Psoriasis

1
Psoriasis

• A review of therapeutics

2
A definition from Clinical EvidenceNaldi L and
Rzany B. Clinical Evidence 2006151-4 (Search
Date July 2006)

• Chronic plaque psoriasis, or psoriasis vulgaris,
  is a chronic inflammatory skin disease that is
  characterised by well demarcated erythematous
  scaly patches on the extensor surfaces of the
  body and scalp
• The lesions may itch, sting, and occasionally
  bleed
• Dystrophic nail changes are found in more than a
  third of people with chronic plaque psoriasis,
  and psoriatic arthropathy occurs in 1 to more
  than 10
• The condition waxes and wanes, with wide
  variations in course and severity among
  individuals
• Other varieties of psoriasis include guttate,
  inverse, pustular, and erythrodermic psoriasis

3
Many therapiesNaldi L and Rzany B. Clinical
Evidence 2006151-4 (Search Date July 2006)

• Community-based
• Emollients
• Topical coal tar
• Topical dithranol
• Topical vitamin D analogues
• Topical corticosteroids
• Topical retinoids
• plus combinations
• treatment for specific sites

• Hospital-led therapy
• Phototherapy
• Methotrexate
• Oral retinoids
• Cyclosporin
• Hydroxurea
• Azathioprine
• Systemic steroids
• TNF-alpha drugs
• T-cell drugs efalizumab, alefacept

4
British Association of Dermatologists Guidelines
Recommendationswww.bad.org.uk ? Accessed
25/04/08

• Emollients should be used to soften scaling and
  reduce any irritation
• For localised plaque psoriasis one or more of the
  following topical preparations can be tried
• A tar-based cream, or a tar/corticosteroid
  mixture
• A moderate potency topical corticosteroid (e.g.
  0.05 clobetasone butyrate) stronger agents can
  be used on palms and soles or on the scalp
• A vitamin D analogue
• Calcipotriol with betamethasone dipropionate as a
  combination product
• A vitamin A analogue (tazarotene)
• A dithranol preparation
• Important to use a keratolytic agent (e.g. 5
  salicylic acid in emulsifying ointment) first
  when there is significant scaling, or other
  treatments may fail

5
NICE guidance on etanercept? and efalizumab? ?
1NICE TA103, July 2006

• Etanercept?, within its licensed indications, is
  recommended for the treatment of adults with
  plaque psoriasis only when the following criteria
  are met
• The disease is severe (PASI score of 10 or more
  and DLQI score gt10)
• The psoriasis has failed to respond to standard
  systemic therapies, or the person is intolerant
  to, or has a contraindication to, these
  treatments
• Etanercept? treatment should be discontinued in
  patients whose psoriasis has not responded
  adequately at 12 weeks
• Further treatment cycles are not recommended in
  these patients
• An adequate response is defined as either
• a 75 reduction in the PASI score from when
  treatment started (PASI 75), or
• a 50 reduction in the PASI score (PASI 50) and a
  five-point reduction in DLQI from when treatment
  started

6
NICE guidance on etanercept? and efalizumab? ? 2
NICE TA103, July 2006

• Efalizumab?, within its licensed indications, is
  recommended for the treatment of adults with
  plaque psoriasis under the circumstances detailed
  for etanercept? only if their psoriasis has
  failed to respond to etanercept? or they are
  shown to be intolerant of, or have
  contraindications to, treatment with etanercept?
• Further treatment with efalizumab? is not
  recommended in patients unless their psoriasis
  has responded adequately at 12 weeks (as defined
  for etanercept)
• Use of etanercept? and efalizumab? for psoriasis
  should be initiated and supervised only by
  specialist physicians
• If a person has both psoriasis and psoriatic
  arthritis their treatment should be managed by
  collaboration between a rheumatologist and a
  dermatologist

7
NICE guidance on infliximab? NICE TA134, Jan 2008

• Infliximab?, within its licensed indications, is
  recommended as a treatment option for adults with
  plaque psoriasis only when the following criteria
  are met
• The disease is very severe (PASI score of 20 or
  more and DLQI score gt18)
• The psoriasis has failed to respond to standard
  systemic therapies, or the person is intolerant
  to, or has a contraindication to, these
  treatments
• Continue beyond 10 weeks only if an adequate
  response to treatment within 10 weeks has
  occurred, defined as either
• a 75 reduction in the PASI score from when
  treatment started (PASI 75), or
• a 50 reduction in the PASI score (PASI 50) and a
  five-point reduction in DLQI from when treatment
  started
• NICE TA for adalimumab? expected June 2008

8
Summary

• Psoriasis is one of the most common skin
  conditions seen in primary care
• Most common form is chronic plaque psoriasis
• Can cause poor quality of life and some
  complications can be life threatening
• Many patients can be managed in primary care
• Emollients useful as long-term management
• Evidence base limited, especially for older
  treatments
• More severe psoriasis needs specialist care
• Self-help groups can be beneficial