1. Psoriasis

2. Definition and causes Definition and causes Types Types GP management GP management Pitfalls Pitfalls Hospital treatments Hospital treatments Psoriasis

3. Psoriasis Definition A chronic, non-infectious, inflammatory skin disorder, with well defined, erythematous plaques & large adherent silvery scales Prevalence 1.5-3% Age onset 20-30y or 50-60y

4. Psoriasis Epidermal hyperproliferation Vascular dilatation Inflammatory infiltrate

5. What causes psoriasis ? T cell mediated autoimmune disease → increased keratinocyte proliferation Environmental and genetic factors

6. Psoriasis Genetics 40% have FHx 40% have FHx 73% monozygotic twins concordant v 20% dizygotic twins 73% monozygotic twins concordant v 20% dizygotic twins 1 st degree relatives have 4-6 fold increased risk 1 st degree relatives have 4-6 fold increased risk Environmental triggers Environmental triggers

7. GP Management Time (for proper examination and to communicate with the patient) Explanation Information and support sources (patient.co.uk, psoriasis- association.org.uk) Follow-up

9. Emollients Emollients Bath oils Bath oils Site-specific topical treatments Site-specific topical treatments GP Management

10. Vitamin D analogues Dovonex (calcipotriol) oint Dovobet (calcipotriol & betamethasone) oint or gel Silkis (calcitriol) oint Curatorderm (tacalcitol) oint & lotion Zorac (tazarotene) gel (retinoid) Vitamin D analogues Dovonex (calcipotriol) oint Dovobet (calcipotriol & betamethasone) oint or gel Silkis (calcitriol) oint Curatorderm (tacalcitol) oint & lotion Zorac (tazarotene) gel (retinoid) Dovonex cream and scalp application no longer available Dovonex cream and scalp application no longer available Topical treatments

11. Tar Carbo-dome Exorex Psoriderm Alphosyl HC Sebco Cocois Tar-based bath oils & shampoos Tar Carbo-dome Exorex Psoriderm Alphosyl HC Sebco Cocois Tar-based bath oils & shampoos Topical treatments

12. Steroids Often in conjunction with Vit D analogue as Dovobet or separate steroid Eumovate (only oint available) Trimovate Scalp preparations (eumovate to dermovate strength) Steroids Often in conjunction with Vit D analogue as Dovobet or separate steroid Eumovate (only oint available) Trimovate Scalp preparations (eumovate to dermovate strength) BE CAREFUL (but not mean) BE CAREFUL (but not mean) Topical Treatments

13. Dithranol Dithrocream Micanol Psorin Dithranol Dithrocream Micanol Psorin Stains skin Has to be washed off Start and low strength and build up Stains skin Has to be washed off Start and low strength and build up Topical Treatments

14. Topical treatments Nails difficult potent topical steroids dovonex tazarotene systemic therapy

15. Scalp Remove scale first Remove scale first Sebco messy but effective Sebco messy but effective Tar or salicylic acid shampoo Tar or salicylic acid shampoo Topical steroids if necessary for short periods Topical steroids if necessary for short periods Topical Treatments

16. Types of psoriasis Plaque Guttate Rupioid Unstable Pustular Erythrodermic ?palmo-plantar pustulosis

36. Guttate psoriasis

40. Pustular psoriasis

43. Erythrodermic psoriasis

45. Plantar pustulosis

49. Acrodermatitis continua of Hallopeau

51. 'It's not working Doc' 'It's not working Doc' It did work, but then he stopped using it and the psoriasis returned It did work, but then he stopped using it and the psoriasis returned It was too greasy/time- consuming/smelly so he stopped using it It was too greasy/time- consuming/smelly so he stopped using it He wasn't applying it properly He wasn't applying it properly It really didn't work It really didn't work Pitfalls

52. Hospital Treatment Out-patient advice and support UVB PUVA Acitretin Methotrexate Ciclosporin Biologics Admission (tar, other topicals)

53. UVB phototherapy Suitability – age, PH skin cancer, medication, radiotherapy, photosensitive disease X3 / week for ~6 weeks Shield genitalia, uninvolved sites SE burning (30%) ↑ risk skin cancer (screen yearly if >150 treatments)

55. PUVA Suitability – as for UVB + CI in renal/hepatic disease, cataracts, pregnancy, children X2 / week for ~6-8 weeks Need eye protection for 24 h after psoralen SE burning, nausea, itch ↑ risk skin cancer (screen yearly if >150 treatments)

56. Systemic therapy acitretin methotrexate ciclosporin

57. 7-20% of patients with psoriasis have arthritis

58. Acitretin mec: affects keratinocyte differentiation CI: ? fertile women (as must avoid pregnancy for 2 years) SE: dry lips, teratogenicity, abnormal LFT, lipids, DISH

59. Methotrexate mec: inhibits DNA synthesis by inhibiting dihydrofolate reductase → reduces proliferation of lymphocytes + keratinocytes CI: pregnancy, lactation, infection, liver/renal disease, peptic ulcers SE: anorexia, nausea, myelosuppression, hepatotoxicity, mouth ulcers, pulmonary toxicity, oligospermia, skin cancer Interactions: NSAIDs, septrin, trimethoprim, penicillin, phenytoin Given once a WEEK

60. Ciclosporin Mec Inhibits T cell activation CI uncontrolled HBP, malignancy, infection SE HBP, nephrotoxicity, skin cancer, other malignancy, gum hypertrophy Not recommended for long term treatment

61. New Biologicals Anti TNF drugs Infliximab, etanercept, adalimumab Targeted T - cell therapy alefacept (binds CD2 & blocks LFA3) efalizumab (binds to LFA-1 & blocks ICAM-1) Anti-IL 17 receptor antibodies Brodalumab Ixekizumab

62. Know what your patient is on (?record as outside script on EMIS) Know what your patient is on (?record as outside script on EMIS) Know what monitoring you are responsible for Know what monitoring you are responsible for Keep a look out for myelosuppression Keep a look out for myelosuppression Don't be afraid of your local Derm department! Don't be afraid of your local Derm department! GP Issues

66. SIGN 121 Patients with psoriasis or psoriatic arthritis should have an annual review with their GP involving the following: documentation of severity using DLQI ƒscreening for depression ƒassessment of vascular risk (in patients with severe disease) ƒassessment of articular symptoms ƒoptimisation of topical therapy ƒconsideration for referral to secondary care