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					Introduction to Psoriasis
Denise Cook, M.D. Medical Officer Division of Dermatology and Dental Drug Products
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Introduction to Psoriasis
• • • • Prevalence Genetics and Pathogenesis Clinical Variants of Psoriasis State of the Armamentarium

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Prevalence
• Psoriasis occurs in 2% of the world’s population • Prevalence in the U.S may be as high as 4.6% • Highest in Caucasians • In Africans, African Americans and Asians between 0.4% and 0.7%
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Prevalence
• Equal frequency in males and females • May occur at any age from infancy to the 10th decade of life • First signs of psoriasis – Females mean age of 27 years – Males mean age of 29 years
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Prevalence
• Two Peaks of Occurrence – One at 20-30 years – One at 50-60 years • Psoriasis in children – Low – between 0.5 and 1.1% in children 16 years old and younger – Mean age of onset - between 8 and 12.5 years
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Prevalence
• Two-thirds of patients have mild disease • One-third have moderate to severe disease • Early onset (prior to age 15) – Associated with more severe disease – More likely to have a positive family history • Life-long disease – Remitting and relapsing unpredictably – Spontaneous remissions of up to 5 years have been reported in approximately 5% of patients

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Genetics and Pathogenesis
• Psoriasis and the Immune System – The major histocompatibility complex (MHC) • Short arm of chromosome 6 – Histocompatibility Antigens (HLA) • HLA-Cw6 • HLA-B13, -B17, -B37, -Bw16 – T-lymphocyte-mediated mechanism

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Psoriasis as a Systemic Disease
• • • • • • • Koebner Phenomenon Elevated ESR Increased uric acid levels → gout Mild anemia Elevated α2-macroglobulin Elevated IgA levels Increased quantities of Immune Complexes
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Psoriasis as a Systemic Disease
• Psoriatic arthropathy • Aggravation of psoriasis by systemic factors – Medication – Focal infections – Stress • Life-threatening forms of psoriasis
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Clinical Variants of Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Characteristic Lesion of Psoriasis
• Sharply demarcated erythematous plaque with micaceous silvery white scale • Histopathology – Thickening of the epidermis – Tortuous and dilated blood vessels – Inflammatory infiltrate primarily of lymphocytes
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Psoriatic Plaque

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Severity of Disease
• Three Cardinal Signs of Psoriatic Lesions – Plaque elevation – Erythema – Scale • Body Surface Area

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Chronic Plaque Psoriasis
• • • • Most Common Variant Plaques may be as large as 20 cm Symmetrical disease Sites of Predilection – Elbows – Knees – Presacrum – Scalp – Hands and Feet
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Chronic Plaque Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Chronic Plaque Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Chronic Plaque Psoriasis
• May be widespread – up to 90% BSA • Genitalia involved in up to 30% of patients • Most patients have nail changes – Nail pitting – “Oil Spots” – Involvement of the entire nail bed • Onychodystrophy • Loss of nail plate

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Widespread Chronic Plaque Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Chronic Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Psoriasis of the Nail

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Psoriasis of the Nail

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Symptoms of Chronic Plaque Psoriasis
• • • • Pruritus Pain Excessive heat loss Patient Complaints – Unsightliness of the lesions – Low self-esteem – Feelings of being socially outcast – Excessive scale
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Guttate Psoriasis
• Characterized by numerous 0.5 to 1.5 cm papules and plaques • Early age of onset • Most common form in children • Streptococcal throat infection often a trigger • Spontaneous remissions in children • Often chronic in adults
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Guttate Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Life–Threatening Forms of Psoriasis
• Generalized Pustular Psoriasis • Erythrodermic Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Generalized Pustular Psoriasis
• Unusual manifestation of psoriasis • Can have a gradual or an acute onset • Characterized by waves of pustules on erythematous skin often after short episodes of fever of 39˚ to 40˚C • Weight loss • Muscle Weakness • Hypocalcemia • Leukocytosis • Elevated ESR
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Generalized Pustular Psoriasis
• Cause is obscure • Triggering Factors – Infection – Pregnancy – Lithium – Hypocalcemia secondary to hypoalbuminemia – Irritant contact dermatitis – Withdrawal of glucocorticosteroids, primarily systemic
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Generalized Pustular Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Erythrodermic Psoriasis
• Classic lesion is lost • Entire skin surface becomes markedly erythematous with desquamative scaling. • Often only clues to underlying psoriasis are the nail changes and usually facial sparing
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Erythrodermic Psoriasis
• Triggering Factors – Systemic Infection – Withdrawal of high potency topical or oral steroids – Withdrawal of Methotrexate – Phototoxicity – Irritant contact dermatitis
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Erythrodermic Psoriasis

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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State of the Armamentarium
• Wide range of therapies for the treatment of moderate to severe psoriasis • None induce a permanent remission • All have side effects that can place limits on their use

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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State of the Armamentarium
• Therapies – Topical Corticosteroids – Topical Vitamin D3 Analogues – Topical Retinoids – Photo(chemo)therapy – Systemic Therapies • Oral • Parenteral
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Topical Corticosteroids
• High potency and Super potent topical steroids • These include – Fluocinonide family (cream, ointment, gel) – Betamethasone dipropionate cream – Clobetasol propionate family (cream, ointment, gel, foam, lotion) – Diflorasone diacetate ointment – Betamethasone dipropionate ointment
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Topical Corticosteroids
• Side effects associated with use – Skin atrophy – Burning and stinging – Suppression of the hypothalamicpituitary-adrenal (HPA) axis • This may occur after 2 weeks of use with certain topical corticosteroids
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Topical Vitamin D3 Analogues
• Prototype for this group is calcipotriene • 3 formulations – cream, ointment, and scalp solution • Former two are approved for plaque psoriasis • Latter for moderate to severe psoriasis of the scalp
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Topical Vitamin D3 Analogues
• Side Effects – Cutaneous • Burning • Stinging • Pruritus • Skin irritation • Tingling of the skin
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Topical Retinoids
• Tazarotene Gel and Cream – Available in two strengths • 0.05% and 0.1% – Side Effects • Pruritus • Burning/Stinging • Erythema • Worsening of psoriasis • Irritation • Skin pain • Hypertriglyceridemia
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Topical Tazarotene
• Additional Indications – 0.1% gel - approved for the treatment of facial acne vulgaris of mild to moderate severity – 0.1% cream approved as an adjunctive agent for use in the mitigation of facial fine wrinkling, facial mottled hyper- and hypopigmentation, and benign facial lentigines in patients who use comprehensive skin care and sunlight avoidance programs
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Topical Tazarotene (con’t)
• Both products are pregnancy category X • Are contraindicated in women who are or may become pregnant • Requirements before and during therapy – A negative pregnancy test 2 weeks prior – Therapy initiated during a normal menses – Women of childbearing potential should use adequate birth control
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Photo(chemo)therapy
• Two types of phototherapy – Ultraviolet B (UVB) – Ultraviolet A + psoralen (PUVA)

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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UVB
• Two types – Broadband UVB – Narrowband UVB (311-313 nm) • Treatment is time consuming – 2-3 visits/week for several months • Side effect – possibility of experiencing an acute sunburn reaction
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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PUVA
• Consists of ingestion of or topical treatment with a psoralen followed by UVA • Usually reserved for severe, recalcitrant, disabling psoriasis • Time consuming – 2-3 visits/wk; at least 6 weeks • Precautions – Patients must be protected from further UV light for 24 hours post treatment – With oral psoralen, wrap around UV-blocking glasses must be worn for 24 hours post treatment

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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PUVA
• Side effects with oral psoralen – Nausea – Dizziness – Headache • Side effects with PUVA – Early • Pruritus – Late • Skin damage • Increased risk for skin cancer, particularly squamous cell (SCC) and after 200 - 250 treatments, increased risk for melanoma

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Contraindications to PUVA
• Patients less than 12 years of age • Patients with a history of light sensitive disease states • Patients with, or with a history of melanoma • Patients with invasive SCC • Patients with aphakia
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Systemic Therapies
• Oral – Methotrexate – Neoral (cyclosporine) – Soriatane (acitretin) • Parenteral – Amevive (alefacept) – Raptiva (efalizimab) – Enbrel (etanercept)
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Methotrexate
• Folic acid antagonist • Usually reserved for severe, recalcitrant, disabling psoriasis • Maximum improvement can be expected after 8 -12 weeks

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Contraindications - Methotrexate
• • • • • Nursing mothers Patients with alcoholism Alcoholic liver disease Other chronic liver disease Patients with overt or laboratory evidence of immunodeficiency syndromes • Patients who have preexisting blood dyscrasias

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Methotrexate
• Pregnancy Category X drug product – Contraindicated in pregnant women with psoriasis – Pregnancy must be excluded in women of childbearing potential – Pregnancy should be avoided if either partner is receiving MTX during and for a minimum of 3 months after therapy for male patients and for at least one ovulatory cycle after therapy for female patients
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Methotrexate – Side Effects
• • • • • • • • • • • Acute or chronic hepatotoxicity Hepatic cirrhosis Leukopenia Thrombocytopenia Anemia, including aplastic anemia Rarely, interstitial pneumonitis Stomatitis Nausea/vomiting Alopecia Photosensitivity Burning of skin lesions
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Methotrexate
• Multiple prescreening tests necessary • Recommendations for hepatic monitoring – Periodic LFTs including serum albumin – Liver biopsy • Pretherapy or shortly thereafter • Cumulative dose of 1.5 grams • After each additional 1.0 to 1.5 grams

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Neoral
• Potent Immunosuppressive • Adult, non-immunocompromised patients with severe, recalcitrant plaque psoriasis • Maximum efficacy achieved at 16 weeks of therapy

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Contraindications - Neoral
• Concomitant PUVA or UVB therapy • Methotrexate or other immunosuppressive agents • Coal tar or radiation therapy • Patients with abnormal renal function • Patients with uncontrolled hypertension • Patients with malignancies • Nursing mothers

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Neoral – Side Effects
• • • • • • • • • • • Possibility of Irreversible renal damage Hypertension Headache Hypertriglyceridemia Hirsutism/hypertrichosis Paresthesia/hyperesthesia Influenza-like symptoms Nausea/vomiting Diarrhea Lethargy Arthralgia
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Neoral
• Multiple prescreening tests are required • Tests must continue throughout treatment with dosage adjustment as necessary to prevent end-organ damage

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Soriatane
• Oral retinoid approved for the treatment of severe psoriasis in adults • Significant improvement can be achieved with 8 weeks of therapy

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Soriatane - Contraindications
• Patients with severely impaired liver or kidney function • Patients with chronic abnormally elevated blood lipid values • Patients who are taking methotrexate • Ethanol use when on therapy and for 2 months following therapy in female patients
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Soriatane
• Pregnancy Category X drug product as it is a human teratogen • Contraindicated in pregnant females or those who intend to become pregnant during therapy or any time up to three years post therapy

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Soriatane – Side Effects
• Those associated with retinoid therapy – Cheilitis – Alopecia – Skin peeling – Dry skin – Pruritus – Rhinitis – Xeropthalmia – Arthralgia
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Soriatane – Side Effects
• Laboratory Abnormalities – Hypertriglyceridemia (66%) – Decreased HDL (40%) – Hypercholesterolemia (33%) – Elevated liver function tests (33%) – Elevated alkaline phosphatase (10-25%) – Hyperglycemia (10-25%) – Elevated CPK (10-25%) • Hepatitis and jaundice occurred in < 1% of patients in clinical trials on Soriatane
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Soriatane
• Multiple prescreening tests must be obtained • Continued monitoring throughout therapy necessary with possible dosage adjustment

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Parenteral Therapy Amevive
• Immunosuppressive dimeric fusion protein – Extracellular CD2-binding portion of the human leukocyte function antigen-3 (LFA-3) – Linked to the Fc portion of human IgG1
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Amevive
• Indicated for the treatment of adult patients with moderate to severe chronic plaque psoriasis • With 12 weeks of therapy, a disease state of clear or almost clear was achieved by 11% (via IV) and 14% (via IM) of patients, respectively

Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004

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Amevive – Side Effects
• Dose dependent reduction in circulating CD4+ and CD8+ T lymphocytes – Should not be administered to patients with low CD4+ counts – CD4+ counts must be monitored before and weekly throughout therapy
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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Amevive – Side Effects
• Lymphopenia • Increase risk of malignancies – Skin cancer – BCC and SCC – Lymphoma • Serious infections requiring hospitalization • Risk of reactivation of chronic, latent infections • Hypersensitivity reactions
Dermatologic and Ophthalmic Drugs Advisory Committee July 12, 2004
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