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PSORIASIS
Psoriasis is a recurring, non-contagious skin disorder that is characterised by raised, thickened patches of red skin covered with silvery white scales.
Cause
Psoriasis originates in the immune system. The key immune system trigger is the activation of T-cells, a type of white blood cell. Once activated, these cells release cytokines, which are the chemicals used by the immune system to communicate messages. In psoriasis, these cytokines tell skin cells to multiply and mature at an accelerated rate, resulting in thickening of the skin. The redness results from the increased blood supply required for the increased growth of cells.
Aggravating factors
Psoriasis is worsened by stress, alcohol and certain medications
Comorbidities associated with psoraisis
We know now that the low grade inflammation in psoriasis impacts organs beyond the skin. Below is a list of the most common commodities.
Classic
Psoriatic arthritis
Inflammatory bowel disease
Psychological and psychiatric disorders
Uveitis
Emerging
Metabolic syndrome and its components
Cardiovascular diseases
Atherosclerosis
Nonalcoholic fatty liver disease
Lymphomas
Sleep apnea
Chronic obstructive pulmonary disease
Osteoporosis
Parkinson's disease
Celiac disease
Erectile dysfunction
Related to lifestyle
Smoking habit
Alcoholism
Anxiety
Related to treatment
Dyslipidemia
(acitretin and cyclosporine)
Nephrotoxicity (cyclosporine)
Hypertension (cyclosporine)
Hepatotoxicity (methotrexate, leflunomide and acitretin)
Skin cancer (PUVA)
Types of Psoriasis
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Plaque Psoriasis
common type in which there are large patches of red skin with silvery-white scales.
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Guttate Psoriasis
small patches, usually less than 1cm in diameter.
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Inverse Psoriasis
Psoriasis occuring in the body folds such as armpits and groins
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Eyrthrodermic Psoriasis
almost the entire body is red with Psoriasis
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Pustular Psoriasis
small pustules (pus filled areas) are scattered throughout the body
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Nail Psoriasis
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Psoriatic Arthritis
Plaque psoriasis. Thick plaques of psoriasis involving the abdomen
Plaque psoriasis. The most common type of psoriasis
Guttate Psoriasis. Small (<1cm) areas of scaling and redness.
Nail Psoriasis
Hand psoriasis
Psoriasis of the ear
Ref: Oliveira Mde F, Rocha Bde O, Duarte GV. Psoriasis: classical and emerging comorbidities. An Bras Dermatol. 2015 Jan-Feb;90(1):9-20..
Sites of Psoriasis
Common areas of involvement include:
elbows
knees
scalp
ears
genitalia
nails
flexures - armpits, groins and gluteal cleft (groove between buttocks). Type of psoriasis where the flexures are predominantly involved is called flexural psoriasis.
Nail changes in Psoriasis
Psoriasis-nails-1Total destruction of all nails in psoriasis | Psoriasis-nails-2Classical nail pitting in psoriasis |
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Psoriasis-nails-3Psoriasis of the nail with arthritis of the joint | Psoriasis-nails-4textural changes on the bases of the nails in Psoriasis |
The nail changes of psoriasis cannot be distinguished from a fungal infection by just looking at the nails. For this reason, nail clippings need to be sent to the laboratory for analysis. Treatment for fungal infection should be administered only if the nail shows fungus.
Ixekizumab (Copellar)
The biologics are a new line of psoriasis treatments which target specific parts of the immune system.
They therefore are expected to have fewer side effects than existing treatments.
Unlike other systemic drugs, the biologics are administered by injection.
The cost of a biologic medication ranges from around R1500 to R30000 per injection, the cost being largely due to the method of manufacture of the medication, the laboratory that manufactures it and how long it has been on the market.
Medical aid societies differ in their cover for this medication. Please check with your medical aid if you have cover for this. Alternatively, you have the option of self funding.
The following biologics are currently available in South Africa
Treatment:
Topical (Applied on the skin)
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2% Ung acid sal
this medication peels the thickened skin and restores normal skin thickness -
Tar
reduces the rapid growth of skin cells -
Dithranol
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Calcipotriol / Betamethasone combination (Dovobet)
effective in restoring normality in psoriasis areas -
Clobetasol shampoo (Clobex). This is a strong topical steroid preparation and its use on the scalp must be limited to 2 weeks at a time.
Ultraviolet light
PUVA
Excimer laser/light
Home care phototherapy
Oral treatments
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Methotrexate
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Acitretin (Neotigason)
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Cyclosporin
New treatments for Psoriasis (Biologics)
ANTI TNFs
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Infliximab (Revellex/Remicaide)
Infliximab is given intravenously in the doctors office. Initial treatment is administered at weeks 0,2 and 6. Thereafter, treatment is given at 8 week intervals. (For more information on Infliximab - also known as Revellex or Remicaide - please click here, bearing in mind that the cost support does not apply to South Africa)
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Etanercept (Enbrel)
This biologic has been approved for the treatment of psoriatic arthritis and is undergoing final testing in patients with skin psoriasis. Intitial studies have shown that half the patients achieved more than 70% clearance and that 70% of patients achieved 50% clearance. It is administered by subcutaneous injection twice weekly. Patients can be taught to administer the treatment at home, much like injecting insulin at home for diabetes. (For more information on Enbrel, please click here)
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Adalimumab (Humira)
Self injected subcutaneously, 80mg followed by 40mg a week later, then 40mg every fortnight. (More information)
ANTI IL12/23
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Ustekinumab (Stelara)
Given by subcutaneous injection at week 0, 4 then once every 3 months. Patients weighing less that 100kg get 45mg and those over 100kg receive 90mg per injection. (For Ustekinumab use in psoriasis, please click here. Remember that special offers on this website applies to USA only)
ANTI IL 17
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Secukinumab (Cosentyx)
Secukinumab is administered on Week 0, 1, 2, 3, 4 then every 4 weeks. The mode of action is different from the other biologics. It is given by subcutaneous injection. In clinical trials, the majority of people taking COSENTYX 300 mg were clear or almost clear at 12 weeks. Approximately 8 out of 10 people saw 75% skin clearance. Approximately 6 out of 10 people saw 90% skin clearance. Many who saw results at 1 year maintained them at 5 years.
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Ixekizumab (Copellar)
A recently launched IL17 drug from Lilly laboratories. The dose of Copellar is 160mg (2 injections of 80mg) on week 0, the 80 mg (1 injection) every 2 weeks for 12 weeks, then 80mg every 4 weeks. In addition to skin psoriasis, it can be used for psoriatic arthritis. It shows high clearance rates in psoriasis. For those interested in the statistics: of 206 patients at Week 60, PASI 75/90/100 responses were 94.7%, 85.0% and 62.1%, respectively, and at year 5 were 90.3%, 71.3% and 46.3%, respectively. Read more
ANTI IL23
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Guselkumab (Tremfya)
Launched in October 2020, Tremfya is one of the most recent biologic to be available. It is administered at a dose of 100mg on Weeks 0, 4 and 8, thereafter every 8 weeks. In clinical studies at week 16, 7 out of 10 patients with moderate to severe plaque psoriasis saw 90% clearer skin. In a clinical study, nearly 9 out of 10 patients who saw 90% clearer skin at week 28 maintained it at week 48.
Lebwohl, et al. examined psoriasis relapse rates on treatment discontinuation following 1 year of secukinumab. After 1 year of secukinumab treatment, a significant portion of patients remained relapse-free even after discontinuing the medication. Notably, 20.8% of patients stayed relapse-free for 1 year, and 10% for 2 years post-treatment..
Side Effects of Biologics
1. Worsening of TB or new onset TB. All patients are screened for TB before starting a biologic. The tests include a Chest Xray and a Mantoux test (small injection on the forearm. The results are read 3 days later). An alternative TB test is called the Quantiferon test. This is a blood test.
2. Worsening of heart failure. Let the doctor know if you have any swelling of the legs or shortness of breath.
3. Peripheral neuritis - tingling of the fingers and toes.
4. Lumps / bumps or cancers. These are looked for at every visit and are rare consequences of suppressing the immune system, although biologics do not fall under the traditional category of immune suppressants.
Guidelines
The Psoriasis Advisory Board of South Africa has put together a set of guidelines for the management of Psoriasis. This has been published in the South African Medical Journal (SAMJ).
PUVA
Psoralen is taken orally 2 hours before exposure to UVA light. Treatment is administered three times a week for 7 weeks - a total of 21 treatments. the use of PUVA is declining throughout the world and has now given way to Narrow band UVB.
Gallery
21 treatments with psoralen and ultraviolet A resulting in complete resolution with long term remission
Treatment with PUVA (psoralen and UVA0. 21 treatments over 7 weeks
psoralen and UVA (PUVA). 21 treatments over 7 weeks
21 treatments with psoralen and ultraviolet A resulting in complete resolution with long term remission