CC March 2016 Psoriasis treatment

echoecho's version from 2016-06-05 18:47


Question Answer
Psoriasis is a chronic inflammatory skin condition affecting what percent of the adult population I in the US?2%
Is it more common in those with a family history of psoriasis?Yes
What is the mode of inheritance?Unknown
What has been indentured as a risk fx for both the development of psoriasis and it's severity ?Tobacco
Psoriasis is a ______- mediated disease?Immune
What other diseases can Psoriasis cause?1) nails ( psoriatic onychodystrophy) 2) sero-negative inflammatory arthritis (psoriatic arthritis)
Has the severity of any arthritic manifestations been linked to the severity of the skin s/s?no
What is the most common variant?chronic plaque psoriasis
Describe chronic plaque psoriasis?1) lesions well demarcated, erythematous, raised with thick silvery scale 2) symmetrical 3) commonly on scalp, knees, elbows, back
Define mild disease?< 5% of body surface area (BSA)
Define moderate disease?> 5% but less than 10% BSA
Define severe disease?> 10% of BSA OR if it involves the genitals, hands, feet, face
Treatment?tailored upon severity of psoriasis or presence of arthritis
*** Initial treatment for patients with mild/moderate disease is?1) topical corticosteroids 2) vitamin D analogs (calcipotriene {Dovonex}) 3) calcitrol (Vectical) 4) tazarotene (Tazorac)
Comment on which topical steroids lead to faster resolution of s/s?class 1 and 2 (while lesions are thick, adverse effects of topical steroids like skin irritation and atrophy are unlikely as penetrance and absorption are minimal. Once skin returns to normal, these adverse effects are more likely
Use of potent corticosteroids should be limited to < ____ weeks (with weaning of potency as lesions improves)?4
Compare the vitamin D analogs with topical steroids? 1) the vit D analogs have a slower onset of action than topical steroids but a longer disease-free interval 2)vit D analogues are not as efficacious as class 1 topical corticosteroids although they are effective as class 2 agents 3) vitamin D analogues can be used as monotherapy and are often administered with steroids to improve efficacy and minimize atrophy
Major adverse effect of vitamin D analogs is?skin irritation
Describe what Tazarotene is?1) topical retinoid 2) produces longer disease-free interval than topical steroids 3) teratogenic 4) contraindicated in women who are or might become pregnant
What can be used to help potentiate effects of topical agents and help restore barrier function to the skin?emollients
Why are anthralin and tar infrequently used now?1) significant adverse effects (staining, skin irritation) 2) lower efficacy compared to other topical agents 3) time to improvement is longer compared to vitamin D analogues and corticosteroids
*** A 2013 Cochrane review comparing topical corticosteroids to vit D analogues concluded what?1) both were equally efficacious but there were fewer local side effects with the topical corticosteroids 2) data on long-term side effects (dermal atrophy) from topical corticosteroid use are lacking
How are mild to moderate exacerbations and good response to first-line therapy treated?episodically
What happens to patients with more frequent exacerbations of mild/moderate disease? What type of treatments may they benefit from?1) they may have side effects due to frequent use of these topical 2) Calcineurin inhibitors tacrolimus (Protopic) OR 2) pimecrolimus (Elidel) provided that are older than 2 y.o.
What are the advantages of using tacrolimus (Protopic) or Pimecrolimus (Elidel)?1) less skin atropy than topical corticsoteroids when used for a prolonged period of time 2) preferred by patients w/ facial psoriasis 3) though less efficacious for typical plaque psoriasis than corticosteroids, they are effective for intertriginous and genital lesions
What are the disadvantages of using tacrolimus (Protopic) or Pimecrolimus (Elidel)? carry boxed warning about an increased risk of skin CA and lymphoma
*** Patients with more severe disease may required what?combination therapy with systemic therapy or phototherapy
List the current FDA-approved therapies for systemic psoriasis therapy?1) cyclosporine 2) methotrexate 3) acitretin (Soriatane) 4) etanercept (Enbrel) 5) adalimumab (humira) 6) infliximab (Remicade) 7) ustekinumab (Stelara) 8) secukinumab (Cosentyx) 9) apremilast (Otezla)
Define cyclosporine?1) systemic immunosuppresant 2) often used intermittently 3) should not be used for over 1 year due to the risk of renal damage 4) should not be used for individuals with normally functioning immune systems
Define methotrexate?1) systemic antimetabolite 2) contraindicated in pregnancy 3) may use for long term use 4) should receive supplemental folate 5) hepatotoxicity is a risk (esp in those with risk fx for hepatic injury like chronic hepatitis infection, alcohol consumption, diabetes and obesity)
Define Acitretin?1) synthetic oral retinoid 2) works very slowly but does provide good relief particularly when combined with phototherapy 3) litke its topical counterpart, it is contraindicated in pregnancy, so use is limited in some women
Tumor necrosis factor alpha (TNF-alpha) is blocked by?1) blocked by biologics etanercept, adalimumab and infliximab
Define ustekinumab?1) blocks the actions of interleukin 12/23
Who should not take biologic agents?those with TB, CHF, MS, compromised immune systems should not this medication
How are all these systemic therapies administered?IV
Of all these systemic therapies, which one is most effacious?infliximab
Define Apremilast?1) most recently approved systemic treatment 2) inhibits intracellular phosphodiesterase 4 (PDE 4) 3) taken orally 4) not approved for < 18 y.o. 5) shortterm diarrhea and weight loss side effects 6) not as efficasious as other systemic agents excluding methotrexate
All of these newer agents are very expensive, true or false?true
What 2 radiations does phototherapy use?1) ultraviolet A (UVA) OR 2) ultaviolet B (UVB)
What 2 UV bands can be used alone or with other agents? Name these other agents?1) broadband UVB and narrowband UVB (NBUVB) 2) vit D analogues, retinoids, methotrexate, cyclosporine, or etanercept). Combination improves efficacy and allows lower UVB exposure
Compare NBUVB with broadband UVB?NBUVB has a lower photocarcinogenic risk than broadband UVB
The combination of psoralen and UVB (PUVA) is another option but requires what? What can be added?1) the use of psoralen (oral or as a bath) prior to radiation exposure 2) topical or oral retinoids or vitamin D analogues may be added if appropriate
What can be said about comparisons of UVA and UVB treatment efficacy?are inconsistent
What is the disadvantage of phototherapies?1) can accelerate photodamage of the skin 2) can increase the risk of cutaneous, but not other malignancies
Comment on oral steroids for plaque psoriasis?there is no role of oral steroids either alone or in combination with phototherapy
Patients with psoriatic arthritis often require co-management with what specialist?rheumatologist
Regarding psoriatic arthritis, while nonspecific rx may be tried for mild cases (NSAIDs), what agents are often recommended for initial treatment? List one biologic agent that is FDA approved for psoriatic arthritis, but not psoriasis?1) biologic agents 2) golimumab (Simponi)
*** SUMMARY = Treatment is tailored based on what?severity of the psoriasis or presence of arthritis
*** SUMMARY = What are the initial treatments for patients with mild/moderate disease?1) topical corticosteroids 2) vitamin D analogues
*** SUMMARY = Which agents are effective for intertriginous and genital lesions?calcineurin inhibitors
*** SUMMARY = Severe disease requires what treatment?systemic treatment or phototherapy
*** SUMMARY = Psoriasis is associated with arthritis, does the severity of the joint findings correlated with skin disease severity?no