Roles & Responsibilities of the Advanced Nurse Practitioners

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Chapter 15:

Psoriasis

Debilitating disease characterized by recurrent exacerbations and remissions

Symptoms: element of physical discomfort, with pain, itching, stinging, cracking, and bleeding of the lesions

Causes: abnormal epidermal cell cycle, hereditary factors, and trigger factors, including trauma, infection, endocrine imbalance, climate, and emotional stress

Drugs Known to Exacerbate Psoriasis

Systemic corticosteroids (when dose is decreased or stopped)

Lithium carbonate

Antimalarials

Beta-blockers

Systemic interferon

Alcohol

Pathophysiology of Psoriasis

Autoimmune-mediated process are driven by abnormally activated helper T cells.

APC activation requires costimulatory signals.

Once activated, psoriatic T cells produce a type 1 helper T cell–dominant cytokine profile that includes interleukin-2 (IL-2), tumor necrosis factor-alpha (TNF-α), interferon-γ, and IL-8.

These cytokines act to attract and activate neutrophils, which are responsible for much of the inflammation seen in psoriasis.

Psoriasis/Diagnostic Criteria

Observation of characteristic, well-demarcated, erythematous papules or plaques surrounded by silvery or whitish scales.

Lesions are symmetric and usually found on the face, extensor joints, anogenital area, palms and soles, intertriginous areas (known as inverse psoriasis), trunk, scalp, ears, and nails.

Types of Psoriasis

Plaque: sharply demarcated, erythematous papules, and plaques with marked silvery-white scales

Guttate: small, scattered, teardrop-shaped papules, and plaques

Erythrodermic: generalized intense erythema and shedding of scales

Pustular: three forms: generalized, localized, and palmar-plantar with similar characteristic: 2- to 3-mm sterile pustules on specific body regions

Question

A patient presents with a rash manifesting small, scattered, teardrop-shaped papules and plaques. What type of psoriasis would the practitioner suspect?

Plaque

Guttate

Erythrodermic

Pustular

Answer

B. Guttate

Rationale: The guttate type of psoriasis is characterized by small, scattered, teardrop-shaped papules and plaques. The plaque type produces sharply demarcated, erythematous papules and plaques with marked silvery-white scales. The erythrodermic form is characterized by generalized intense erythema and shedding of scales. The pustular type manifests as 2- to 3-mm sterile pustules on specific body regions.

Initiating Drug Therapy for Psoriasis

First counsel to avoid precipitating factors.

Discourage cigarette smoking.

Determine whether psoriasis is localized or general to choose from three treatment modalities:

Topical agents: 10% or less of body involvement

Phototherapy: greater than 10% BSA

Systemic agents: greater than 10% BSA

Goals of Drug Therapy

Decrease size and thickness of the plaque

Decrease pruritus

Improve emotional well-being and quality of life

Put the patient in remission

Have minimal side effects from treatment

Drug Therapy for Psoriasis/Emollients and Topical Corticosteroids

Emollients (adjunct therapy)

Eucerin cream/lotion, Lubriderm, and Moisturel

Hydrate the stratum corneum, decrease water evaporation, and soften the scales of plaque

Topical corticosteroids

Decrease erythema, pruritus, and scaling

Low-potency corticosteroids

Medium- or high-potent agent

Drug Therapy for Psoriasis/Coal Tars

Coal tars (polycyclic hydrocarbon compounds of coal)

Depress DNA synthesis and have anti-inflammatory and antipruritic properties

Available in ointment, gel preparation, bath preparation, and shampoo

Anthralin

Inhibits DNA synthesis and decreases epidermal proliferation

Good therapy for limited number of lesions

Drug Therapy for Psoriasis/Vitamin D Analogs

Vitamin D analogs (calcipotriene [Dovonex] and Calcipotriol)

Supplied in creams, ointments, and topical foam

Reduction of cell proliferation by binding to receptors in epidermal keratinocytes; anti-inflammatory effect

Drug Therapy for Psoriasis/Retinoid

Retinoid (vitamin A derivative)

Tazarotene (Tazorac): mild to moderate psoriasis

Clear, nonstaining gel and cream (0.05% and 0.1%) applied in a thin layer once a day at bedtime

Systemic retinoids

Acitretin (Soriatane) used for long-term therapy

Diminishes cell hyperproliferation and inflammation

Contraindicated in pregnancy, lactation, and alcohol

Drug Therapy for Psoriasis/Methotrexate

Inhibits folic acid reductase, resulting in the inhibition of cellular replication and selection of the most rapidly dividing cells

Initial dose is 2.5 mg a week administered in three doses over a 24-hour period; then titrated to a dose of 12.5 to 25 mg a week

Contraindicated in pregnancy and lactation; used with caution in patients with renal and hepatic disorders and leukopenia

Question

A practitioner is considering drug therapy for a patient who has psoriasis and is pregnant. What drug would be safe for this patient?

Tazarotene

Acitretin

Methotrexate

Calcipotriene

Answer

D. Calcipotriene

Rationale: Calcipotriene is a topical vitamin D analog used for treating mild to moderate psoriasis. It is not contraindicated in pregnancy. Tazarotene can cause fetal harm, and acitretin and methotrexate are both contraindicated in pregnancy and lactation.

Drug Therapy for Psoriasis/Cyclosporine

Action: suppresses cell-mediated immune reactions and humoral immunity; inhibits production of IL-2, which is responsible for producing T-cell proliferation

Dosage: maximum dose is 2 to 5 mg/kg/d

Contraindications: pregnancy and lactation; cautioned with impaired renal function and malabsorption

Interactions: nephrotoxic agents, digoxin, lovastatin (Mevacor), diltiazem (Cardizem), and ketoconazole (Nizoral), hydantoin (Dilantin), rifampin (Rifadin), and sulfonamide use

Phosphodiesterase 4 Inhibitors/Apremilast

Action: oral small molecule specific to cyclic adenosine monophosphate (cAMP)

Dosage: 30 mg twice daily

Contraindications: hypersensitivity to apremilast

Adverse event: GI distress and diarrhea

Interactions: Otezla coadministered with strong CYP450 inducers (i.e., rifampin)

Drug Therapy for Psoriasis/Etanercept (Enbrel)

Action: contains human TNF receptor; binds and inhibits TNF, the cytokine that helps regulate the body’s immune response to inflammation

Dosage: initial: 50 mg sq twice a week for 3 months. Maintenance: 50 mg sq weekly, with a maximum of 25 mg given at one site

Contraindications: live vaccine, active infection

Adverse events: infection, injection site pain, localized erythema, rash, URIs, abdominal pain, vomiting

Drug Therapy for Psoriasis/Infliximab and Adalimumab

Infliximab

Action: monoclonal antibody that targets TNF-α and inhibits its activity

Dosage: 5 mg/kg at week 0, week 2, and week 6, and then once every 8 weeks via IV infusion over 2 hours

Adalimumab

Action: recombinant humanized immunoglobulin G1 monoclonal antibody that binds to TNF-α

Dosage: 80 mg followed by 40 mg every other week

Factors Affecting Selection of Agent

Patient’s age

Type of lesion

Site and involvement

Previous treatments

Recommended Order of Therapy for Psoriasis

First-line therapy: moisturizers and topical steroids

For 2 weeks, a high-potency or very–high-potency topical steroid is applied twice a day and covered by an occlusive dressing of plastic wrap.

Second-line therapy

1-week rest from the topical corticosteroids; 2 weeks of therapy with same agent for two more times

Taper high-potency topical corticosteroid use to once or twice a week; add a vitamin D analog twice a day

Recommended Order of Therapy for Psoriasis (cont.)

Third-line therapy:

Refer to a dermatologist

Dermatologist may use ultraviolet B light treatments, antimetabolites, etanercept, or psoralens plus ultraviolet A light therapy

Summary

In patients with psoriasis, education regarding stress monitoring and control is important, as is education regarding the disease process and treatment goals.

The patient should understand that psoriasis is not contagious.

Symptom control, rather than cure, is the goal of therapy for psoriasis.