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Diagnosis of psoriasis: what is NOT diagnostic of psoriasis

Skin biopsies

psoriasis: mild

< 3% BSA

psoriasis: moderate

3-10% BSA

psoriasis: severe

>10 % BSA (or w/ face, genital, scalp involvement)

Treatment psoriasis: mild

1. topical agents

2. Topical + phototherapy

3. Topical + systemic

Treatment psoriasis: Mod to severe

1. Systemic agent +/- topical or phototherapy

2. More potent systemic agent or 2 or more systemic agents (less common) +/- topical 

3. Biologic agent +/- other agents (biologics can be first line but consider cost)

Topical: corticosteroids

Use LOW potency 

1. Infants

2. Lesions on face, intertriginous areas, areas with thin skin 

Use Mild to High potency 

1. Very thick plaques, recalcitrant disease (plaques on palms)

2. Only use class 1 for 2-4 weeks

3. Studies show safe in preggo at standard durations

Low vs potent topical corticosteroids

Low - Hydrocortisone

Potent - Betamethasone, clobetasol, flucinonide

Topical: Vit D analog

Calcipotriene (dovonex) 0.005%→ synthetic vit D3 analog 

Topical retinoids

Tazarotene (tazorac) 

ADE: Dose dependent irritation, burning, stinging, erythema

• Photosensitivity: avoid long periods in sun, use sunscreen 

• Fetal risk has been demonstrated 

Topical: aryl hydrocarbon receptor agonist: Tapnarof

Anti-inflam effects (dcr IL-17) and promotes epidermal differentiation via aryl hydrocarbon receptor binding 

OTC: salicylic acid

• Keratolytic properties, may enhance penetration of corticosteroids, systemic absorption may occur when used on > 20% BSA or in renal impairment 

• DO NOT USE in children 

• May be used in preggo when mild lesions present

Counseling for creams

1. Wash hands after applying (unless psoriasis on hands)

2. Apple topicals to lesions, avoid unaffected skin 

3. Generally avoid eyes, genitals, and sensitive skin. Dermatologist may direct to do so

4. If using multiple topicals, separate by hours to allow to dry as much as possible

UV light ADR

sunburns, blistering, potential incr skin cancer risk

Use sunscreen on unaffected skin → 2-3x per week

Non-biologics: methotrexate

5-30 mg PO/SQ weekly 

Monitoring + ADR (refer to RA) → Preggo X

Non-biologics: Apremilast (Otezla)

MOA: PDE-4 inhibitor → elevates intracellular cAMP levels → dcr cytokines (modulation, non-immunosuppressant) 

ADR: GI intolerance, weight loss, depression 

CYP 3A4 inducers dcr levels 

Non-biologics: acritretin (not commonly used)

MOA: activated retinoid agonist (not-immunosuppressant)

Dose: need to titrate when starting, then 30 PO BID → renal dose adjust

Efficacy: useful for plaque psoriasis → less effective than other oral/biologics → typically combined with UV light 

ADR: dcr night vision and dry eyes, Pregnancy X, sun sensitivity, brittle nails 

DDI potential (CYP3A4 elimination) inducers will dcr levels 

DO NOT USE W/ MTX

Which non-biologics can be combined

Apremilast can be combined with any others

Anti-TNF biologics

Adalimimumab 

Etancercept 

Infliximab

Certolizumab

Golimumab (psoriatic arthritis) 

TNF inhibitors: Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia)

Approved for moderate to severe treatment of plaque psoriasis and psoriatic arthritis + Crohn's disease 

SE:

• Infection: URTI, pneumonia, UTI, skin and soft tissue infection 

• Opportunistic infection: TB (reactivation of latent disease), invasive fungal infection, reactivation of hep B

• Cancer: lymphoma, nonmelanoma skin cancer
  
  

Warnings, precautions:

• Not recc in pt with CHF, transient neutropenia, and blood dyscrasias 

• Screen for TB and fully treat if needed prior to starting treatment 

Ustekinumab (Stelera)

IL-12/23:

SQ q12-week dosing schedule (once reach steady-state) 

Approved for mod to severe treatment of plaque psoriasis and psoriatic arthritis and Crohn's disease 

ADR: respiratory infection, risk of malignancies, TB infection risk (not as bad as TNFi) 

Guselkumab (tremfya)

IL-23

SQ q 8 weeks dosing schedule (once reach steady-state)

Approved for moderate to severe treatment of plaque psoriasis and psoriatic arthritis. Data support use in  Crohn's disease 

ADRs: infection, TB infection risk (not as bad as TNFi) 

Risankizumab (skyrizi)

IL-23

Sq 12-week dosing 

Approved for moderate to severe treatment of plaque psoriasis and psoriatic arthritis + Crohn's disease 

ADR: infections, TB infection risk (not as bad as TNFI)

Ixekizumab (Taltz)

 IL-17 antagonist → faster acting 

SQ q 4 weeks dosing 

Approved for moderate to severe treatment of plaque psoriasis and psoriatic arthritis 

ADR: upper respiratory infections, IBD (Crohns) exacerbation, TB infection risk (MIGHT not be as bad as TNFI)

Brodalumab (SiliQ)

Human IL-17 receptor antagonist generally faster acting 

SQ q 2-weeks 

Approved for moderate to severe treatment of plaque psoriasis 

ADR: upper resp infection, IBD (Crohns) exacerbation, TB infection risk, BBW suicidal tendencies (REMS program) (INFECTION RISK MIGHT NOT BE as bad as TNFi)

Secukinumab (cosentyx)

MOA: human IL-17 antagonist faster active biologic (1-2 weeks)

SQ 4-week

Approved for moderate to severe treatment of plaque psoriasis and psoriatic arthritis 

ADRs: infections, IBD (Crohns) exacerbation, TB risk

What can be used for Crohns ?

TNFi, IL-12/23

What is okay with CHF

IL-12/23, IL-17