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 The leading web portal for pharmacy resources, news, education and careers June 24, 2017
Pharmacy Choice - Psoriasis Disease State Management - June 24, 2017

Psoriasis Disease State Management

Psoriasis: A Primer for Pharmacists
by Darrell Hulisz, RPh, PharmD
Associate Professor, Department of Family Medicine
Case Western Reserve University, School of Medicine


Psoriasis is a non-contagious, auto-immune, chronic skin disease characterized by erythematous (reddened) papules and plaques often covered with silver-white scales. These plaques or lesions occur because the immune system releases altered signals that accelerate the growth cycle of skin cells. Psoriasis requires the same amount of awareness and attention as that of other major medical diseases because it is often associated with arthritis, intense itching, inflammation, psychiatric and cardiovascular problems, as well as potentially disfiguring dermal manifestations. About 10-15% of individuals who have psoriasis develop joint inflammation. When this occurs, it is called psoriatic arthritis.

Psoriasis is fairly common in the United States because it affects approximately 7 million Americans, or approximately 2-3% of the population. Every ethnicity is prone to this disease, but it is most common in the white population. Psoriasis can develop at any age, but individuals between the ages of 20-30 are at the highest risk, while the risk starts to decline around the age of 50. Environmental factors such as climate, stress, alcohol, smoking, infection, trauma, and drugs enhance the severity of psoriasis. Reports show that warm seasons and sunlight cause improvement of psoriasis in 80% of patients, whereas 90% of patients report worsening in cold weather. In addition, stress increases the severity of psoriasis in up to 40% of patients. Even though the occurrence of psoriasis is equal in men and women, they are affected differently by it. Alcohol seems to have a greater impact on the progression of psoriasis in men, and the correlation between smoking and psoriasis seems to be stronger in women. Psoriasis is thought to have a genetic basis since most patients have at least one immediate relative with the disease.

The symptoms of psoriasis vary with the type of psoriasis. In addition to psoriatic arthritis, the different types of dermal psoriasis include plaque, guttate, inverse, erythrodermic, and pustular. Plaque psoriasis is the most common form, with lesions usually found on the extensor surfaces on the extremities, scalp, lower back, and buttocks. The lesions have a highly distributed size from a few millimeters to tens of centimeters. Guttate psoriasis have lesions that are shaped like a tear drop and can appear on large areas of the body, scalp, and arms. The lesions of this type are usually less than 1 cm in diameter. Inverse psoriasis is found on intertriginous areas such as axillae, gluteal folds, and submammary areas. The areas affected are reddened and glazed. Erythrodermic psoriasis is an obscure type in which erythema with fine scaling covers the entire skin surface. This can lead to hypothermia and may even be associated with high-output cardiac failure. Pustular psoriasis affects the palmoplantar areas of the skin. The use or abrupt withdrawal of systemic steroids is often the cause of this type of psoriasis.

There are different modalities for treatment of psoriasis which include topical medications, phototherapy and photochemotherapy, systematic therapies, and biological agents. Patients that are treated with topical medications have the stable, plaque-type of psoriasis that covers less than 10% of the body’s surface area. The medications used for this type of treatment are corticosteroids (e.g. betamethasone), coal tar, and topical vitamin D analogs (e.g. calcipotriene). Possible side effects of these medicines are skin atrophy, telangectasia, dermatitis, and local irritation. Phototherapy with ultraviolet light (UV) or photochemotherapy is also used for stable, plaque psoriasis that covers greater than 10% of the body’s surface area. The medications used for this type of treatment are UVB (broad band and narrow band) and PUVA. PUVA is a combination of UVA light plus oral or topical psoralen therapy, such as methoxsalen. Possible side effects of using UVB include photodamage, photoallergic reactions, and a potentially skin aging, especially if used chronically. Possible side effects for using PUVA are increased risk of acute burns with treatment and long-term risk of skin cancer.

Systemic therapies are reserved for patients with severe psoriasis. Examples of medications used for this type of treatment include acitretin, an oral retinoid drug, and cyclosporine. The possible side effects of using acitretin include hepatoxicity and lipid abnormalities. Troublesome side effects of using cyclosporine include nephrotoxicity and hypertension. Other systemic oral immune modulators sometimes used for psoriasis include methotrexate, hydroxyurea and mycophenolate. Injectable biological agents are reserved for patients with severe recalcitrant psoriasis and psoriatic arthritis. Biological therapies are immune modulators and include TNF inhibitors, such as etanercept, infliximab, and adalimumab, a CD2-LFA3 blocker, known as alefacept, and an ICAM1-LFA1 blocker known as efalizumab. The potential side effects of using TNF inhibitors are numerous, but recent concerns include the ability to precipitate autoimmune diseases, such as multiple sclerosis and increased risk of lymphoma and other malignancies. The possible side effect of using CD2-LFA3 blockers and 1CAM1-LFA1 blockers is a theoretical increased risk of serious infections, such as tuberculosis and malignancies.

Psoriasis is a potentially serious skin condition with multiple types that vary in clinical severity. The choice of pharmacotherapy used to treat psoriasis is determined by the type of psoriasis, severity of a patient's condition and the probability of controlling long-term symptoms with minimal adverse effects.

References:
  1. Koo J, Lee E, Lee CS, Lebwohl M. Psoriasis. J Am Acad Dermatol, 2004;50(4):613–622.
  2. Pearce DJ, Stealey KH, Balkrishnan R, et al. Psoriasis treatment in the United States at the end of the 20th century. Int J Dermatol 2006;45(4):370–374.
  3. Krueger G, Ellis CN. Psoriasis - Recent advances in understanding its pathogenesis and treatment. J Am Acad Dermatol 2005;53(1 Suppl 1):S94–S100.
  4. van de Kerkhof PCM. Update on retinoid therapy of psoriasis in: An update on the use of retinoids in dermatology. Dermatol Ther 2006;19(5):252–263.

Links - Psoriasis
National Psoriasis Foundation

American Academy of Dermatology

American Osteopathic College of Dermatology

American College of Rheumatology

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