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Psoriasis

Psoriasis. A review of therapeutics. A definition from Clinical Evidence Naldi L and Rzany B. Clinical Evidence 2006 ;15:1-4 (Search Date July 2006).

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Psoriasis

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  1. Psoriasis A review of therapeutics

  2. A definition from Clinical EvidenceNaldi L and Rzany B. Clinical Evidence 2006;15:1-4 (Search Date July 2006) • Chronic plaque psoriasis, or psoriasis vulgaris, is a chronic inflammatory skin disease that is characterised by well demarcated erythematous scaly patches on the extensor surfaces of the body and scalp • The lesions may itch, sting, and occasionally bleed • Dystrophic nail changes are found in more than a third of people with chronic plaque psoriasis, and psoriatic arthropathy occurs in 1% to more than 10% • The condition waxes and wanes, with wide variations in course and severity among individuals • Other varieties of psoriasis include guttate, inverse, pustular, and erythrodermic psoriasis

  3. Community-based Emollients Topical coal tar Topical dithranol Topical vitamin D & analogues Topical corticosteroids Topical retinoids plus combinations treatment for specific sites Hospital-led therapy Phototherapy Methotrexate Oral retinoids Cyclosporin Hydroxurea Azathioprine Systemic steroids TNF-alpha drugs T-cell drugs – efalizumab, alefacept Many therapiesNaldi L and Rzany B. Clinical Evidence 2006;15:1-4 (Search DateJuly 2006)

  4. British Association of Dermatologists Guidelines – Recommendationswww.bad.org.uk  Accessed 25/04/08 • Emollients should be used to soften scaling and reduce any irritation • For localised plaque psoriasis one or more of the following topical preparations can be tried • A tar-based cream, or a tar/corticosteroid mixture • A moderate potency topical corticosteroid (e.g. 0.05% clobetasone butyrate); stronger agents can be used on palms and soles or on the scalp • A vitamin D analogue • Calcipotriol with betamethasone dipropionate as a combination product • A vitamin A analogue (tazarotene) • A dithranol preparation • Important to use a keratolytic agent (e.g. 5% salicylic acid in emulsifying ointment) first when there is significant scaling, or other treatments may fail

  5. NICE guidance on etanercept and efalizumab  1NICE TA103, July 2006 • Etanercept, within its licensed indications, is recommended for the treatment of adults with plaque psoriasis only when the following criteria are met: • The disease is severe (PASI score of 10 or more andDLQI score >10) • The psoriasis has failed to respond to standard systemic therapies, or the person is intolerant to, or has a contraindication to, these treatments • Etanercept treatment should be discontinued in patients whose psoriasis has not responded adequately at 12 weeks • Further treatment cycles are not recommended in these patients • An adequate response is defined as either: • a 75% reduction in the PASI score from when treatment started (PASI 75), or • a 50% reduction in the PASI score (PASI 50) and a five-point reduction in DLQI from when treatment started

  6. NICE guidance on etanercept and efalizumab 2NICE TA103, July 2006 • Efalizumab, within its licensed indications, is recommended for the treatment of adults with plaque psoriasis under the circumstances detailed for etanerceptonly if their psoriasis has failed to respond to etanercept or they are shown to be intolerant of, or have contraindications to, treatment with etanercept • Further treatment with efalizumab is not recommended in patients unless their psoriasis has responded adequately at 12 weeks (as defined for etanercept) • Use of etanercept and efalizumab for psoriasis should be initiated and supervised only by specialist physicians • If a person has both psoriasis and psoriatic arthritis their treatment should be managed by collaboration between a rheumatologist and a dermatologist

  7. NICE guidance on infliximabNICE TA134, Jan 2008 • Infliximab, within its licensed indications, is recommended as a treatment option for adults with plaque psoriasis only when the following criteria are met • The disease is verysevere (PASI score of 20 or more andDLQI score >18) • The psoriasis has failed to respond to standard systemic therapies, or the person is intolerant to, or has a contraindication to, these treatments • Continue beyond 10 weeks only if an adequate response to treatment within 10 weeks has occurred, defined as either: • a 75% reduction in the PASI score from when treatment started (PASI 75), or • a 50% reduction in the PASI score (PASI 50) and a five-point reduction in DLQI from when treatment started • NICE TA for adalimumab expected June 2008

  8. Summary • Psoriasis is one of the most common skin conditions seen in primary care • Most common form is chronic plaque psoriasis • Can cause poor quality of life and some complications can be life threatening • Many patients can be managed in primary care • Emollients useful as long-term management • Evidence base limited, especially for older treatments • More severe psoriasis needs specialist care • Self-help groups can be beneficial

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