pharmacotherapy psoriasis
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Pharmacotherapy
PSORIASIS
Yani Mulyani, M.Si, apt
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Komponen
Definisi
Pathofisiology
Clinical Presentation
Diagnosis
Desired outcome
Treatment
Evaluation of theurapeutic outcomes
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Definisi
• Jenis penyakit gangguan imun, yang mempengaruhitampilan pada kulit
• Penyakit tidak menular ini ditandai oleh lesiperadangan yang ditutupi dengan keropeng putih
perak dari kulit mati.• Psoriasis disebabkan sel-sel kulit menua dalam waktu
kurang dari seminggu.
• Karena tubuh tidak dapat melepaskan kulit tua secepat
sel-sel baru meningkat ke permukaan, pengelupasankulit mati menimbulkan keropeng yang berkembang dilengan, punggung, dada, siku, kaki, kuku, lipatan antarapantat, dan kulit kepala.
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Tingkatan Psoriasis
• Mild/Ringan, jika mempengaruhi kurang dari
5% dari permukaan tubuh,
• Sedang/moderat, jika 5-30% dari kulit yang
terlibat, dan
• Parah/severe , jika penyakit memengaruhi
lebih dari 30% dari permukaan tubuh.
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What is the genetic risk of psoriasis?
• 41% if both parents have psoriasis
14% if one parent
4% if no genetic link
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Penginduksi Psoriasis
Penyebab Diinduksi Oleh
The main climatic trigger of psoriasis
is? Cold, dry weather
The primary drug triggers of psoriasis
are?
ACE inhibitors
Beta-blockers
Chloroquine
Progesterone
Lithium
Indomethacin
Corticosteroid withdrawel
The primary infectious triggers of
psoriasis are?
Streptococcal (strep throat, tonsillitis)
HIV
HPV (ED form)
NSAID that can improve psoriasis? Meclofenamate
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ICAM, Intracellurar ce;; adhesion molecules
APCs, Antigen Presenting Cell
LFA, Leucocyte function associated type 3Yani Mulyani - STFB
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Phatofisiology
T Cell,diproduksibanyak
T cell diikatkuat oleh
ICAM padasel endhotel
MerangsangPelepasanAntigen APC,Aktivated TCELL
Kehadiran LFA-3-CD2,MeningkatProliferation TCell . SaatAktivasi T Cell,MeningkatInterleukin,
Cytokines,dll,..yangmenginisiasiInflamasi diKULIT
PSORIASIS
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In which layer of the skin does
psoriasis begin?
In the basal layer ofthe epidermis where
keratinocytes form.
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Clinical Presentation
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Psoriasis: Clinical Presentation
Type CharacteristicsPlaque psoriasisGuttate psoriasis
Erythrodermicpsoriasis
PustularpsoriasisNail psoriasis
Palmar/PlantarpsoriasisPsoriatic arthritis
Scalp psoriasis
Dry scaling patches (AKA common psoriasis) 75%Drop-like dots, occurs after strep or viral infection 12%
Exfoliation of fine scales (total body “dandruff”),widespread, often accompanied by severe itching andpain 7%Pus-like blisters, noninfectious, fluid contains white bloodcells 2%Seen on toenails and fingernails, starts as numerous pits,
at times progresses to yellowing, crumbly, and thickenednail; nails may sloughErythema, thickening and peeling of the skin, blistering isoften present. Can lead to disability.Inflammation, swelling, and joint destruction
Plaque-type lesionYani Mulyani - STFB
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Psoriatic Plaque
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Chronic Plaque Psoriasis
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Erythrodermic Psoriasis
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Nail changes
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Guttate Psoriasis
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Nail Changes
• In 78% of psoriatic patients
• Fingernails>Toenails
• Four changes
1. Onycholysis (= separation from nail bed)
2. Pitting*
3. Subungual debris accumulation
4. Color alterations
*Pitting rules out a fungal infectionYani Mulyani - STFB
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DIAGNOSIS
Physical examination
BSA (body surface Area)
Psoriasis Area and Severity Index
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OLA Photonumeric Guidelines(overall lesion assessment)
0 = none
5 = very severe4 = severe3 = moderate
1 = minimal 2 = mild
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Desired Outcome
Caranya???
• Mencegah Aktivasi T Cell
• Menghambat Kerja dari
Inflammatory agent
• Menurunkan Imun
• Mengurangi pembentukan
Keratin
• Membuang Keratin yangg
terbentuk
Outcome
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1 Leonardi, 2003; 2 Market Measures/Cozint LLP, June 2003.
Othertherapies
54%
Topicalsonly
46%
The Majority of Moderate-Severe Psoriasis Patients Are
Under-Treated
• 50% of patients with moderate orworse disease are currentlyuntreated1
– 46% have topical therapy only• Reason dermatologists
do not use moreaggressive therapies2
–
Safety concerns – Time consuming
– Cost
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Psoriasis: Treatment
• Lubrication
• Removal of scales
•
Slow down lesion proliferation• Pruritus management
• Prevent complications
• Lessen patient stress• Season and climate
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Treatment
Non Pharmacology
Pharmacology Treatment
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Non Pharmacology
• Mengurangi stress
• Memberikan Pelembab
• Menggunakan Jenis
sabun khusus• Sunscreen
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Pharmacology Treatment
Korticosteroid
Keratolytic
Keratonycte proliferation inhibitor
Phototherapy (UV a dan UV B)
Photochemotherapy (Broadband UV B)
Systemic Therapies
BRM (biologic response modifiers)
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Algorithm Treatment Of Psoriasis
Mild to Moderate
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Algorithm Treatment Of Psoriasis
For Severe
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Step 1
Anthralin Calcipotriene
Coal Tar
Tazarotene Intralesional Steroid
Topical Steroid
Climatotherapy Moisturizers Keratolytics
Step 2
PUVA PUVA +Step 1 agent
Acitretin
Step 3
Methotrexate Cyclosporine
Rotational:12-24 months
of eachstep 3 agent
Supplementary
Tx
Step 4
Enbrel/Remicade/Amevive/Raptiva
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Corticosteroid
Betamethasone
Amcinonide
Triamcinolone
Fluticasone,
Dll
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Corticosteroids
Level of Potency Corticosteroid Commercial Products
Ultra-high Halobetasol propionate
Clobetasol propionate
Betamethasone dipropionate
Diflorasone diacetate
Ultravate crm/oint
Temovate crm/oint
Diprolene oint
Psorcon oint
High Halcinonide
Amcinonide
Betamethasone dipropionate
Mometasone furoate
Diflorasone diacetateFluocinonide
Desoximetasone
Halog crm
Cylocort oint
Diprolene AF crm
Elocon oint
Florone ointLidex crm,gel,oint
Topicort crm,oint,gel
Mild to high Halcinonide
Triamcinolone acetonide
Betamethasone dipropionate
Fluocinonide
Halog oint,crm,soln
Aristocort A oint
Diprosone crm
Lidex-E crmYani Mulyani - STFB
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Corticosteroids
Level of Potency Corticosteroid Commercial Products
Mild Hydrocortisone valerate
Triamcinolone acetonide
Flurandrenolide
Mometasone furoateFluocinolone acetonide
Westcort
Kenalog crm and oint
Cordran oint
Elocon crmSynalar oint
Low to mild Hydrocortisone valerate
Triamcinolone acetonide
Flurandrenolide
Betamethasone dipropionate
Hydrocortisone butyrateFlucolone acetonide
Westcort crm
Kenalog crm and oint
Cordran crm
Diprosone lotion
Locoid crmSynalar crm
Low Alclometasone dipropionate
Betamethasone valerate
Fluocinolone acetonide
Hydrocortisone, dexamethasone,
prednisolone, methylprednisolone
Aclovate crm and oint
Valisone lotion
Synalar soln and crm
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Inhibitor keratinocyte
Calcipotriene
Tazarotene
Anthralin
Coal tar
Asam salisilat
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Phototherapy
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( l bl TNF t )Yani Mulyani STFB