Australian Doctor Australian Doctor 12 May 2017 | Page 22

How to Treat – Psoriasis
from previous page
the new gold standard in the treat-
ment of severe psoriasis.
Since their development, newer
drugs within the biologic class
have emerged as more refined
versions requiring greater time
between doses and exhibiting
higher efficacies.
In patients where psoriasis
has persisted for more than six
months with a PASI greater than
15, the PBS allows for prescrip-
tion of a biologic in patients who
have failed three of the following
four conventional therapies: UVB,
methotrexate, cyclosporine and
acitretin, or if patients have con-
traindications or defined toxicity-
related adverse reactions to these
conventional modalities. 6,9
Because of the immunosup-
pressive and immunomodulatory
qualities of biologics, these drugs
should be avoided in patients
with severe or recurrent infections
(such as TB), or active malignan-
cies. 6
Similarly, depending on the
biologic agent, monitoring for
injection site reactions, hypersen-
sitivity reactions, certain infective,
malignant, neurological, haemato-
logical, and cardiovascular com-
plications such as heart failure is
required. 6
For example, adalimumab, an
anti-TNF-alpha monoclonal anti-
body , is a widely used biologic
for psoriasis and exhibits 80%
PASI-75 efficacy (grade 1 recom-
mendation). 2 Precautions that are
specific for adalumimab include
monitoring for reactivation of TB
or hepatitis B, and ongoing age
specific cancer screenings.
Table 3 outlines some of the
more common biologics used in
Table 3. Characteristics and efficacy (at least PASI-75) of biological agents
Drug
Mechanism of Action Efficacy Dosing Schedule
Anti-TNF-alpha 70% at week 16 Fortnightly
Anti-TNF-alpha 80% at Week 10 Every 8 weeks
Enteracept Anti-TNF-alpha & Anti-TNF-beta 50% at Week 24 Weekly
Ustekinumab 1,4 Anti-IL12 and Anti-IL23 70% Every 12 weeks
Secukinumab 1,4 Anti-IL17A 80% Every four weeks
Adalumimab 1,4
1,3
Infliximab
2,4
1. Monoclonal antibody. 2. Recombinant DNA fusion protein. 3. Available as an intravenous. 4. Available as subcutaneous
injection.
Adapted from Lancet 2015; 386:983–94; Australian Journal of Pharmacy 2013; 94: 68-71; Journal der Deutschen
Dermatologischen Gesellschaft 2012; 10 (suppl 2): S1–95.
EMILY, 19, presents to her GP
with a three-month history of
red flaky skin affecting her scalp,
forehead, elbows, knees, and
post-auricular and peri-umbilical
regions.
She presents feeling embarrassed
and anxious in social situations
A
B
22
| Australian Doctor | 12 May 2017
Australian Government Department
of Human Services
PASI calculator
http://bit.ly/2kIcvj7
Health Professional Online Services
(HPOS)
http://bit.ly/2ncP0m5
Figure 7A. Pre-ustekinumab therapy. Figure 7B. Three months post-ustekinumab therapy.
psoriasis treatment, their efficacy,
and the mechanism of action.
All of these biologics are sup-
ported by level 1 evidence. Inter-
estingly, sometimes patients can
develop antibodies to the biologic
molecule itself, rendering the drug
less efficacious or ineffective.
Loss of response to a certain biologic agent may be an indica-
tion to change treatment within
the same class or to consider class
switching. In general, biologics are
well-tolerated, interact less with
other medications, and exhibit less
toxicity. They are therefore a good
long-term option. 2
Psoriasis is unfortunately a life- long disease with a remitting and
relapsing course. 6
As the disease carriers a sig-
nificant physical and psychoso-
cial burden, timely treatment and
referral is key. However, both
patients and healthcare staff need
to know an array of options exist
for patients with persistent disease.
because of cosmetic disfigurement.
Though she cannot remember any
triggering factors, she notes that her
father also developed psoriasis at a
young age. She does not report any
joint pain. Emily reports no other
significant past medical history and
does not take any medications.
On examination, she has plaques of mildly erythematous indurated
skin with a thin layer of scale cover-
ing approximately 8% of her body
surface area.
Her PASI score is calculated as
3.3. Onycholysis is observed on
four nails. Emily is started on a
topical vitamin D analogue with
good response. She reports improvement in her
anxiety and self-confidence, in
addition to her physical symptoms.
She will need ongoing monitoring
for joint symptoms and relapses.
In the future, she may need refer-
ral to a dermatologist and rheuma-
tologist for specialist opinion and
escalation of treatment.
B
A. Pre-treatment and B. post-topical treatment with ustekinumab.
Colin, a 56-year-old construction
worker, has a one-year history of
psoriasis. He has been treated by
his GP with topical corticosteroids.
He was referred to a dermatolo-
gist six months ago to explore his
treatment options. Colin has a past
medical history of hypertension and
hypercholesterolaemia controlled
on ramipril and atorvastatin. He
smokes 20 cigarettes a day. He has
no significant family history.
On his first visit to the der-
matologist, Colin’s examination
Australian Academy of
Dermatologists
http://bit.ly/2df71gF
References
A
Case study two
Health Direct Psoriasis
http://bit.ly/2kEFjca
Severe chronic plaque psoriasis
http://bit.ly/2mZ9uwp
Case studies
Case study one
Online resources
reveals moderate psoriasis cover-
ing approximately 10% of his body
surface area, and his PASI score is
9.0.
Colin is started on UVB therapy
three times a week. Unfortunately,
12 weeks into treatment Colin’s
psoriasis relapses, and his PASI
score returns to baseline.
As a result of the relapse he is
started on 10mg/week of metho-
trexate, which is increased to 20mg/
week (and is prescribed concurrent
folic acid 5mg/week). Colin’s psori-
asis is well-controlled on this treat-
ment regimen, and his