Psoriasis Dr Laura Savage Clinical Research Fellow and Specialist Registrar in Dermatology Leeds Centre for Dermatology
2010/10898 January 2012
Learning objectives • This presentation will: – Assess/challenge what you already know about psoriasis – Describe the common forms of psoriasis – Detail the epidemiology and aetiology of psoriasis – Explain the main disease processes underlying psoriasis – Differentiate and review various psoriasis treatments – Examine patient perspectives on treatment and explore barriers to adherence – Consider the causes of non-compliance and how this can be addressed – Review support programmes available for people with psoriasis
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26 y.o. female – 2 week Hx of pharyngitis – acute onset of rash “all over” (spares face) – grandmother had PsO from age 21
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19 y.o. female – 14 month history of worsening, isolated scalp PsO – only used OTC anti-dandruff shampoo – c/o heavy scale fall & itch
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42 y.o. hairdresser – 3 year history of nail PsO – clear elsewhere
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51 y.o. male – PsO for 30 years – lives alone, unemployed – previous phototherapy x3 then MTX for six years – stopped due to raised ALT
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28 y.o. female – 7 year Hx of PsO managed in primary care – using Dovobet ointment and Diprobase cream – due to get married in five months
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Psoriasis : Background
Psoriasis •
Psoriasis is a common, chronic, inflammatory, immunemediated disease affecting the skin1
•
Prevalence of psoriasis is up to 2% of the population2
•
Around 1.2 million individuals in the UK are affected 3
•
Most common presentation is chronic plaque psoriasis1 – Characterised by well-demarcated bright red plaques covered by adherent silvery white scales
•
Approximately 94% of patients in primary care are managed with topical therapy4
1. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults; October 2010. Available from www.sign.ac.uk (Last accessed 16 January 2012) 2. Papp K et al. J Eur Acad Dermatol Venereol 2007;21:1151-1160 3. Burd RM et al. Br J Hosp Med 2006;67:259-62 4. Gillard SE & Finlay AY. Int J Clin Practice 2005;59:1260-1267
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Epidemiology •
Psoriasis may develop at any age – Most frequently presents in young adults & 50-60 year olds1
•
Two key types2 – Early onset (Type I) • Family history, severe disease, on or before 40 years old
– Late onset (Type II) • No family history, after 40 years old
• • • 1. 2. 3.
Both sexes affected equally3 Higher incidence in white people3 Uncommon in certain populations1
Neimann AL et al. Expert Rev Dermatol 2006;1:63-75 Langley RGB et al. Ann Rheum Dis 2005;64:ii18-ii23 National Institute of Clinical Excellence (NICE) Etanercept and efalizumab for the treatment of adults with psoriasis. July 2006: TA103. Available from www.nice.org.uk (Last accessed 16 January 2012)
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The impact of psoriasis for patients • The daily burden of the disease: – Sense of stigmatisation1 • Embarrassment and shame at visible nature of disease1
– Considerable treatment burden2 • Messy, strong-smelling preparations - application up to TDS – Strong patient dissatisfaction with medical PsO management1
•
Negative impact of psoriasis on health-related quality of life is comparable to ischaemic heart disease, diabetes, depression and cancer1
1. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults; October 2010. Available from www.sign.ac.uk (Last accessed 16 January 2012) 2. National Institute of Clinical Excellence (NICE) Etanercept and efalizumab for the treatment of adults with psoriasis. July 2006: TA103. Available from www.nice.org.uk (Last accessed 16 January 2012)
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How does psoriasis affect patients? “Most days I don’t want to start my ritual of putting on my creams and showering … by the time I’m ready I can’t be bothered to go out.”
“They can say they’re not looking, but I can tell when people are looking”
1.
Psoriasis patients, ‘Exposed’ documentary 2011
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“The only treatment that helps is the cream that I have to plaster on every day, but that’s greasy and sticky and doesn’t stop the pain”
“I want to challenge the medical profession to take the disease seriously”
Everyday impact •
Impact of psoriasis is evident in all areas of everyday life • Sense of stigmatisation1 • Embarrassment and shame at visible nature of disease1 • Impact on confidence – reported by two thirds of patients2
– Considerable daily treatment burden3 • Messy, strong-smelling preparations to use • Time consuming application up to x3 per day
1. 2. 3.
Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults; October 2010. Available from www.sign.ac.uk (Last accessed 16 January 2012) LEO Pharma Data on file (European Psoriasis study) National Institute of Clinical Excellence (NICE) Etanercept and efalizumab for the treatment of adults with psoriasis. July 2006: TA103. Available from www.nice.org.uk (Last accessed 16 January 2012)
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Types of psoriasis
1. 2. 3.
Menter A et al. J Am Acad Dermatol 2008;58:826-850 Langley RGB et al. Ann Rheum Dis 2005;64:ii18-ii23 British Association of Dermatologists (BAD) and Primary Care Dermatology Society (PCDS). Recommendations for the initial management of psoriasis. 2009. Available from www.bad.org.uk (Last accessed 17 January 2012)
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Affected body areas Body and scalp involvement is found in 50–80% • Scalp psoriasis • Fine dandruff-like scale to thick, crusted plaques1 • May extend beyond hairline - check forehead, posterior neck, around ears 1
• Nail psoriasis (seen in 79%) • Pitting, oil spots, loss of transparency, leuconychia, splinter haemorrhages2 • Subungual hyperkeratosis & onycholysis2 • If severe – refer for a biologic therapy
Musculoskeletal Signs and Symptoms 1. 2.
Papp K et al. J Eur Acad Dermatol Venereol 2007;21:1151-1160 Langley RGB et al. Ann Rheum Dis 2005;64:i18-ii23
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Plaque psoriasis •
Most common form (80-90% of cases1)
•
Symmetrical with predilection for extensor surfaces1
•
Red, well-defined plaques2
•
Silvery surface scale2
•
Scalp disease can extend outside the hairline3
1. 2. 3.
Menter A et al. J Am Acad Dermatol 2008;58:826-850 Langley RGB et al. Ann Rheum Dis 2005;64:ii18-ii23 Papp K et al. J Eur Acad Dermatol Venereol 2007;21:1151-1160
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Guttate psoriasis
1.
Menter A et al. J Am Acad Dermatol 2008;58:826-850
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•
Even body distribution, esp. on trunk and proximal limbs
•
Small, dew-drop like salmonpink papules 1-10mm within a fine scale
•
Typically seen in young adults
•
Preceding strep. Pharyngitis (if symptomatic – oral pen V)
•
<2% of all PsO
Generalised pustular psoriasis • Uncommon • Red, painful and inflamed skin with fever • Similar sized, sterile pustules - may coalesce to form sheets • Unstable, active PsO • Iatrogenic (methotrexate) • ?Genetic disorder (DITRA)
1.
Langley RGB et al. Ann Rheum Dis 2005;64:ii18-ii23
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Palmoplantar pustulosis
• Found on palms and soles1 • Erythematous plaques + tender yellow/brown pustules1 • Triggers: focal infections, stress and smoking • SAPHO – synovitis, acne, pustulosis, hyperosteosis and osteitis
1.
Langley RGB et al. Ann Rheum Dis 2005;64:ii18-ii23
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Erythrodermic psoriasis •
Covers almost entire body surface area with various degrees of scale1
•
Altered thermoregulatory properties of skin: – Hypothermia & dehydration due to fluid loss1,2
•
Requires intensive topical therapy and systemic care – – – –
1. 2.
Fluid and electrolytes Temperature regulation Nutrition Secondary infection
Menter A et al. J Am Acad Dermatol 2008;58:826-850 Langley RGB et al. Ann Rheum Dis 2005;64:ii18-ii23
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Pathophysiology Two key disease processes underlie psoriasis1
Cell proliferation
Inflammation
1.
Ryan S. Br J Nurs 2010;19:820-825
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Cell proliferation • Normal skin: • Cell reproduction and proliferation takes ~28 days1
• Psoriatic skin: • Skin turnover just 4 days1
• Immature cells deposited on skin surface1
1.
Ryan S. Br J Nurs 2010;19:820-825
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Inflammation • Immune-based inflammatory disease processes initiated and maintained by T-cells1 • Abnormally large numbers of T-cells trigger the release of pro-inflammatory cytokines in the skin1 – Innate immune cytokines: TNF-alpha, IL-1, IL-6 – Adaptive Th1 cytokines: IFN-γ, IL-2
1.
Racz and Prens. Expet Rev Mol Med 2009;11:1-18.
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Aetiology •
Family history in 75% of cases beginning before age 40 1
•
High concordance in monozygotic twins1
•
Genetic predisposition: GWAS identified several psoriasis susceptibility loci – PSORS1(Chr 6p21) - up to 50% of PsO • Genetic polymorphisms code HLA-Cw6 risk allele – Caucasians: RR 13 – Japanese: RR 25
Genetic predisposition + Environmental factors + Trigger
1. .
Neimann AL et al. Expert Rev Dermatol 2006;1:63-75
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Aetiology â&#x20AC;&#x201C; lifetime risk1
Sibling with psoriasis (Lifetime risk 8%)
1.
Neimann AL et al. Expert Rev Dermatol 2006;1:63-75.
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One parent affected (Lifetime risk 16%)
Both parents affected (Lifetime risk up to 50%)
Factors affecting psoriasis Triggers Smoking1 •Risk factor for palmoplantar pustulosis
Affect disease severity Pregnancy3 •PsO may improve in pregnancy
Drugs1 •Wide range of medicines reported to exacerbate PsO
Trauma2 •Köbner phenomenon
Infection1 •Streptococcal throat infection strongly associated with the onset/flaring of guttate PsO
HIV1 •Higher incidence of PsO in HIV patients
1. Neimann AL et al. Expert Rev Dermatol 2006;1:63-75 2. Buxton PK. BMJ 1987;295:904-906. 3. Murase JE et al. Arch Dermatol 2005;141:601-606.
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Stress1 •May worsen symptoms •The data is conflicting
Alcohol1 •Heavy drinking more common in psoriasis patients •Resulting reduction in compliance
Sunlight2 •Generally beneficial – advice caution!
Drugs and psoriasis •
Many commonly-prescribed drugs can impact on PsO
•
Drugs that may precipitate or worsen PsO include: 1,2 – Beta-blockers – NSAIDS – ACE inhibitors
•
Drugs associated with severe deterioration of PsO:1,2 – Lithium – Antimalarials
•
Recommendation: Avoid or limit use/search for alternatives where possible
1. 2.
Ryan S. Br J Nurs 2010;19:820-825 Neimann AL et al. Expert Rev Dermatol 2006;1:63-75
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Common co-morbidities •
Psoriatic arthritis: 20% of psoriasis patients1
•
Inflammatory bowel disease – Association between PsO and Crohn’s disease1
•
Coronary heart disease – PsO may be an independent risk factor for MI1
•
Lymphoma1
•
Depression1 Consider comorbidities in patients with psoriasis and perform a detailed assessment to identify & manage comorbid conditions1
1. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults; October 2010. Available from www.sign.ac.uk (Last accessed 16 January 2012)
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Risk factors for CV disease •
Patients with PsO have higher risk of:1 – Diabetes mellitus – Hypertension – Hyperlipidaemia – Obesity – Smoking
• Recommendation - annual CV risk review for all moderate-severe PsO or PsA patients: •
BMI, fasting glucose, blood pressure, lipid profile1
1. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults; October 2010. Available from www.sign.ac.uk (Last accessed 16 January 2012)
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Psoriasis: Management
Targeting dual disease processes Two key disease processes underlie psoriasis1 AIM: Reduced cell turnover time and reduce scale
Cell proliferation
AIM: Prevent the infiltration of inflammatory cells into the epidermis
Inflammation
1. Ryan S. Br J Nurs 2010;19:822-5
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Traditional treatment routes •
NICE recommendations: – Mild-to-moderate plaque psoriasis - topical treatments: • Emollients, occlusive dressings, keratolytics (salicylic acid), coal tar, dithranol, corticosteroids, retinoids and Vitamin D analogues1
– More severe/resistant psoriasis – systemic therapy: • Phototherapy, systemic agents (ciclosporin, methotrexate, acitretin, FAE etc.) or injectable biologics1
•
94% of PsO patients begin therapy with topical treatments 2 – Various formulations and vehicles - gels, creams, ointments applied to the skin and/or scalp
1. 2.
National Institute of Clinical Excellence (NICE) Etanercept and efalizumab for the treatment of adults with psoriasis. July 2006: TA103. Available from www.nice.org.uk (Last accessed 16 January 2011) Gillard SE & Finlay AY. Int J Clin Practice 2005: 59: 1260-1267
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Three step management
1.
Adapted from Primary Care Dermatology Society (PCDS) 2010. Available from www.pcds.org.uk (Last accessed 24 January 2012)
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Treatment options - Topical Treatment type
Mode of action
Treats inflammation
Treats cell proliferation
Emollients1
Reduce dryness, scaling and cracking
?
Topical corticosteroids2
Dampen down inflammation
Tar preparations1
Remove loose scales may act as an anti-inflammatory
Dithranol2
Suppresses production of skin cells
Vitamin D analogues2
Reduce excessive skin cell production
Vitamin D + steroid combination3
Reduce excessive skin cell production + dampen down inflammation
Tazarotene2
Slows production of skin cells
1.British National Formulary (BNF) BNF 62 Section 13.5.2; September 2011: 62. Available from www.bnf.org (Last accessed 19 January 2012) 2.Menter A et al. J Am Acad Dermatol 2009:60;643-659 3.Dovobet® Gel Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 9 January 2012)
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Treatment options - Phototherapy Bandwidth
Characteristics • Patients receive TL01 narrowband UVB1
Narrowband UVB (311nm)
• UVB slows keratinocyte proliferation and differentiation2 • 3x weekly for 6-8 weeks (max. once weekly) • Equivalent to a two week holiday in the Mediterranean • Penetrates skin more deeply than UVB3
PUVA (Psoralen + UVA)
• Used for those with a long history of PsO unresponsive to NBUVB3 – or considered first line for palmoplantar PsO • Maximum 150 exposures in a lifetime • Twice weekly for 5-10 weeks
1. 2. 3.
Gambichler T et al. J Am Acad Dermatol 2005:52;660-670 Menter A et al. J Am Acad Dermatol 2010:62;114-135 Lapolla, W et al. J Am Acad Dermatol 2011:64:936-949
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.
Treatment options - Systemic Treatment
Action Systemics
Methotrexate1 5-25mg weekly (PO or SC)
Acitretin1 (10-75mg OD)
Folate antagonist with immunosuppressive, cytostatic and anti-inflammatory effects Retinoid – reduces keratinocyte production/turnover. Anti-inflammatory effects. Can combine with TLO1
(3-5mg/kg/day)
Calcineurin inhibitor – prevents T-cell activation from translation into the release of inflammatory cytokines
Others
Fumaric acid esters, Mycophenolate mofetil, Calcitriol
Ciclosporin1
Biologics TNF-α blockers2 Etanercept, Adalimumab, Infliximab
Anti IL-12/23p40 Ustekinumab
1. 2.
Menter A et al. J Am Acad Dermatol 2009;61:451-485 Menter A et al. J Am Acad Dermatol 2008;58:826-850
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Block activity of TNF alpha – the master regulator (central cytokine) involved in psoriasis2 Neutralises all Th1(IL-12) and Th17(IL-23) cellmediated responses
Topical Treatment
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Emollients
1. 2. 3.
•
Recommended for ALL to soften scale & make skin more comfortable1
•
May be the only treatment necessary in mild psoriasis 2
•
?Minimises Koebnerisation
•
When in control of psoriasis, regular use of emollients should continue to be encouraged3
•
Use a vehicle that matches the patient’s lifestyle
•
Pump, spray, foam…
•
Consider additives (urea, lauromacrogols, lactic acid)
•
Prescribe bath/shower emollients – dual approach
British Association of Dermatologists (BAD) and Primary Care Dermatology Society (PCDS). Recommendations for the initial management of psoriasis. 2009. Available from www.bad.org.uk (Last accessed 17 January 2012) British National Formulary (BNF) BNF 62 Section 13.5.2; September 2011: 62. Available from www.bnf.org (Last accessed 19 January 2012) Adapted from Primary Care Dermatology Society (PCDS) 2010. Available from www.pcds.org.uk (Last accessed 24 January 2012)
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Vitamin D Analogues •
Inhibits epidermal proliferation and induces normal keratinocyte differentiation1
•
Recommended first-line treatments for plaque psoriasis2 – Tacalcitol (Curatoderm®), Calcipotriol (Dovonex®) and Calcitriol (Silkis®)
•
Available in a range of preparations for body & scalp PsO3,4
•
Consider the vehicle, additive agents and multi-site use…
1. British National Formulary (BNF) BNF 62 Section 13.5.2; September 2011: 62. Available from www.bnf.org (Last accessed 19 January 2012) 2. British Association of Dermatologists (BAD) and Primary Care Dermatology Society (PCDS). Recommendations for the initial management of psoriasis. 2009. Available from www.bad.org.uk (Last accessed 17 January 2012) 3. Curatoderm Summary of Product Characteristics. Available from www.medicines.org.uk (Laccessed 25 January 2012st) 4. Curatoderm OintmentSummary of Product Characteristics. Available from www.medicines.org.uk (Laccessed 25 January 2012st)
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Calcipotriol/betamethasone dipropionate •
Combination product - betamethasone dipropionate and calcipotriol (Dovobet®)
•
Considered as a first-line topical therapy for the majority of patients for the management of plaque psoriasis1
•
Available in gel and ointment formulations2,3 – Gel is suitable for both mild-moderate body and scalp PsO2 – Ointment is suitable for topical treatment of stable plaque psoriasis vulgaris amenable to topical therapy in adults2
• 1. 2. 3.
Explain carefully to patients about application method!
British Association of Dermatologists (BAD) and Primary Care Dermatology Society (PCDS). Recommendations for the initial management of psoriasis. 2009. Available from www.bad.org.uk (Last accessed 17 January 2012) Dovobet® gel Summary of Product Characteristics; Available from www.medicines.org.uk (Last accessed 9 January 2012) Dovobet® ointment Summary of Product Characteristics; Available from www.medicines.org.uk (Last accessed 9 January 2012)
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Coal Tar Preparations •
Treatments available for skin and/or scalp psoriasis1 – Body: 5% Coal tar in WSP (non-proprietary) – Scalp: Tar pomade 1% coal tar lotion (Exorex®) Sebco® scalp ointment (CT, S.A., Sulphur, Coconut)
1. 2.
•
Excellent anti-inflammatory properties
•
Keep away from the eyes and all mucous membranes2
•
Local side-effects do not normally occur2
•
Much more refined than days of old!
British Association of Dermatologists (BAD) and Primary Care Dermatology Society (PCDS). Recommendations for the initial management of psoriasis. 2009. Available from www.bad.org.uk (Last accessed 17 January 2012) PsoridermTM Cream Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012)
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Dithranol •
Topical treatment of sub-acute and chronic PsO1 since 1916
•
Anti-hyperproliferative effect (inhibits T-cell proliferation)
•
Not recommended skin folds (e.g. groin, submammary area)1
•
Undesirable effects:1 – Skin irritation/burning sensation (must avoid normal skin) – Staining (brown) of the skin and/or hair – Permanent staining may be seen in contact with fabrics, plastics and other materials1 - warn patients!!
1.
•
Titration of concentration necessary – inpatient use
•
80% clear in 3-5/52
•
Alternate days with Dovobet®
Dithrocream Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012)
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Topical corticosteroids •
Not indicated for widespread psoriasis – careful supervision1
•
Can enhance effects by occlusion ONLY in suitable patients 1
•
Use for specific targeted flares, e.g. scalp (Dovobet® gel, Etrivex® Shampoo)
•
Consider combination products, e.g. Diprosalic® ointment for thick scale
•
Maybe hazardous for a number of reasons including:1 – Rebound relapses – Development of tolerance – Risk of generalised pustular psoriasis – Development of local/systemic toxicity due to impaired barrier function
1.
Betnovate Cream Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012)
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Systemic Treatment
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Cyclosporin
1.
•
Licensed for severe recalcitrant PsO when topical therapy and at least one other systemic therapy (e.g. PUVA) is ineffective or inappropriate1
•
Treatment should be discontinued if no response seen in 6 weeks1
•
Available in capsules and oral solution1
•
Rapid action – good to rescue for flares
•
Maximum duration – 12/12 if maintenance therapy
•
Baseline: FBC, U&E (eGFR), LFT, lipids, uric acid (if risk of gout), BP, CXR
•
Monitoring: FBC, U&E, LFT, Lipids, BP – every 2/52 for 3/12, then monthly for 3/12, then every 8-12/52
•
SE: Hypertension (60%), GI upset (20%), hepatotoxicity (mild cholestasis), hyperkalaemia, hypomagnesaemia, hyperuricaemia, hyperlipidaemia, burning sensation/parasthesia (continue), gingival hyperplasia, hypertrichosis, increased risk of malignancy (skin Ca) (Pregnancy category C)
•
Long term: GLOMERULOSCLEROSIS
Neoral Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012)
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Methotrexate
1. 2.
•
Indicated for the control of severe recalcitrant psoriasis which is not responsive to other forms of therapy1
•
Available as tablets or s/c injection – once weekly1,2
•
Test dose initially (5mg) – check FBC at one week/assess skin
•
A good option for patients with evidence of PsA or severe scalp disease
•
Particular advice should be given regarding liver toxicity – limit alcohol intake to 10 units per week (maximum)
•
Baseline: FBC, U&E, LFT, Gamma-GT, Hep B&C serology, Urinalysis, CXR
•
Monitoring: FBC, U&E, LFT weekly for 2/52 after each dose increase, then every 8-12/52 once stable2 (blue book) – PIIINP in secondary care (Bx)
•
SE: N&V, Folic acid deficiency, Myelosuppression, Hepatotoxicity (acute/chronic), pulmonary fibrosis, SJS/TEN
•
Pregnancy category D
Methotrexate tablet Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012) Methotrexate injection Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012)
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Acitretin
1. 2.
•
Licensed for severe, extensive psoriasis
•
Beneficial in palmo-plantar pustular and erythrodermic psoriasis1
•
Avoid in women of childbearing potential - teratogenicity
•
Should only be prescribed by physicians who are experienced in the use of systemic retinoids and understand the risk of teratogenicity1 (secondary care prescription)
•
Available in two strengths: 10mg and 25mg1,2
•
Can be safely combined with NBUVB phototherapy
•
Baseline: PT, FBC, LFT, fasting cholesterol and lipids, glucose
•
Monitoring: LFT every 1-2/52 until stable, FBC and fasting cholesterol and lipids at 1/12 then every 3/12. DISH survey at 2 years/if symptomatic
•
SE: Teratogenicity, hyperlipidaemia, hepatitis, mucocutaneous effects, alopecia, dry eyes, epistaxis, myalgia, hyperosteosis/calcified tendons
•
Pregnancy category X
Neotigason 10mg Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012) Neotigason 25 mg Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012)
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Biologics Indicated for treatment of adults with moderate-to-severe plaque psoriasis who have failed to respond to, or who have a contraindication to, or are intolerant to at least two forms of systemic therapy including ciclosporin, methotrexate and PUVA Baseline: FBC, U&E, LFT,CP, ANA, Hepatitis B&C serology, Quantiferon gold, CXR, BP, ECG, urinalysis Monitoring: Performed in secondary care every 3/12 â&#x20AC;&#x201C; FBC, U&E, LFT, CRP, BP, urinalysis (ANA every 12 months) SE: Injection site reactions, increased susceptibility to infections, diarrhoea, hypersensitivity reactions, headache, fatigue, dizziness, arthralgia/myalgia, nasal congestion, pruritus, reactivation of latent TB, demyelination, exacerbation of CCF, antibody formationâ&#x20AC;Ś 1.
Enbrel 50mg solution in pre-filled pen Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 25 January 2012)
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The ideal treatment pathway
Flare controlled
FLARE
*In accordance with the SPC of the product prescribed 1. Adapted from Primary Care Dermatology Society (PCDS) 2010. Available from www.pcds.org.uk (Last accessed 24 January 2012)
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Maximising outcomes
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The problem of compliance •
Patient compliance - one of the biggest challenges in PsO1
•
Up to 40% are estimated to be non-compliant2
•
Key barrier to adherence – persistent need for topical Rx
•
Patients stop using treatment for a wide variety of reasons: – Time-consuming application3 – Perceived lack of efficacy3 – ‘Unpleasant’ (inconvenient) preparation1 – Several times daily application1
1. 2. 3.
LEO Pharma Data on file (European Psoriasis study) Richards HL et al. J Eur Acad Dermatol Venereol 2006;20:370-379 Brown KK et al. J Am Acad Dermatol 2006; 55:607-613
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Dissatisfaction leads to non-compliance1 European study: 73% did not comply with prescribed treatment
1.
Figure adapted from FouĂŠrĂŠ S et al. JEADV 2005;19:2-6.
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Supporting adherence The best vehicle for psoriasis treatment is… one that patients will use1 •Shorter duration and less frequent usage2 •Regular patient review is vital3 – Offer a follow-up appointment within 6 weeks of initiating or changing topical therapy to assess efficacy and acceptability – Keep number of treatments to a minimum – consider combination therapies… but cover ALL relevant pathologies!
*Please refer to manufacturers guidelines 1. Zivkovich AH & Feldman SR. J Drugs Dermatol 2009;8:570-572 2. Richards HL et al. J Eur Acad Dermatol Venereol 2006;20:370-379 3. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults; October 2010. Available from www.sign.ac.uk (Last accessed 16 January 2012)
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Sources of Support •
GP survey: – 50% of those questioned do not routinely ask patients what impact psoriasis has on their quality of life1 – 94%of these respondents said it was due to insufficient time during consultation1
•
Refer patients to the internet (reliable sources) and support groups…
1.
LEO Pharma, Data on File – Psoriasis Perceptions (Opinion Health) ‐ November 2010
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Internet Resources Additional resources for psoriasis patients: • The Psoriasis Association http://www.psoriasis-association.org.uk/ • The Psoriasis and Psoriatic Arthritis Alliance (PAPAA) http://www.papaa.org • Psoriasis Scotland Arthritis Link Volunteers http://www.psoriasisscotland.org.uk/
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About Touch • Who is Touch for? – All patients aged 18+ with PsO in the UK – Carers • Collaborative development: – Patients – Key opinion leaders – Experts in the field of health psychology and patient support
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Summary •
Psoriasis is a chronic, disabling dermatosis
•
Significant physical and psychosocial morbidity
•
Psoriasis is treatable with the right combination of therapies
•
Consider the dual pathogenic process - inflammation AND overproliferation
•
94% of patients in primary care are managed with topical therapy – is your prescription adequate/feasible/fit with their lifestyle?
•
In mild to moderate disease, reserve active treatments for flares
•
Once controlled, take a holiday! Emollients throughout!
•
Know how to monitor patients on systemic and biological treatment
•
Adherence constitutes a key challenge
•
Patient education and support
2010/10898 January 2012
26 y.o. female – 2 week Hx of pharyngitis – acute onset of rash “all over” (spares face) – grandmother had PsO from age 21
2010/10898 January 2012
19 y.o. female – 14 month history of worsening, isolated scalp PsO – only used OTC anti-dandruff shampoo – c/o heavy scale fall & itch
2010/10898 January 2012
42 y.o. hairdresser – 3 year history of nail PsO – clear elsewhere
2010/10898 January 2012
51 y.o. male – PsO for 30 years – lives alone, unemployed – previous phototherapy x3 then MTX for six years – stopped due to raised ALT
2010/10898 January 2012
28 y.o. female – 7 year Hx of PsO managed in primary care – using Dovobet ointment and Diprobase cream – due to get married in five months
2010/10898 January 2012
2010/10898 January 2012
Thank You L.J.Savage@leeds.ac.uk