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What is the epidemiology of psoriasis?
- 1-3% of the population
- Less common in blacks
- Even distribution between genders
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What is the clinical presentation of plaque psoriasis?
- MOST Common type
- Erythematous (red) plaques with "silvery" scale.
- Most patients have chronic localized disease, but there can be systemic manifestations
- Affects the extensor (outside) more than the flexor (pits)surfaces
- Usually not on face, palms, soles of feet
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What is the etiology of psoriasis?
- unknown
- Genetics contribute: 40% have PSORS1 locus in the MHC I region
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What is the pathophysiology of psoriasis?
- An unknown antigen may inappropriately trigger the APC cells and falsely initiates T-cell activation = cytokine and growth factor overproduction = migration of T-cells to the skin resulting in:
- increased turnover rate of epidermal cells (keratinocytes)
- increased numbers of epidermal stem cells
- abnormal differentiation of skin cells (thickened skin)
- decreased cell turnover time (37h vs 300h)
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What are the risk factors/exacerbating factors for psoriasis?
- Streptococcal infections
- Overuse of alcohol
- Psychological stress
- Trauma to the skin (scratching, sunburn, or surgery)
- Meds:
- Li
- BBL
- Antimalarials
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What are the complications of psoriasis?
- Itching may be experienced and can be severe
- Impaired mobility and daily functioning
- Psychological stress
- Reduced QOL
- Dehydration
- Hypothermia
- Infection (Skin and soft tissue, sepsis)
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What are the non-pharmacological options for treating psoriasis?
- Avoid excessive alcohol consumption
- Soaking baths to remove scale, followed by emollient use
- Psychological stress reduction
- Sun exposure (avoid sunburn)
- Phototherapy (UVB and PUVA)
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How is UV light used for treatment of psoriasis?
- UVB:
- safest treatment for extensive psoriasis in pregnancy
- can be combined with Calcipotriene, Tazarotene, Coal tar, or Anthralin
- PUVA:
- UVA plus Psoralen
- UVA penetrates deeper and doesn't burn as readily as UVB
- Re-PUVA:
- using PUVA plus retinoids (Tazarotene, Acitretin) to reduce dose of PUVA
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What are the SE of PUVA?
- Burning sensation
- Photosensitivity (use eye protection with PO Psoralen until eliminated from body)
- Nausea
- Vomiting
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What are the topical agents used for psoriasis?
- Emollients
- Salicylic acid
- Topical Corticosteroids
- Calcineurin inhibitors (Tacrolimus, Pimecrolimus)
- Vitamin D analog (Calcipotriene)
- Retinoid (Tazarotene)
- Coal tar
- Anthralin
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What are the systemic agents used for psoriasis?
- Methotrexate
- Cyclosporine, Tacrolimus
- Retinoid (Acitretin - DON'T use this)
- Sulfasalazine (Psoriatic arthritis only)
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What are the immunomodulatory agents used for psoriasis?
- Etanercept (TNF)
- Infliximab (TNF)
- Adalimumab (TNF)
- Alefacept (LFA-3)
- Ustekinumab (IL-12, IL-23)
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What are the SE of salicylic acid in psoriasis?
- Burning and stinging of applied areas
- Large area application:
- N,V
- Hyperventilation (occasionally)
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What is the advantage of topical calcineurin inhibitors (Tacrolimus, Pimecrolimus)?
Desirable for use on face and intertriginous areas (thin-skinned)
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What are the SE of Vitamin D analog (Calcipotriene)?
- Hypercalcemia
- Skin irritation
- Burning and stinging
- Worsening of psoriasis sx (rare)
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What are the SE of topical Retinoid (Tazarotene)?
- Teratogenic (Do not apply to more than 20% of body surface area)
- Burning and stinging
- Dry skin
- Erythema
- Pruritis
- Skin pain
- Worsening of psoriasis
- Photosensitivity
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What are the SE of Coal tar and Anthralin?
- Staining of skin
- Teratogenic
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What is the MOA of Salicylic Acid in psoriasis?
Remove scale, smooth the skin, and decrease hyperkeratosis
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What is the MOA of vitamin D analog (Calcipotriene) in psoriasis?
Inhibits growth and differentiation of keratinocytes by binding the vitamin D receptors in the epidermis
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What is the MOA of topical retinoid (Tazarotene) in psoriasis?
Interacts with the retinoic acid receptor to control symptoms
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What are the SE of systemic retinoid (Actretin)?
- Teratogenic (3yrs after DC!)
- Hepatotoxic
- Renal toxicity
- Hypervitaminosis A (dry lips, mouth, nose, eye, skin; pruritis, scaling, and alopecia)
- Hyperlipidemia (esp triglycerides)
- Electrolytes abnormality
- Skeletal/bone changes
- Increased intracranial BP when used with TCN
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What is the MOA of systemic retinoid (Acitretin) in psoriasis?
Unknown, but works by interacting with the retinoic acid receptor
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What are the special considerations for systemic retinoid (Acetretin)?
- Do not donate blood for 3yrs after DC
- Use at lease 2 forms of birth control
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Which biological agent has the quickest onset of action in psoriasis?
Infliximab
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Which biological agent has the best SE profile?
Ustekinumab
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Which biological agent has the most convenient dosing schedule for psoriasis?
Ustekinumab
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Which biological agent has the slowest onset of action in psoriasis?
Alefacept
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Which biological agent has a restricted distribution (only found in physician offices and specialty pharmacies)?
Alefacept
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Which biological agent is contraindicated in HIV patients?
Alefacept
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