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CPD 51: PSORIASIS Biography - Ronan Sheridan graduated from the Robert Gordon University,

Aberdeen in 2009 with a Masters in Pharmacy with Distinction. Ronan worked as a pre-registration and clinical pharmacist at the Chelsea and Westminster Hospital NHS Foundation Trust, London for three years. He currently works as Supervising Pharmacist at Market Point Pharmacy, Mullingar, Co Westmeath. Ronan was awarded the 2012 Helix Health Young Pharmacist of the Year. He is a Peer Support Pharmacist at Irish Institute of Pharmacy and a tutor with IPU Academy.

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap

- will this article satisfy those needs - or will more reading be required? 4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs?

The normal production of skin cells takes place anywhere between 23 to 30 days, being produced deep in the skin and rising slowly to the surface. For those suffering from psoriasis, this process occurs in a short number of days. The fast rising number of cells begin to pile up on the surface of the skin, causing patches of thick red skin with silvery scales. The plaques vary in size but are usually symmetrically distributed, and generally develop around the elbows, knees, legs, scalp, lower back, face, nails, feet and genitals1,2,3. Psoriasis of the skin can lead to psoriatic arthritis, a very painful condition that effects up to 30% of those suffering from psoriasis.

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Getting under the skin of Psoriasis Management Psoriasis is a common chronic relapsing skin condition characterised by red, flaky, crusty patches of skin covered with silvery scales. It is estimated that around 100,000 people in Ireland are affected with the disease. It most commonly occurs for the first time in those aged between 15 and 351,2.

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This chronic disease substantially impacts patients by impairing their quality of life, causing psychosocial distress, and creating an ongoing financial burden. 4. Flare Up In most people who suffer with psoriasis, there is no apparent reason why a flare-up develops at any given time. However, in some people, psoriasis is more likely to flare up in certain situations. These include stress, infection, medication, smoking, trauma, excessive sunlight, hormonal changes and alcohol. TREATMENT OPTIONS Treatment of this condition is not curative but is aimed at inducing temporary control of clinical manifestations and improving the impact of the disease on quality of life and the level of acceptance of the disease.

60 Second Summary Psoriasis is a common chronic relapsing skin condition characterised by red, flaky, crusty patches of skin covered with silvery scales. The clinical presentation of scalp psoriasis ranges from visible pink plaques covered in silvery scales, similar to those seen on other parts of the body, to patchy scaling, and the extreme end of the spectrum, layers of asbestos like scales. The management of a chronic disease like psoriasis is complex and is conditioned by multiple factors, including, but not limited to: • The objective severity and distribution of skin lesions, • The influence on psychosocial aspects • The response to previous therapies, • The presence of concomitant psoriatic arthritis and comorbidities

The management of a chronic disease such as psoriasis is complex and is conditioned

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CPD 51: PSORIASIS

TYPES OF PSORIASIS PLAQUE PSORIASIS

MOST COMMON

Pustular Psoriasis Is rare and manifests in intense inflamed scaling on the skin and wet weeping lesions. Guttatte Psoriasis

Is a form of psoriasis that often begins in childhood or young adulthood, resembles small, red, individual spots on the skin, which commonly appear on the trunk and limbs, but are not usually as thick as plaque lesions.

Erythrodermic Psoriasis

Characterised by intense shedding and redness of the skin.

Inverse Psoriasis

Produces severe inflammation

Psoriatic Arthritis

Is an inflammatory disease causing pain, stiffness and swelling around the joints. It affects up to 30 percent of Psoriasis sufferers.

by multiple factors, including, but not limited to, the objective severity and distribution of skin lesions, the influence on psychosocial aspects, the response to previous therapies, and the presence of concomitant psoriatic arthritis and comorbidities.

A general rule of thumb is that oils and ointments lock in skin moisture more effectively than creams, which in turn do this better than lotions. Aqueous cream is a type of moisturiser that

does not contain dyes, perfumes, or other substances, which often result in reactions and rashes, which makes the cream an excellent alternative to other moisturisers. Emulsifying ointment can be used as a moisturiser and as a soap substitute. For use as a soap substitute, scoop a spoonful into a container, add some hot water and stir until the ointment melts. If used as a moisturiser, it can leave an oily residue and is less suitable for the face or scalp. Silcocks base is a rich moisturiser that is used to relieve dry skin. It is particularly beneficial as a face cleanser and a moisturiser and, to a lesser extent as a soap substitute 1, 4, 5. Coal Tar Coal tar is a thick, heavy oil derived from coal and wood and is one of the oldest treatments for psoriasis. It can help slow the rapid growth of skin cells and restore the skin’s appearance. In addition, it can help reduce the inflammation, itching and scaling of psoriasis. Tar products can vary dramatically from brand to brand. Generally, the higher the concentration of tar, the more potent the product. Salicylic Acid Salicylic acid is classified as a keratolytic, or peeling agent, and works by causing the outer layer of skin to shed. It is a common

Moisturising and hydrating the skin will help to soothe the affected areas and reduce the redness and dryness that accompanies the build up of skin on psoriatic plaques. As the mainstay of topical psoriasis therapy, these topical agents help lubricate the affected area and work by reducing scaling, cracking, soreness and itching. Hydrating products can be added to the bath or used directly on the skin2,4. TOPICAL TREATMENTS Emollients and Moisturisers Emollients and moisturisers can help in a number of ways, including reducing itching and scaling of the skin, making it feel more comfortable. There is also evidence that certain topical treatments work better on well-moisturised skin, although at least half an hour should be left between applying an emollient and another topical treatment. People with psoriasis who carry out a daily bath and moisturising routine will find it not only helps to minimize scaling but also helps to alleviate itching, which results in psoriasis patches being less noticeable.

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CPD 51: PSORIASIS

and effective treatment for a wide variety of skin problems. As a psoriasis treatment, it acts as a scale lifter, helping to soften and remove psoriasis scales. Strong salicylic acid preparations can cause irritation if left in contact with the skin for too long. The body may absorb too much salicylic acid if it is used over large areas of the skin. Salicylic acid may also weaken the hair shafts and make them more likely to break, resulting in temporary hair loss. Scale lifters (keratolytics) Scale lifters help loosen and remove scale allowing medications to reach the psoriasis lesions. There are scale-lifting products designed for the scalp, body or both. Note that scalp products are usually stronger and may be too harsh for other skin sites. OTC products that contain an active ingredient of salicylic acid, lactic acid, urea or phenol can be used as scale lifters. Vitamin D Anaogues These include Calcipotriol (Dovonex), Tacalcitol (Curatoderm) and Calcitriol (Silkis). Vitamin D derivatives come in gel, ointment, lotion and scalp solution applications. The vitamin D treatments act by promoting normal skin cell growth and development and prevent excessive growth rate of skin. As they are not steroids, they can be used for longer-term use.

Topical Corticosteroid Treatments Topical corticosteroids is the mostcommonly used treatment for psoriasis. Low-strength corticosteroids are used on sensitive areas of skin, such as the face and genitals. Mid-strength preparations are used on the torso, arms, legs, hands and feet. Low- and mid-strength corticosteroids should be used for no longer than three weeks. The highest-strength corticosteroids should be used for no longer than two weeks and only on areas resistant to previous treatment or on the palms of the hands and soles of the feet. Calcineurin Inhibitors These include Protopic / Elidel. Calcineurin inhibitors block the chemical calcineurin. This chemical activates inflammation in the skin; causing redness and itching. Calcineurin inhibitors are licensed for atopic eczema, but are frequently being used ‘off licence’ for other inflammatory skin conditions, such as psoriasis, because of their ability to reduce inflammation. Dithranol Preparations  These are used to treat well-defined plaques of psoriasis and need to be applied carefully to avoid irritating non-affected skin. Dithranol should not be used on the face, flexures (skin folds) or genitals. At-home dithranol preparations such as Micanol and

Dithrocream come as ointments or creams in different strengths, and treatment should usually begin with the lowest strength. SYSTEMIC THERAPIES Oral Corticosteroids The use of systemic steroids in the treatment of psoriasis is not recommended because of the risk of disease deterioration after dose reduction or withdrawal. Methotrexate Methotrexate is an effective antipsoriatic agent and has been widely used to treat severe psoriasis since the 1960s. Methotrexate is used for refractory psoriasis, erythrodermic/general postural psoriasis. It has immunosuppressive, cytostatic and anti-inflammatory effects. It is not suitable for acute conditions, which systemic corticosteroids therapy is preferred. Methotrexate begins working within a month of initiation of therapy and its effects can be fully seen within two months. The major side effects of methotrexate include myelosuppression, hepatotoxicity, gastrointestinal and skin/mucosal membrane effects. Incremental dosing of methotrexate can be used, starting with an initial dose of 2.5mg and gradually increasing up to an effective dose and to a maximum of 25mg a week1, 4.

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CPD 51: PSORIASIS

Ciclosporin Ciclosporin is usually used for the induction of psoriasis remission at a daily dose included in the range of 2.5–5 mg/kg and with intermittent short-term regimens, lasting on average 3–6 months. The magnitude and rapidity of response are dose dependent, as well as the risk of development of adverse events. Biological Systemic Therapies Biologics such as Adalimumab, Alefacept, Etanercept, Infliximab are used to treat moderate to severe chronic plaque psoriasis and psoriatic arthritis. Some biologics may be used for treating both conditions. These biologics significantly reduce symptoms of psoriasis, providing rapid and sustained improvement. Continued treatment can lead to extended remission from symptoms. Biologics are reserved for patients who have not responded to traditional forms of treatment and are in a moderate to severe phase of the disease 1,4,6,8. Phytotherapy Artifical high densityb ultraviolet A light (UVA) in conjunction with a photosensitising agent taken orally is known as PUVA and is usually highly effective for treating extensive psoriasis. This type of treatment is suitable for patients with severe psoriasis, but there is an increased risk of UV-induced skin cancer due to exposure 7 . PSORIASIS OF THE SCALP Scalp involvement in psoriasis is common and, in a lot of cases may be the initial site of involvement. The presence of typical psoriasis elsewhere on the body or nails aids the diagnosis. In several cases, the scalp can remain continually involved in a break-out of psoriasis, while lesions elsewhere on the body may be fully healed. The clinical presentation of scalp psoriasis ranges from visible pink plaques covered in silvery scale, similar to those seen on other parts of the body, to patchy scaling and, at the extreme end of the spectrum, layers of asbestos like scales. Hair loss may occur but this is usually reversible and will rarely result in scarring alopecia. Treatment options include tar-based or

keratolytic shampoo and topical calcipotriol for milder cases. Severe cases often respond to topical keratolytic agents, such as cocois or arachis oil. The oils can be applied liberally, left on the skin for several hours and then removed using a coal tar-based shampoo. This treatment should continue for at least 7-10 days. Once cleared, maintenance treatment should continue on a weekly basis.

 Ensure patients are offered practical support and use of how to apply topical corticosteroids in a safe way, and are aware of the side effects of applying excessive amounts.

For more severe cases, topical steroids may be appropriate. Topical steroids alone are not effective against thick scales, and in these cases the use of a keratolytic agent may be required 9.

 Discuss patient preference for creams, ointments and lotions, taking into account practical aspects of application and the sites and extent of psoriasis affected.

ARTHRTIC PSORIASIS This occurs in 5-8% of patients with psoriasis, particularly in those with nail disease, and may precede the skin disease. The mainstay to treatment is with analgesia and NSAIDs. Intra-articular corticosteroids may be administered to affected joints, for acute pain. In severe cases DMARD’s such as methotrexate and ciclosporin as well anti-TNF agents are used. These agents are effective for both the arthritis and the skin lesions 4.

 Ensure families and carers of patients are given the information and support that they need to assist the treatment where appropriate.

 If a person of any age with psoriasis requiring topical therapy has a physical disability or cognitive or visual impairment, offer advice and practical support that take into account the person’s individual needs.  Ensure patients are educated on the importance of continuing treatment until a satisfactory outcome is achieved  Pharmacists can play an active role in the management of patients receiving biologic therapies.

PSORIASIS AND DIET

REFERENCES

So far, research on diet and psoriasis is limited. Still, some small studies have provided clues into how food may affect the disease. Some recent research shows that a low-fat, low-calorie diet may reduce the severity of psoriasis. A study found that patients with gluten sensitivities on glutenfree diets experienced improvement in psoriasis symptoms. Once they returned to their regular diet, the psoriasis worsened.

1.

Psoriasis Guideline 2006, British Association of Dermatologists. Available at: www.bad.org. uk/healthcare/guidelines/psoriasis.asp. Accessed 19/12/07

2.

The Irish Skin Foundation. Accessed online. http://irishskinfoundation.ie/

3.

Evaluation of psoriasis symptoms and disability in Textbook of Psoriasis, Second Edition. Ed. Charles Camisa, Publishers: Blackwell UK, 2005. pps 88-103

Dermatologists have long-recommended that a healthy diet is best for those with psoriasis. That means lots of fruits and vegetables, whole grains, and lean proteins. In addition, maintaining a healthy weight may provide significant relief as well.

4.

National Institute of Clinical Excellence. The assessment and management of psoriasis, 2012.

5.

Pharmacy Times. Psoriasis and Psoriatic Arthritis Patient Care: What Pharmacists Should Know. September 2014. https://www.pharmacytimes.org/landing/562

6.

New psoriasis treatment expected. The Pharmaceutical Journal. Published online: 13 December 2013. Http: http://www. pharmaceutical-journal.com/pj-online-newsnew-psoriasis-treatment-expected/20010849. article

7.

Psoriais, Pathophysiology and diagnois, Clinical Pharmacist, Vol 5, June 2013

8.

National Institute of Clinical Exceleence. Etanercept and infliximab for the treatment of psoriatic arthritis. 2006

9.

Farrrel, A et al. Disorders of the hair and scalp. Health Press

PHARMACIST ROLE  Explain the efficacy, safety and adverse effects of medicines used for the treatment of psoriases, for both topical and systemic therapies.  Patients should be well informed that psoriasis is a lifelong disease and requires long time monitoring and treatment.  Monitor patient responses and adverse effects from psoriasis treatment and provide informed recommendations for changes in therapies if or when required.  Explain the efficacy, safety, and adverseeffect data for currently approved systemic therapies for the treatment of psoriasis.

10. Warin A, Psoriasis: addressing your patient’s concerns. Prescriber 5 June 2002, pps 51-56.

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