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Psoriasis

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LEARNING OBJECTIVES

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LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

  1. Discuss the etiology of psoriasis, including genetic and immune changes.

  2. Describe the pathophysiology of psoriasis, including the types of psoriasis and clinical presentations.

  3. Describe the comorbidities and risks in patients with psoriasis.

  4. Compare and contrast the pharmacologic treatment modalities for psoriasis, that is, topical therapies, systemic therapies including biologics, and phototherapies.

  5. Recommend an appropriate treatment plan for a patient with psoriasis, including nonpharmacologic and pharmacologic therapies

  6. Recommend appropriate monitoring parameters for a patient with psoriasis.

  7. Provide appropriate counseling information to a patient with psoriasis.

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KEY CONCEPTS

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  • Image not available. Patients with psoriasis have a lifelong illness that may be very visible and emotionally distressing. There is a strong need for empathy and a caring attitude in interactions with these patients.

  • Image not available. Psoriasis is a T-lymphocyte–mediated inflammatory disease that results from a complex interplay between multiple genetic factors and environmental influences. Genetic predisposition coupled with some precipitating factor triggers an abnormal immune response, resulting in the initial psoriatic skin lesions. Keratinocyte proliferation is central to the clinical presentation of psoriasis.

  • Image not available. Diagnosis of psoriasis is usually based on recognition of the characteristic plaque lesion and is not based on lab tests.

  • Image not available. Treatment goals for patients with psoriasis are to minimize signs such as plaques and scales; alleviate symptoms such as pruritus; reduce the frequency of flare-ups; ensure appropriate management of any associated comorbidities such as psoriatic arthritis, cardiovascular disorders, Crohn's disease, or clinical depression; and minimize treatment-related morbidity.

  • Image not available. Management of patients with psoriasis generally involves both nonpharmacologic and pharmacologic therapies.

  • Image not available. Nonpharmacologic alternatives such as stress reduction and the liberal use of moisturizers may be extremely beneficial and should always be considered and initiated when appropriate.

  • Image not available. Pharmacologic alternatives for psoriasis include topical agents, phototherapy, and systemic agents, including the use of biologic response modifiers (BRMs).

  • Image not available. In initiating pharmacologic treatment, the choice of therapy is generally guided by the severity of disease: topical agents would be appropriate for mild to moderate disease, whereas a systemic agent would be a more appropriate choice for moderate to severe disease. Phototherapy or photochemotherapy is used for patients with moderate to severe psoriasis, generally when topical therapies alone are inadequate. Patient-specific concerns such as existing comorbid conditions (e.g., hypertension, hyperlipidemia, diabetes mellitus, renal impairment or hepatic disease) must also be taken into consideration in the choice of therapy. Once the disease is under control, it would be important to step down to the least potent, least toxic agent(s) that maintain control.

  • Image not available. Rotational therapy (i.e., rotating systemic drug interventions in a sequential manner) is a means to minimize drug-associated toxicities since systemic agents for psoriasis often have differing toxicities. However, continuous treatment has largely replaced rotational therapies and is now the standard of care.

  • Image not available. Some BRMs have proven efficacy for psoriasis; however, there are differences among these agents, including mechanism of action, duration of remission, and adverse-effect profile. In ...

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