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    Psor 1

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    Muhammed Sajal
    Drugs used in treatment of psoriasis

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    Psor 1

    Uploaded by

    Muhammed Sajal
    10 views25 pages
    Drugs used in treatment of psoriasis

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    psor 1

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    Drugs used in treatment of psoriasis

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    10 views25 pages

    Psor 1

    Uploaded by

    Muhammed Sajal
    Drugs used in treatment of psoriasis

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 25

    Drugs for Psoriasis

    Introduction to Psoriasis

     common, chronic, inflammatory dermatosis.


     It is characterised by erythematous, well demarcated plaques, and rounded
    scales which look like silvery mica. Pruritus may be present.
     Lesions are usually symmetrical and occur on the extensor surfaces such as
    the elbows and knees, and on the scalp.
     About 50% of the patients have involvement of the finger nails and some have
    psoriatic arthritis.
    Risk factors of Psoriasis

     Genetic predisposition to psoriasis is known.


     Infections, particularly due to streptococci can trigger an attack.
     drug-induced flares of psoriasis can occur
    Some systemic drugs (Beta blockers, ACE inhibitors,Lithium,Chloroquine)
     Injury to skin
     Psychological stress
    Pathogenesis

     The commonest variety of psoriasis is characterised by plaques, which consist of


    greatly thickened horny layer of the skin (hyperkeratosis).
     They are characterised by hyperproliferation of the epidermal keratinocytes and
    inflammation of both the epidermis and the dermis, along with angiogenesis.
     These changes are due to cytokines released by T-lymphocyte, which initate
    autoimmune dermal response to unidentified antigenic stimuli (keratinocyte proteins).
    Pathogenesis Cntd

     The affected dermis shows predominance of CD4 lymphocytes. The activated


    T cells from the dermis cause the keratocytes to proliferate;

     the inflammatory changes include infiltration of the epidermis by leucocytes.

     It is now known that TNF-a is the primary activator of the T-lymphocytes and
    it also contributes to the maintenance of a complex inflammatory reaction.
    current therapy only suppresses the disease and recurrence is common .

    However, the disease may undergo spontaneous remission


    Treatment
     depends on the type, the location and the extent of the lesions.
     The patients are advised to avoid known exacerbating factors.
     Mild cases of psoriasis may not warrant any drug therapy, since drugs used can produce toxicity.

    Indications for drug treatment


     Marked local symptoms such as pain and itching.
     Prominent lesions on hand, leg or face
     Diminished mobility.

    Drugs used in the treatment of psoriasis either cause keratolysis and/or inhibit cell division.
    They do not cure the disease
    Treatment of Psoriasis

     Topical therapy
     Systemic therapy
     Phototherapy
    Topical Therapy

     Emollients

     Keratolytic agents: Salicylic acid 2–10%.

     Cytostatic agents: Coal tar, Dithranol

     Glucocorticoids.

     Calcipotriol, Tacalcitol
    Emollients

     act by hydrating and softening the scales


     used in mild cases
     commonly used emollients - yellow, soft paraffin and aqueous cream.
     greasy emollients are sometimes preferred, they are less accepted by the patients.
    Salicylic acid

     most widely used keratolytic agent,


     used either alone or with coal tar.
    (It is an irritant…… avoid contact with the eyes )
    Cytostatic agents
     dithranol and coal tar are used, along with UVB phototherapy, in the treatment of
    psoriasis and other hyperplastic skin disorders.
     restore a normal rate of epidermal proliferation.
     In severe cases, systemic therapy with either etretinate or methotrexate both of
    which, act as cytostatic agents in the skin, may be needed
     Crude coal tar (3% ointment) :
     used to treat chronic, lichenified lesions.
     Coal tar, even in low concentration, has an unpleasant odour, and can cause irritation
    and acneform eruption. ( less acceptable.)
    GLUCOCORTICOIDS

     Topical glucocorticoid preparations of the mild and moderately potent varieties are
    preferred because of their
    1. efficacy,
    2. high degree of acceptability to the patients
    3. low cost.
     Once a day application to the lesions is probably as effective as the twice a day regimen
    and is less liable to cause ADR.
     act mainly as anti-inflammatory agents.
     Relapse rate is higher than with other forms of therapy.
    CALCIPOTRIOL

     vitamin D derivative
     applied locally to mild to moderate psoriatic lesions.
     effective as topical, medium potency glucocorticoids but is much less toxic.
     applied daily as an ointment containing 50 mcg/g for about 8 weeks.
     The ointment is colourless, does not stain clothes and no unpleasant smell.
     It can sometimes cause irritation and hypercalcemia.
     Tacalcitol is another vitamin D analogue which is effective.
    Systemic therapy
     most patients respond to local therapy,
     about 20% may require systemic therapy.
     expensive, more toxic and needs supervision.
     The drugs used are:
    o ETRETINATE
    o METHOTREXATE
    o CYCLOSPORINE
    o MYCOPHENOLATE MOFETIL
    o Systemic glucocorticoids
    o Biological agents

    Alefacept , Infliximab, Etanercept, Adalimumab, Ustekinumab


    ETRETINATE(methoxsalen)

     second generation retinoid


     It inhibits keratinisation and proliferation, and normalises differentiation of epithelial
    tissues.
     Used alone, it has limited efficacy in psoriasis.
     It is usually combined with psoralen and UV-A phototherapy in chronic plaque
    psoriasis.
     The drug accumulates in the adipose tissue and the liver.
     Dosage
    orally in the dose of 0.5-1.0 mg/kg per day
    Cntd…

    adverse reactions
     dryness,
     scaly erythema
     tenderness.
     teratogenic and should not be used in woman of the reproductive age until pregnancy is
    excluded. patient must avoid pregnancy during treatment and for at least 3 years after the
    treatment is over because of its long half life (about 120 days).
     Patients taking this drug should not donate blood for 3 years after stopping it.
     Acitretin, a metabolite of etretinate, is now preferred to etretinate in therapy. Its limitations are
    similar to those of etretinate. Topical tazarotene, a retinoid applied once daily, is also effective.
    METHOTREXATE
     folic acid antagonist ,acts by blocking DNA synthesis and inhibiting cell proliferation.
     also act as an immunosuppressant..
     It is preferred in severe case with arthritis, where coal tar-U V therapy has failed.
     It should be used only in patients with normal hematological, renal and hepatic status.
     The drug is usually well tolerated in the doses recommended.
     The main long term toxicity is hepatic cirrhosis

     Dosage
     It is given orally in 3 doses, usually 2.5-5.0 mg. at 12 hourly, intervals, every week
    CYCLOSPORINE

     This drug is used as an immunosuppressant


     acts by inhibiting the production of IL2, a cytokine necessary for proliferation of
    activated T cells, and other T cell cytokines .
     The important adverse effects are hypertension and renal toxicity which may be
    irreversible.
     for patients with severe refractory psoriasis.
    MYCOPHENOLATE MOFETIL

     immunosuppressant
     has been reported to be useful in the treatment of psoriasis.
     Adverse effects reported are mild and dose dependent.
    Systemic glucocorticoids

     though very effective, needs high doses to suppress the disease, causes ADR.
     relapse rate is high.
     should be reserved for acutely ill patients with erythrodermic psoriasis.
    Biological agents
     Recently introduced in the treatment of psoriasis.
     Given parenterally, they are effective in about 30-70% of patients with
    moderate to severe psoriasis.
     They are:
     (1) Alefacept
     (2) Infliximab
     (3) Etanercept
     (4) Adalimumab
     (5) Ustekinumab
    Biological Agents

     (1) Alefacept
    action
    binds to CD2 on activated T cells

    impairs co-stimulatory signals of leucocyte-function-associated antigen-3 (LFA-3).

    decreases the number of T cells.


     (2) Infliximab inihibits TNF-α functionally.
     (3) Etanercept is a recombinant human TNF receptor antagonist
     (4) Adalimumab,
     humanised IgG1mAb,
     blocks TNF-α.
     Chances of development of neutralising antibody are less compared to infliximab.

     (5) Ustekinumab:
     human monoclonal antibody
     reduces skin inflammation by blocking the activity of IL-12 and IL-23.
     indicated in patients with moderate to severe plaque psoriasis who cannot take standard
    therapy.
    Psoriatic Arthritis

     TNFα inhibitors, golimumab and certolizumab, are


    approved for psoriatic arthritis…expensive
     Selectivephosphodiesterase -4(PDE-4) inhibitor,
    apremilast, is also available for psoriatic arthritis

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