Drugs for Psoriasis

1. DRUGS FOR PSORIASIS
Dr. ANCY GEORGE
JUNIOR RESIDENT/ DEPT OF PHARMACOLOGY

2. CONTENTS
1. Pathology
2. Etiology
3. Types
4. Treatment modalities

4. PSORIASIS
Chronic inflammatory skin disease - multisystem
Incidence – 3.2% population (0.4-2.8%)
Presenting features:
Well demarcated red plaques with silver scales
Scalp, elbow, knees and presacral regions

5. PATHOLOGY
Inflammatory immune mediated condition
Involves cutaneous T cells, dendritic cells and keratinocytes
Keratinocytic hyperproliferation Scaly plaques

6. ETIOLOGY

7. TYPES OF PSORIASIS
Chronic plaque psoriasis
Erythrodermic psoriasis
Guttate psoriasis
Pustular psoriasis

8. PSORIATIC ARTHRITIS
5-30% of patients with cutaneous psoriasis
Severity depends on:
 Initial presentation at early age
 Female gender
 Polyarticular involvement
 Genetic predisposition

9. DRUGS EXACERBATING PSORIASIS
β-blockers
Lithium
Antimalarials
Terbinafine
Captopril
G CSF
Hypolipidemics
CCB

10. MANAGEMENT OF PSORIASIS
Topical therapy
PUVA Therapy
Systemic therapy

11. TOPICAL THERAPY
1. Emollients
2. Keratolytic Agents- Salicylic acid
3. Cytostatic agents- Coal tar, Dithranol
4. Vit D3 analogues
5. Retinoids
6. Glucocorticoids

12. TOPICAL AGENTS
Salt water bath
Topical salicylic acid 5-10%
Anti inflammatory antipruritic action

13. COAL TAR
Exerts phototoxic action – exposed to light
Relapses common
Use declined – carcinogenicity and photo
toxicity

14. ANTHRALIN
Dithranol – ointment/ paste/ paint
Anti-proliferative effect
Inhibits T- lymphocyte proliferation and epidermal DNA
synthesis
Don’t apply on face and scalp

15. Indication - Mild to moderate or severe psoriasis as 2nd line
treatment in combination
Contraindications
 Unstable plaque psoriasis
 Pustular psoriasis
 Erythrodermic psoriasis

16. VITAMIN D3 ANALOGUES
Calcipotriene/
Calcipotriol
• Along with
corticosteroids
• 50 µg/g BID
• Ointment,
creams, lotion
Calcitriol
• 3 µg/g BID
ointment
Tacalcitol
• 2µg/g BID
daily,
ointment,
lotions

17. RETINOIDS
1st GENERATION 2nd GENERATION 3rd GENERATION
Retinol
Tretinoin
Alitretinoin
Isotretinoin
Etretinate
Acitretin
Tazarotene
Bexarotene
Adapalene
17

18. TOPICAL RETINOIDS - TAZAROTENE
• Selectively binds to retinoid acid receptors and decrease
epidermal proliferation
• Cream or gel formulation applied once or twice daily
Indication
Mild to moderate psoriasis

19. GLUCOCORTICOIDS
Indications
 Mild to moderate psoriasis – monotherapy or combination
 Severe psoriasis- combination with Vit D3 analogue, retinoids, anthralin
 Monotherapy for flexural or facial psoriasis
Contraindications
 Bacterial, viral, mycotic infections
 Atrophy of skin

20. PHOTO(CHEMO)THERAPY
Broadband (290-320nm)or narrow band (311nm)UVB
PUVA – Psoralen + UVA
Indication
Moderate to severe psoriasis as 1st line therapy

21. GOECKERMANN THERAPY
Combination of UVB & Coal tar
EXCIMER LASER
Only the involved skin is treated
UVB light

22. PUVA
UVA(320-340nm) with
photosensitizing agent psoralen
Orally administered- methoxsalen
Psoralen intercalate with DNA
strand

23. Oral methoxsalen 10-70 mg (0.4-0.6 mg/kg)
1.5-2 hr before UVA exposure
Remission for 3-6 months
ADR
Phototoxic reaction, pruritus, hypetrichosis
Photo ageing, Melanoma

24. SYSTEMIC THERAPY

25. ACITRETIN
2nd generation synthetic retinoid
Suppress inflammation
Indication - Recalcitrant pustular psoriasis
Teratogenic
Eliminated slowly

26. ETRETINATE
2nd generation retinoid
Inhibits keratinization and proliferation
Combined with PUVA therapy

27. CYTOTOXIC AND IMMUNOSUPPRESSANT
DRUGS
METHOTREXATE
 Moderate to severe psoriasis
 MOA – suppress immunocompetent cells
 Decrease the expression of CLA positive T cells
 10-25 mg once weekly as single dose
 Psoriatic arthritis
 Hepatic cirrhosis on long term use

28. CYCLOSPORINE
Inhibits production of IL-12
Refractory cases of psoriasis
ADR - HTN, Renal toxicity

29. CYTOKINES INVOLVED IN PSORIASIS

31. TNF- α INHIBITORS
Reduces inflammation
Decreases keratinocyte proliferation
Decreases vascular adhesion

32. Infliximab
Adalimumab
Etanercept
Golimumab
Certolizumab pegol

35. ETANERCEPT
Binds both TNF alpha and beta
Plaque psoriasis and psoriatic arthritis
Pediatric psoriasis

36. INFLIXIMAB
Chronic severe plaque psoriasis and psoriatic arthritis
ADALIMUMAB
Plaque psoriasis and psoriatic arthritis

37. Golimumab
Once a month s.c. injection
Certolizumab
s.c. injection of 200 mg
Plaque psoriasis &
Psoriatic arthritis

38. IL 12/23 INHIBITORS
USTEKINUMAB
Moderate to severe plaque psoriasis and psoriatic arthritis
RISANKIZUMAB
 For moderate to severe psoriasis
 For candidates of phototherapy and systemic therapy

39. GUSELKUMAB (2017)
Plaque psoriasis
TILDRAKIZUMAB (2018)
Subcutaneous injection

40. IL 17 INHIBITORS
IL 17 stimulation causes increased keratinocyte
expression of inflammatory cytokines
SECUKINUMAB
Moderate to severe plaque psoriasis in adults

41. IXEKIZUMAB – Plaque psoriasis and psoriatic arthritis
160 mg s.c. 80 mg twice weekly
BRODALUMAB (2017)
Moderate to severe psoriasis
s.c.

42. JAK INHIBITORS
TOFACITINIB
Rheumatic Arthritis
Demonstrated efficacy in psoriatic arthritis
Oral tablet

43. T CELL ACTIVATION INHIBITORS
Efalizumab
Chronic moderate to severe plaque psoriasis
Withdrawn in 2009 – progressive multifocal leucoencephalopathy
Alefacept
Moderate to severe chronic plaque psoriasis
7.5mg once a week i.v. / 15mg once a week i.m. for 12 weeks

44. PDE4 INHIBITORS
APREMILAST
Decreases inflammatory cytokines
Moderate to severe plaque psoriasis and psoriatic
arthritis in adults
ADR – Weight loss and depression

48. SUMMARY
Topical therapy
PUVA therapy
Systemic agents

49. THANK YOU