term use include:1,2

– Skin atrophy and telangiectasia

– Hypopigmentation

– Striae

– Rapid relapse or rebound on stopping therapy

– Precipitation of pustular psoriasis

– Pituitary-adrenal axis suppression through significant systemic

absorption (rare)



59

TOPICAL THERAPIES:

CALCIPOTRIOL (DAIVONEX®)

• Synthetic vitamin D analogue1

• For chronic plaque-type psoriasis1

• Reverses abnormal keratinocyte changes by:1

– Inducing differentiation

– Suppressing proliferation of keratinocytes

1. Daivonex Product Information, 23 September, 2006.

60

TOPICAL THERAPIES:

CALCIPOTRIOL (DAIVONEX®)

• Response may require 4–6 weeks1,2

• Adverse effects include erythema and irritation3

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 2. Weller PA. Psoriasis. In: Marks R, ed.

MJA practice essentials – dermatology. 2nd ed. Sydney: Australasian Medical Publishing Company, 2005. 3. Daivonex

Product Information, 23 September, 2006.

61

TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE

DIPROPIONATE OINTMENT (DAIVOBET®)

• For plaque-type psoriasis1

• Combination of calcipotriol and a potent topical

corticosteroid (betamethasone dipropionate)1

– Stable formulation for both actives1

• Provides rapid, effective psoriasis control1,2

1. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.

62



Adapted from Kaufmann R et al. Dermatology 2002; 205(4): 389–93.

63

– Combination of calcipotriol and betamethasone dipropionate in

Daivobet is more effective than either active constituent used alone

• 39.2% mean reduction in PASI score after 1 week



• Once-daily treatment with the

potential to improve compliance1,2

• Can be used intermittently in 4-weekly cycles with

Daivonex® used in between for maintenance1

• Most common adverse events include pruritus,

rash and burning sensation1

1. Daivobet Product Information, 3 December 2007. 2. Kaufmann R et al. Dermatology 2002; 205(4): 389–93.

64


DIPROPIONATE GEL

• Newly TGA approved product not yet available in

Australia

• Specially formulated for the scalp1

• Provides rapid, effective control of scalp

psoriasis1,2,3

– More effective than treatment with individual actives alone

– 53.2% (more than half) of patients had absent or

very mild disease after just two weeks of gel application1

• Once-daily formulation may

encourage compliance2

1. Daivobet ®Gel Product Information, 14 July 2010. 2. van de Kerkhof et al. BJD 2008; 160: 170–6.

3. Jemec GBE et al. J Am Acad Dermatol 2008; 59:455-463.

65

OTHER THERAPIES

• Phototherapy

• Systemic therapies

• Biological agents

66

PHOTOTHERAPY

• For psoriasis resistant to topical therapy and

covering > 10% of body surface area1

• Immunomodulatory and anti-inflammatory effects2

• Three main types of phototherapy:2

– Broadband UVB

– Narrowband UVB

– PUVA (administration of psoralen before UVA exposure)

• Treatment usually administered 2–3 times/week1,2

1. Menter A et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004.2. Dermatology Expert Group. Therapeutic guidelines:


67

SYSTEMIC THERAPIES

• Reserved for patients with widespread

or severe psoriasis1

• Potentially serious adverse effects

and drug interactions2

• Many require PBS authority

prescription from dermatologist3


et al. Fast facts: psoriasis. 2nd ed. Oxford: Health Press, 2004. 3. Department of Health and Ageing. Schedule of Pharmaceutical Benefits.

http://www.pbs.gov.au (accessed online 14 August 2010).

68

SYSTEMIC THERAPIES:

METHOTREXATE

• Most commonly used systemic

treatment for psoriasis1

• Slows epidermal cell proliferation

and acts as immunosuppressant1

• Closely monitor kidney, liver and

bone-marrow function2

• Perform PASI score before starting treatment


2. Methoblastin Product Information, 11 August 2004.

69

SYSTEMIC THERAPIES:

CYCLOSPORIN

• Immunosuppressive agent1

• For patients with severe psoriasis

that is refractory to other treatments2

• Requires ongoing monitoring of

blood elements, and renal and liver function2


2. Neoral Product Information, 22 October 2009.

70

SYSTEMIC THERAPIES:

ACITRETIN1

• Oral retinoid

• For treatment of all forms of severe psoriasis

• Once-daily oral therapy

• Teratogenic – pregnancy must be avoided

1. Neotigason Product Information, 18 March 2008.

71

BIOLOGICAL AGENTS

• Proteins derived from living organisms that exert

pharmacological actions1

• For adults with moderate-to-severe chronic

plaque-type psoriasis who are candidates for

phototherapy or systemic therapy2–5

• Most administered sub-cutaneously2–5

1. Buxton P et al. ABC of dermatology. 5th ed. UK: Wiley-Blackwell, 2009. 2. Humira Product Information, 18 September 2009. 3. Stelara

Product Information, 15 July 2009. 4. Remicade Product Information, 17 September 2008. 5. Enbrel Product Information, 16 February 2010.

72

BIOLOGICAL AGENTS

• Target key parts of immune system

that drive psoriasis1

• Biological agents include:2–5

– Tumour necrosis factor-alpha inhibitors

• Etanercept

• Adalimumab

• Infliximab

– Interleukin (IL-12 and IL-32) inhibitor

• Ustekinumab

1. Dermatology Expert Group. Therapeutic guidelines: dermatology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2009 2. Humira

Product Information, 18 September 2009. 3. Stelara Product Information, 15 July 2009. 4. Remicade Product Information, 17 September 2008.

5. Enbrel Product Information, 16 February 2010.

73

CASE STUDY 1

• ((insert image of condition))

• ((insert information under headings below))

• Presentation

• Clinical examination

• Diagnosis

• Management

• ((Diagnosis and management can appear on

following screen as ‘builds’ after audience

discussion, if preferred))

74

CASE STUDY 2

• ((insert image of presenting condition))

• ((insert information under headings below))

• Presentation

• Clinical examination

• Diagnosis

• Management

• ((Diagnosis and management can appear on

following screen as ‘builds’ after audience

discussion, if preferred))

75

DIAGNOSIS AND MANAGEMENT OF

PSORIASIS: SUMMARY

• Chronic, inflammatory disease of skin

• T-cell mediated disorder

• Classic presentation characterised by red,

scaly plaques

• Management should address both medical and

psychological aspects

• Treatments include topical therapy,

phototherapy, systemic therapy and biological

agents

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MINIMUM PRODUCT INFORMATION

Minimum Product Information: DAIVONEX® cream (50mcg/g calcipotriol), scalp solution (50mcg/mL calcipotriol). Indications: Topical

treatment of chronic stable plaque type psoriasis vulgaris in adults (cream). Psoriasis of the scalp in adults (scalp solution). Contraindications:

hypersensitivity; calcium metabolism disorders; ophthalmic use. Precautions: severe extensive psoriasis, generalised pustular psoriasis,

guttate psoriasis, erythrodermic exfoliative psoriasis; facial use; skin fold use; occlusion; excessive, prolonged use; use in children. Monitor

serum calcium and renal function prior to therapy and then three monthly; max weekly dose, see dosage. No experience with: continuous use

for greater than 1 year in adults, sunlight and UV light, impaired renal or hepatic function, pregnancy (category B1), lactation. Adverse Effects:

Local irritation, photosensitivity, pigmentation changes, hypercalcaemia (excessive use). Dosage and Administration: In adults, twice daily on

affected areas, reduce frequency according to response; maximum dosage 100g/week of cream or 60mL of scalp solution; total calcipotriol

should not exceed 5mg/week; reinstate on recurrence. Minimum Product Information: DAIVONEX® cream (50mcg/g calcipotriol), scalp

solution (50mcg/mL calcipotriol). Indications: Topical treatment of chronic stable plaque type psoriasis vulgaris in adults (cream). Psoriasis of

the scalp in adults (scalp solution). Contraindications: hypersensitivity; calcium metabolism disorders; ophthalmic use. Precautions: severe

extensive psoriasis, generalised pustular psoriasis, guttate psoriasis, erythrodermic exfoliative psoriasis; facial use; skin fold use; occlusion;

excessive, prolonged use; use in children. Monitor serum calcium and renal function prior to therapy and then three monthly; max weekly

dose, see dosage. No experience with: continuous use for greater than 1 year in adults, sunlight and UV light, impaired renal or hepatic

function, pregnancy (category B1), lactation. Adverse Effects: Local irritation, photosensitivity, pigmentation changes, hypercalcaemia

(excessive use). Dosage and Administration: In adults, twice daily on affected areas, reduce frequency according to response; maximum

dosage 100g/week of cream or 60mL of scalp solution; total calcipotriol should not exceed 5mg/week; reinstate on recurrence.

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DAIVONEX® PBS Information: 30g cream and 30mL scalp solution. Restricted benefit.

Treatment of chronic stable plaque-type psoriasis vulgaris. Refer to PBS Schedule for full information.

Please review Product Information before prescribing.

MINIMUM PRODUCT INFORMATION

Minimum Product Information: DAIVOBET® 50/500 Ointment. 50mcg/g calcipotriol / 500mcg/g betamethasone dipropionate. Indication:

Once daily topical treatment of plaque-type psoriasis vulgaris amenable to topical therapy. Contraindications: Allergic sensitisation to any

constituent of DAIVOBET® ointment; disorders of calcium metabolism; viral skin lesions, fungal / bacterial skin infections, parasitic infections,

skin manifestations related to tuberculosis or syphilis, perioral dermatitis, acne vulgaris, atrophic skin, striae atrophicae, fragile skin veins,

ichthyosis, acne rosacea, ulceration, wounds, perianal / genital pruritus; erythrodermic, exfoliative and pustular psoriasis; severe renal or

hepatic insufficiency; ophthalmic use. Precautions: For external use only; avoid application to scalp, face, mouth or eyes; treatment of >30% of

body surface area; monitor serum calcium and renal function; concurrent treatment with other steroids; application to large areas of damaged

skin, occlusive dressings, application to mucous membranes or in skin folds; avoid long term treatment of face and genitals; infected lesions;

generalised pustular psoriasis; sunlight / UV exposure; pregnancy category B1; lactation; children below 18 years of age; renal or hepatic

impairment; HPA axis suppression with excessive prolonged use of topical corticosteroids; risk of rebound when discontinuing long-term

corticosteroids. Recommended treatment period is 4 weeks under medical supervision, for up to 52 weeks. There is clinical trial experience

with intermittent 4 weekly cycles of DAIVOBET® ointment and calcipotriol alone used between treatment cycles. Adverse Effects: Pruritus,

rash, burning sensation, skin pain or irritation, dermatitis, erythema, exacerbation of psoriasis, folliculitis, application site pigment changes,

hypercalcaemia, hypercalciuria, photosensitivity, allergic and hypersensitivity reactions including very rare cases of angioedema and facial

oedema. Local reactions, especially during prolonged application include skin atroph elangiectasia, folliculitis, hypertrichosis, perioral

dermatitis, allergic contact dermatitis, depigmentation, colloid milia and generalised pustular psoriasis. Adrenocorticol suppression,

hypercalcaemia, cataract, infections and increase in intra-ocular pressure can occur, especially after long term treatment. Risk of rebound

when discontinuing long term treatment with corticosteroids. Dosage and Administration: Apply topically to the affected area once daily.

Maximum 15g ointment per day. Maximum 100g of ointment per week. Treated area should be no more than 30% body surface. Treatment

should be intermittent for up to 1 year; treatment should be limited to 4 week periods with calcipotriol used alone for 1 month between periods

of DAIVOBET® use as needed.

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DAIVOBET® PBS Information: Restricted benefit. Treatment of chronic stable

plaque-typepsoriasis vulgaris in a patient who is not adequately controlled with either

calcipotriol or potent topical corticosteroid monotherapy.

Please review Product Information before prescribing.

Product Information is available from CSL Biotherapies Pty Ltd ABN 66 120 398 067, 45 Poplar Road, Parkville, 3052. DAIVOBET® and

DAIVONEX® are registered trademarks of licensor, LEO Pharma, Ballerup, Denmark. DAIVOBET® and DAIVONEX® are distributed by

CSL Biotherapies Pty Ltd under licence from LEO Pharma. ® Thinking Australia is a registered trademark of CSL Limited, Australia. 8713.

Thank you

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Psoriasi dalla diagnosi agli approcci clinici