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Psoriasis. Dr yazan alrashdan Department of biopharmaceutics and clinical pharmacy Faculty of pharmacy University of jordan [email protected] Definition and facts Epidemiology Classification Signs and symptoms Etiology Diagnosis Management Prognosis .

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psoriasis

Psoriasis

Dr yazanalrashdan

Department of biopharmaceutics and clinical pharmacy

Faculty of pharmacy

University of jordan

[email protected]

slide2

Definition and facts

  • Epidemiology
  • Classification
  • Signs and symptoms
  • Etiology
  • Diagnosis
  • Management
  • Prognosis

University of Jordan/Faculty of Pharmacy

slide3

A a common chronic inflammatory skin disorder characterized by recurrent exacerbations and remissions of thickened, erythematous, and scaling plaques.

  • Occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells.
  • Is NOT contagious.
  • Occurs on the skin of the elbows and knees, scalp, palms of hands and soles of feet, and genitals.
  • Fingernails and toenails are frequently affected.
  • Can also cause inflammation of the joints (psoriatic arthritis; 10-40%).
  • The cause not fully understood, however, genetics plus local psoriatic changes are the favorable perpetrators.

University of Jordan/Faculty of Pharmacy

epidemiology
Epidemiology
  • Psoriasis affects both sexes equally.
  • Can occur at any age (most commonly appears for the first time between the ages of 15 and 25 years).
  • The prevalence of psoriasis in Western populations is estimated to be around 2-3%.
  • Around one-third of people with psoriasis report a family history of the disease.
  • Onset before age 40 usually indicates a greater genetic susceptibility and a more severe or recurrent course of psoriasis.

University of Jordan/Faculty of Pharmacy

classification
Classification
  • Non-pustular:

- Psoriasis vulgaris: the most common (80-90)%

- Psoriatic erythroderma: often results from exacerbation of vulgaris particularly following the abrupt withdrawal of systemic treatment.

  • Pustular:

- Appears as raised bumps that are filled with pus.

- The skin under and surrounding the pustules is red and tender.

- Can be localized to the hands and feet or generalized with widespread patches occurring randomly on any part of the body.

University of Jordan/Faculty of Pharmacy

signs
Signs
  • The typical lesion is a well-demarcated, pink to salmon-colored plaque covered by loosely adherent scale that is characteristically silver-white in color.
  • Nail changes occur in 30% of cases of psoriasis and consist of yellow-brown discoloration, with pitting, dimpling, separation of the nail plate from the underlying bed, thickening, and crumbling.

University of Jordan/Faculty of Pharmacy

symptoms
Symptoms
  • Relatively asymptomatic.
  • Pruritus is a complaint in about 25% of patients.
  • Severe, widespread psoriasis can involve fever and chills.

University of Jordan/Faculty of Pharmacy

slide8

Severity:

- Mild

- Moderate

- Severe

  • The Psoriasis Area Severity Index (PASI):

- The most widely used measurement tool for psoriasis.

- Combines the assessment of the severity of lesions and the area affected into a single score in the range 0 (no disease) to 72 (maximal disease).

University of Jordan/Faculty of Pharmacy

etiology
Etiology
  • There are two main hypotheses:

1. Considers it as a disorder of excessive growth and reproduction of skin cells (the problem is simply seen as a fault of the epidermis and its keratinocytes).

2. Considers it as being an immune-mediated disorder in which the excessive reproduction of skin cells is secondary to factors produced by the immune system.

- T cells become active, migrate to the dermis and trigger the release of cytokines (TNFα) which cause inflammation and the rapid production of skin cells.

University of Jordan/Faculty of Pharmacy

slide11

Triggering/Aggravating factors:

- Stress (physical and mental)

- Skin injury (Koebner phenomenon)

- Streptococcal infection

- Changes in season and climate

- Certain medicines (lithium salt, β-blockers & chloroquine)

- Excessive alcohol consumption, smoking and obesity

- Hairspray, some face creams and hand lotions

University of Jordan/Faculty of Pharmacy

genetics
Genetics
  • Psoriasis has a large hereditary component.
  • The MHC and T cells play pivotal role.
  • PSORS1 through PSORS9.
  • The major determinant is PSORS1 (accounts for 35-50%). It controls genes that affect the immune system or encode proteins that are found in the skin in greater amounts in psoriasis:

- HLA (MHC-1)

- IL12B

- IL23R (interleukin-23 receptor)

upregulating TNFα and NFκB

University of Jordan/Faculty of Pharmacy

slide13

APC, antigen-presenting cell; GM-CSF, granulocyte-macrophage colony-stimulating factor; ICAM, intercellular adhesion molecule; INF, interferon; IL, interleukin; IP, inflammatory protein; MHC, major histocompatibility complex; MIG, monokine induced by interferon-; RANTES, regulated on activation, normal T-cell expressed and secreted; TNF, tumor necrosis factor; TH1, T-helper cell type 1; TH2, T-helped cell type 2; VCAM, vascular cell adhesion molecule; VEGF, vascular endothelial growth factor.

Data from Mehlis S, Gordon KB. From laboratory to clinic: Rationale for biologic therapy. Dermatol Clin 2004;22(4):371–377, vii–viii.

University of Jordan/Faculty of Pharmacy

slide14

Diagnosis:

- Based on the appearance of the skin.

- There are no special blood tests or diagnostic procedures.

- A skin biopsy (or scraping) may be needed to rule out other disorders and to confirm the diagnosis.

- When the plaques are scraped, one can see pinpoint bleeding from the skin below (Auspitz\'s sign)

University of Jordan/Faculty of Pharmacy

management treatment
Management/Treatment
  • Topical agents:

1. Moisturizers, mineral oil, and petroleum jelly may help soothe affected skin and reduce the dryness which accompanies the build-up of skin on psoriatic plaques.

2. Ointment and creams containing:

- coal tar

- dithranol (anthralin)

- corticosteroids (desoximetasone & fluocinonide)

- vitamin D3 analogues

- retinoids

University of Jordan/Faculty of Pharmacy

slide16

Phototherapy:

- Wavelengths of 311–313 nm are most effective.

- The amount of light used is determined by a persons skin type.

- Increased rates of cancer from treatment appear to be small.

- Psoralen and ultraviolet A phototherapy (PUVA).

University of Jordan/Faculty of Pharmacy

slide17

Systemic agents:

- Patients are required to have regular blood and liver function tests because of the toxicity of the medication.

- Pregnancy must be avoided for the majority of these treatments.

- Most people experience a recurrence of psoriasis after systemic treatment is discontinued.

- Three main traditional systemic treatments are methotrexate, cyclosporine and retinoids.

- Two drugs that target T cells are efalizumab and alefacept.

- MAbs (infliximab, adalimumab, golimumab and certolizumab pegol).

- Recombinant TNF-α decoy receptor (etanercept).

- Antibodies have been developed against pro-inflammatory cytokines IL-12/IL-23 and IL-17.

University of Jordan/Faculty of Pharmacy

slide19

Alternative therapy:

- Fasting periods, low energy diets and vegetarian diets have improved psoriasis symptoms in some studies, and diets supplemented with fish oil.

- Ichthyotherapy, which is practised at some spas in Turkey, Iran, Iraq, Croatia, Ireland, Hungary and Serbia.

- Hypnotherapy.

University of Jordan/Faculty of Pharmacy

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