Management of severe
psoriasis
Management of severe
psoriasis
Psoriatic erythroderma
Psoriasis is one of the leading causes of
erythroderma
1-2% fo psoriasis patients experience
erythroderma at some time in their life
patients with intense inflammatory lesions
are more unstable and likely to show
dissemination
but a far greater problem is erythroderma
secondary to unsuccesful therapy
In the past the major cause of
erythroderma was the reduction or
discontinuation of systemic
corticosteroids
This is the reason why such therapy is no
longer considered acceptable.
Also too aggressive topical therapy or UV
radiation in early eruptive stage of the
disease may trigger erythroderma.
Clinical findings
The patient is diffusely red with marked
desquamation and often exudation.
Usually clues as to the preexisting psoriasis
are somewhere to be found, sometimes history
helps.
Very rare patient presents almost de novo with
erythroderma and turns out to have psoriasis.
Pruritis is usually present
The patient is often systemically ill with
lymphadenopathy, fever, chills ; fluid
and proteines loss.
A severe complication is an acute
respiratory distress syndrome
Differential diagnosis
Drug eruptions,
Exacerbation of underlying skin disease
- lymphoma – especially mycosis
fungoides.
Pustular Psoriasis
Neutrophils in the epidermis are a
classic feature of psoriasis.
In this disease, pus does not equate
with infection.
Generalized Pustular Psoriasis
von Zumbush Type
This form of pustular psoriasis can be viewed
as the maximum variant of acute, explosive
psoriasis.
The patient is acutely ill with fever, chills and
often an elevated neutrophil count.
Multiple erythematous patches and plaques
dotted pustules cover wide areas of the body.
The pustules may coalesce.
Typically the palms and soles are
involved
In addition, the oral mucosa , genital
mucosa and even upper airways may
show pustules.
As the lesions dry out they become
scaly
Most often there is a trriger for von
Zumbusch pustular psoriasis
In the past it was often the
rapidreduction or termination of
systemic corticosteroid therapy
Other medications such as b-blokers or
antimalarial agents may also be
responsible, as well as pregnancy or oral
contraceptive use
The prognosis is serious- death may
occur
The patients lack effective antibacterial
activity and are at risk of lifethreatening
infections, especially pneumonia.
In addition the massive protein loss
leads to an enterpathy and associated
metabolic derangements.
Psoriatic Arthritis
Seronegative arthritis, often acral, which appears
in associatin with psorisis and has a relatively
typical radiologic appearance.
Psoriatic arthritis has a prevalence of 0.02 – 0.1 %
About 5-7 % of psoriasis patients have arthritis
Children are rarely affected
Over 70% of patients with psoriatic arthritis have
preexisting psoriasis, while in about 10% the two
problems appear in the same time period
Etiology and pathogenesis
The connection between the skin and
the the joints in psoriasis remains
somewhat a mystery.
Certain HLA markers are more common
and may have diagnostic and prognostic
sagnificance.
They include A26 B17 B27 Cw6 DR3
DR4 DR7
Clinical findings
At least 70% of patients with psoriatic
arthritis have nail changes
Affected finger is swelling.
Systemic therapy cytostatic
agents
Methotrexate - the folic acid antagonist
Helpful against psoriatic arthritis
Is usually administrated orally and well
absorbed, although it can be given
intramusculary or intravenously
It is excreted unchanged through the
kidneys, but also metabolized in the liver
to polyglutamated forms that are also
potent
Methotrexate is rarely administrated on
a continouous basis.
Instead it is given as pulse therapy
Most popular is the intermittent therapy
– MTX is given once weekly in three
divided doses 12 h apart – this approach
seems to maximize the antipsoriatic
effect and reduce the side effects
Adverse reactions
Hepatic fibrosis or even cirrhosis
Thrombocytopenia, leukopeniaanemia
Diarrhea,bleeding, ulcers
The RBC and patelet count should be checked
every 2 weeks, later every 4 weeks
Hepatic and renal function must be monitored
A baseline chest X-ray is needed, and
repaeted evaluation every 18-24 months
because of the risk of pulmonary fibrosis
Contraindications for methotrexate use in
psoriasis
Childhood
Renal and hepatic disease
Pregnancy or nursing
Desire for children
HIV/AIDS or other immunodeficiency
Chronic infections
Gastric or duodenal ulcer
Anemia, thrombocytopenia, leukopenia
cyclosporine
Cyclosporine A- has proven to be very
effective for treating severe psoriasis.
It has a rapid onset of action and is the
treatement of choice for severe or
explosive forms of both ordinary and
pustular psoriasis
While it is also helpful in psoriatic
artritis , the onset of action is slower
Cyclosporine is available for intravenous
and oral therapy.
the recommended initial dose is 2.5
mg/kg daily, dose can be gradually
increases to 5.0 mg/kg daily
The main side effects are renal
toxicity, hypertension and hepatic
damage.
Contradications for cyclosporine use in
psoriasis
Pregnancy
Decreased renal function
Sagnificant hypertension
Preexisting malignancy
HIV/AIDS or other chronic infections
Drug or alcohol abuse, current UV
radiation or PUVA therapy
Retinoids
The aromatic retinoids
acitretin
and
etretine
are the major option in treating severe
psoriasis: * generalized pustular
psoriasis
* psoriatic erythroderma
Retinoids
Acitretin is the active form of etretinate
both products have a significant effect
on psorisis:
- blocking epidermal proliferation,
- improving differentiation
- modulating the inflammatory or
immune response
Retinoids
As a monotherapy they are not as effective
as methotrexate, but they are often
combined with other topical modalities or
UV radiation.
After 8-12 weeks of therapy about 70% of
patients have a stisfactory response
Acitretin is prescribed in a single daily dose
of 30-50 mg irrespective of the body weight
Retinoids - contraindications
Patient of child bearing years – because of
teratogenicity
A contraception for 2 years after the end of
treatment are strongly recommended.
Side effects: dryness of the lips, diffuse hair loss
50% of patients develop elevated cholesterol
and TG levels, while 25% abnormalities of liver
function tests
