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D18 Dermatology
Papulosquamous Diseases Toronto Notes 2019
Calcipotriol is a Vitamin D Derivative Dovobet® = calcipotriene combined with betamethasone dipropionate and is considered to be one of the most potent topical psoriatic therapies
Management
• dependsonseverityofdisease,asdefinedbyBSAaffectedorlesscommonlyPASI • mild(<3%BSA)
■ topical steroids, topical vitamin D3 analogues, or a combination of the two are first line
■ topical retinoid ± topical steroid combination, anthralin, and tar are also effective but tend to be less
tolerated than first line therapies
■ emollients
■ phototherapy or systemic treatment may be necessary if the lesions are scattered or if it involves sites
that are difficult to treat such as palms, soles, scalp, genitals • moderate(3-10%BSA)tosevere(>10%BSA)
■ goal of treatment is to attain symptom control that is adequate from patient’s perspective ■ phototherapy if accessible
■ systemic or biological therapy based on patient’s treatment history and comorbidities
■ topical steroid ± topical vitamin D3 analogue as adjunct therapy
Table 13. Topical Treatment of Psoriasis
Treatment
Emollients
Salicylic acid 1-12%
Tar (LCD: liquor carbonis detergens)
Topical Corticosteroids
Vitamin D3 analogues: Calcipotriene / calcipotriol (Dovonex®, Silkis®)
Betamethasone + calciprotriene (Dovobet®)
Tazarotene (Tazorac®) (gel/cream)
Mechanism
Reduce fissure formation Remove scales
Inhibits DNA synthesis, increases cell turnover
Reduce scaling, redness and thickness
Reduces keratinocyte hyperproliferation
Combined corticosteroid and vitamin D3 analogue. See above mechanisms
Retinoid derivative, decreased scaling
Comments
Poor long-term compliance
Use appropriate potency steroid in different areas for degree of psoriasis
Not to be used on face and folds Irritating
Table 14. Systemic Treatment of Psoriasis
Treatment
Acitretin Cyclosporine
Methotrexate Apremilast (Otezla®) PUVA
UVB and “Narrow band” UVB (311-312 nm)
Considerations
More effective when used in combination with phototherapy
Used for intermittent control rather than continuously
Avoid using for >1 yr
Has been used for over 50 yr Extremely safe
Highly effective in achieving remission Avoid >200 sessions in lifetime
UVB much less carcinogenic than PUVA Narrowband has not been shown to increase the risk of skin cancer
Adverse Effects
Alopecia, cheilitis, teratogenicity, hepatotoxicity, photosensitivity, epistaxis, xerosis, hypertriglyceridemia
Renal toxicity, hypertension, hypertriglyceridemia, immunosuppression, lymphoma
Bone marrow toxicity, hepatic cirrhosis, teratogenicity GI upset, headache, loose stool, weight loss
Pruritus, burning, skin cancer
Rare burning
Table 15. Biologics Approved in Canada
Treatment Route
Etanercept (Enbrel®)* SC Adalimumab SC
(Humira®)*
Infliximab IV (Remicade®)*
Ustekinumab (Stelara®) SC Secukinumab SC
(Cosentyx®)
Ixekizumab (Taltz®) SC
Guselkumab (Tremfya®) SC
*Can also be used to treat psoriatic arthritis
Dosing Schedule
Effectiveness Action
+++ Anti-TNF ++++ Anti-TNF
+++++ Anti-TNF
++++ Anti-IL 12/23
+++++ Anti-IL 17A
+++++ Anti-IL 17A
+++++ Anti-IL 23
Figure 6. Psoriasis distribution
Mechanism of Biologics
“-mab” = monoclonal antibody “-cept” = receptor
50 mg twice weekly for 3 mo, then 50 mg weekly
80 mg x 1, then 40 mg at wk 1 and every 2 wk thereafter
5 mg/kg at wk 0, 2, 6, and every 8 wk thereafter
45 mg or 90 mg at wk 0, 4, and every 12 wk thereafter 300 mg at wk 0, 1, 2, 3, 4, and every 4 wk thereafter
160 mg at wk 0, then 80 mg at wk 2, 4, 6, 8, 10, 12, then 80 mg every 4 wk thereafter
100 mg at wk 0, 4, and every 8 wk thereafter
• biologicsunderstudyfortreatmentofpsoriasis:brodalumab,risankizumab,tildrakizumab,guselkumab
© Sonia Seto 2016