A-Textbook-of-Clinical-Pharmacology-and-Therapeutics-5th-edition

PSORIASIS 415
Emollients
Improving
Yes
No
Continue as necessary
Salicylic acid topically,
or
Coal tar topically, or
Dithranol topically
Improving
Yes
No
SPECIALISTS
ONLY
Consider topical/systemic steroids
Consider topical vitamin D 3 analogues
Consider PUVA
Consider oral retinoids (e.g. acetretin)
Improving
Yes
No
SPECIALISTS
ONLY
Consider cytotoxics (methotrexate, ciclosporin)
Consider biologics (etanercept, alefacept, infliximab, efalizumab)
Figure 51.3: Pathway for treatment of psoriasis.
Table 51.2: Novel biological treatments used in psoriasis
Alefacept Efalizumab Etanercept Infliximab
Mechanism of action T cell targeting T cell targeting TNF-α inhibition TNF-α inhibition
Licensed for psoriasis No Yes Yes Yes
in the UK
Method of administration 15 mg i.m. (7.5 mg i.v.) Initial dose 0.7 mg/kg, 25–50 mg s.c. twice 5 mg/kg i.v. at
weekly for 12 weeks then 1 mg/kg s.c. weekly weekly 0, 2 and 6 weeks,
then 8-weekly
Onset of action 6–8 weeks 2–3 weeks 2–3 weeks 1 week
Percentage of patients 20% after 12 weeks 25% after 12 weeks 34% with 25 mg, 49% 80% at 10 weeks
with PASI 75
with 50 mg at 12 weeks
Effects on psoriatic arthritis In phase II trials Modest Yes Yes
Efficacy as monotherapy Yes Yes Yes Yes
Monitoring investigations Peripheral CD4 Monthly FBC for first FBC, renal and LFTs at FBC, renal and LFTs at
T cell count 3 months, then 3 months, then 3 months, then
3-monthly 6-monthly 6-monthly
Safety and efficacy data Up to 12, 12-week Up to 3 years Up to 24 weeks Up to 50 weeks
for long-term use
cycles
From Ghaffar SA, Clements SE, Griffiths CEM. Modern management of psoriasis. Clinical Medicine 2005; 5: 564–68.
FBC, full blood count; i.m., intramuscular; i.v., intravenous; LFT, liver function test; PASI, Psoriasis Area Severity Index; s.c., subcutaneous; TNF, tumour
necrosis factor.