Conclusion
How to Treat – Psoriasis
from page 22
Case study three
Erin, aged 40, is referred to the dermatologist for a three-year history of psoriasis not responding to topical corticosteroids or vitamin D analogues. She weighs 77kg, and has no other significant past medical history, allergies, smoking, or alcohol consumption.
Her PASI score on presentation to the dermatologist is 15.0, and psoriasis covers approximately 24 % of her body surface area.
She is initially treated with nUVB administered three times a week. Despite an initial response, Erin’ s psoriasis flares while on nUVB in the first six weeks.
Following her relapse and cessation of nUVB, Erin is started on 10mg / week methotrexate with 5mg / week folic acid. Three weeks into treatment Erin starts developing nausea and vomiting. In addition, her bloods showed acutely raised transaminases. It takes a few weeks for Erin’ s LFTs to return to normal. She is consequently started on cyclosporine 100mg BD, with close monitoring of her LFTs and kidney function. A less toxic alternative, neotigason, was contraindicated at the time because of elevated transaminases.
Because of lack of efficacy, the cyclosporine dose is escalated to 150mg BD over two months. Despite dose escalation to 4mg / kg / day, Erin’ s psoriasis has an inadequate response, and her PASI and body surface area only decrease by 10-15 % over a 10-week period.
A
B
A. Pre-treatment. B. After 24 weeks on ustekinumab.
Because Erin’ s PASI and body surface area were recorded at each stage of treatment( particularly after six weeks of a given therapy), a successful application for the use of ustekinumab is made. Erin is started on 45mg subcutaneous ustekinumab. At week 24, Erin’ s PASI reaches 0.0 on a maintenance dose of 45mg / three months. This response is maintained over one year, and Erin couldn’ t be happier with her results and treatment regime.
Conclusion
PSORIASIS is a chronic inflammatory disorder that usually presents as erythematous, scaly plaques on the extensor surfaces and scalp after a triggering event in a genetically susceptible individual. The disturbance in the skin’ s immunological balance sets the stage for high keratinocyte turnover, angiogenesis, and the propagation of proinflammatory cytokines that lead to plaque formation. Psoriasis can be a physically and psychosocially debilitating condition.
Recognising the signs and severity of psoriasis( including systemic manifestations such as arthritic symptoms) can help guide appropriate treatment and referral. A special consideration should also be made by medical practitioners to monitor and treat
the associated comorbid conditions, namely those linked to cardiovascular disease.
Recording PASI scores at every treatment stage is important as it can help patients in attaining the best treatment options available through the PBS. And the Dermatology Life Quality Index tool can be used to assess psychological impact of the disease pre-and post-treatment. The treatment pyramid offers a general guide to approaching and escalating treatment.
The recent developments in biological therapies have added a new dimension to managing this chronic persisting condition. This class of drugs is likely to be finetuned and even more efficacious in the coming years.
Summary
• Psoriasis is a chronic inflammatory disorder characterised by epidermal hyperproliferation.
• The disease carries both a physical and psychological burden.
• Recording Psoriasis Area and Severity Index assessments is essential in escalating treatment of severe psoriasis through the PBS.
• Topical treatment options used in general practice can adequately help most patients.
• Development of biologic agents has revolutionised the treatment of severe psoriasis
How to Treat Quiz GO ONLINE TO COMPLETE THE QUIZ
Psoriasis— 12 May 2017 www. australiandoctor. com. au / education / how-to-treat
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1. Which THREE statements regarding the background to psoriasis are correct? a) Psoriasis is characterised by epidermal hyperproliferation and inflammation. b) Psoriasis affects only the skin and mucous membranes. c) Psoriasis usually presents as well-demarcated, monomorphic, indurated, erythematous plaques, covered by silvery scaling skin. d) Psoriasis carries both a physical and psychological burden.
2. Which TWO statements regarding the epidemiology and aetiology of psoriasis are correct? a) The most common type of psoriasis is the chronic plaquetype. b) Chronic plaque-type psoriasis typically affects the flexor surfaces and the scalp. c) Psoriasis most commonly
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presents between 30 and 45 years. d) Psoriasis is a very common condition, prevalent in up to 2-3 % of the adult population.
3. Which THREE have been identified as contributing to the development of psoriasis? a) Trauma. b) Gender. c) Systemic drugs. d) Infections.
4. Which TWO co-morbidities are associated with psoriasis? a) Ulcerative colitis. b) Cardiovascular disease. c) Graves’ disease. d) Dyslipidaemia.
5. Which THREE features may be seen in the nails of patients with psoriasis? a) Leukonychia. b) Dark or greenish discolouration of
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the nail. c) Pitting. d) Splinter haemorrhages.
6. Which THREE are differential diagnoses of psoriasis? a) Lichen sclerosus. b) Eczema. c) Tinea infections. d) Seborrhoeic dermatitis.
7. Which THREE statements regarding the diagnosis of psoriasis are correct? a) The diagnosis of psoriasis is often made clinically. b) A skin biopsy will show typical features. c) The psychological burden of disease should also be considered when determining disease severity and the need for referral. d) The PASI tool is the Psoriasis Activity and Severity Index.
8. Which TWO statements
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regarding the management of psoriasis are correct? a) The first-line management of psoriasis is oral therapy. b) Some 70-80 % of patients with psoriasis can be controlled with topical therapies. c) Tar preparations are no longer recommended because of significant local side effects. d) Salicylic acid and emollients are often used in combination with topical therapies to help reduce scale and assist in penetration of topical therapies.
9. Which THREE statements regarding the management of psoriasis are correct? a) Light therapy is the next treatment option after topical treatment. b) A potential limitation to using light therapies is that numerous doses per week administered at a clinic may not always be feasible for all patients.
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c) PUVA is the standard treatment and is considered superior to other light therapies in that it is clears plaques more quickly and has a higher rate of clearance. d) Possible acute adverse reactions to nUVB include erythema, blistering and hyperpigmentation.
10. Which THREE statements regarding the management of psoriasis are correct? a) Methotrexate is often used as a first-line systemic therapy. b) Acitretin is a viable alternative to methotrexate as it is safe in pregnancy. c) The biologic class of drugs are the new gold standard in the treatment of severe psoriasis. d) Because of the immunosuppressive and immunomodulatory qualities of biologics, these drugs should be avoided in patients with severe or recurrent or active malignancies.
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NEXT WEEK’ S HOW TO TREAT
HEADACHES IN CHILDREN, The author is Professor Peter G Procopis, Sydney, NSW.
HOW TO TREAT Editor: Dr Claire Berman Email: claire. berman @ adg. com. au
24 | Australian Doctor | 12 May 2017 www. australiandoctor. com. au