Tofacitinib for Plaque Psoriasis: A Case Report and Clinical Review

Dr. Komal Jerath

MD (Dermatology)

Dermatologist, Cosmetologist and Trichologist

Komal Skin and Cosmetology Clinic

Amritsar, Punjab

Psoriasis is a chronic autoimmune skin condition that causes the rapid build up of skin cells. It is characterized by the development of thick, scaly patches on the skin's surface. These patches called as plaques which is typically red, inflamed and it can be itchy or painful. The most common form of psoriasis is plaque psoriasis, which affects about 80-90% of people with psoriasis.1

The exact cause of psoriasis is not known, but the condition results from the immune system signalling, in which immune cells called T cells mistakenly attacks healthy skin cells causing them to grow and multiply too quickly, leading to inflammation and the rapid turnover of skin cells forming the build up of the characteristic plaques.2 This can happen as a result of a genetic predisposition, environmental triggers, or a combination of both. Certain triggers, such as stress, injuries to the skin, certain medications and infections, can cause psoriasis to worsen.

Symptoms of psoriasis can range from mild to adverse condition which include:2

• Raised, red, scaly patches of skin (plaques)

• Itching and burning sensation

• Dry, cracked bleeding skin

• Thickened, pitted nails with ridges

• Swollen and painful joints (in the case of psoriatic arthritis)

While there is no cure for psoriasis, but it is treatable and most people with psoriasis are able to reduce the severity and frequency of flare-ups and improve their quality of life with proper treatment and management. It can be managed with a variety of treatments including topical medications like creams, light treatment, and oral or parenterals. Light therapy popular as phototherapy, uses natural or artificial light to slow down skin cell growth. Systemic medications can include oral or injectable medications which target the immune system to slow down the skin cell production and reduce inflammation.2

The severity of psoriasis can vary greatly from person to person. Some people may have only a few small patches, while others may have extensive coverage of their skin.

Since psoriasis is a chronic condition, ongoing monitoring and regular follow-up are necessary to adjust treatment as needed and to monitor for any potential side effects. Furthermore, lifestyle changes such as diet, exercise, relaxation techniques to reduce stress, avoiding smoking and alcohol can also help in the management of plaque psoriasis.3

Psoriasis can have a significant impact on a person's quality of life, both physically and emotionally. People with psoriasis may feel self-conscious about their appearance and may experience anxiety and depression.

The main types of psoriasis are: 2, 4

1. Plaque psoriasis

Plaque psoriasis is the most common form of psoriasis and is characterized by raised, red patches of skin (plaques) that are covered by a silvery white buildup of dead skin cells. These plaques can appear anywhere on the body, but they are most commonly found on the elbows, knees, scalp and lower back.

2. Guttate psoriasis

Guttate psoriasis is the type of psoriasis, it is characterized by small, red, drop-shaped patches of skin. It is most commonly found on the trunk, limbs and scalp. Guttate psoriasis is more common in children and young adults, often appears after a streptococcal infection.

3. Inverse psoriasis

Inverse psoriasis appears as smooth, red patches of skin in the armpits, groin and under the breasts. It is more common in people who are overweight or have a lot of skin folds.

4. Pustular psoriasis

Pustular psoriasis is characterized by red, tender skin covered by white or yellow pustules (blisters filled with pus). It can be localized to a specific area of the body or can cover a large area.

5. Erythrodermic psoriasis

Erythrodermic psoriasis is a severe and very rare form of psoriasis that causes widespread, fiery redness and scaling of the skin. It can also cause severe itching and pain.

6. Scalp psoriasis although the symptoms can be similar, psoriasis is a distinct condition from eczema, seborrheic dermatitis and other skin conditions and should be diagnosed by a dermatologist.

Scalp psoriasis is characterized by red, scaly patches on the scalp. This type of psoriasis can be associated with severe itching, burning and hair loss.

Case Presentation

A 29 years old male patient presented to our Dermatology

7. Nail psoriasis

Nail psoriasis affects the nails and can cause discoloration, thickening and separation from the nail bed.

8. Psoriatic Arthritis

Psoriatic arthritis affects the joints; it can be a debilitating condition and cause a lot of pain in affected areas.

A B

It's also possible to have more than one type of psoriasis at the same time that can affect different parts of the body and each type has its own unique set of symptoms and characteristics. A dermatologist can diagnose the type of psoriasis based on a person's symptoms, medical history and a physical examination of the affected skin. It's important to note that

OPD with the chief complaint of numerous plaques on his body since 5 years. Physical examination revealed welldemarcated erythematous, scaly plaques with overlying thick white scales distributed throughout his body with the major involvement of elbows, forearms, back, abdomen, legs, palms and dorsum of feet and nails. There was no history of similar complaints on his face and scalp but rest of the body parts were affected. The patient experienced itching often and described the intensity as unbearable affecting his quality of life. He had no medical history of any other disease in the past. He had no history of alcohol intake. On close observation of his history found winter exacerbation of disease because it was aggravating in winter and sometimes he had summer flares also. Based on his history and physical examination; the diagnosis of plaque psoriasis was made. Fewer tests were performed like montoux test which is typically performed on skin to confirm tuberculosis. The test turned out to be normal. Chest x-ray was also conducted which was also normal. These 2 tests were conducted as mandatory tests for starting the therapy with the drug Tofacitinib. The basic blood work including CBC, LFT, RFT, Cholesterol were all normal.