Management of Psoriasis in special

circumstances

Prof Tariq Rashid

Dermatology Department
AIMC/Jinnah Hospital
Lahore
 Clinical scenario 1
• Management concerns in
patients who are Hepatitis B
and C positive
 Concerns regarding
systemic therapy

- Direct Hepatotoxic effects

- Reactivation
 Systemic Options
• Acetretin

• Cyclosporin

• Aprelimast

• Biologics
 Acitretin
- Not an immunosuppressant, so no
report on reactivation.

- Patients may be more susceptible to

mild hepatotoxic effects of Acitretin.

- Can be used if no alternative with close

monitoring
 Cyclosporin
Possibility of reactivation of HBV.
- Initiation of antiviral therapy recommended
before starting cyclosporin by hepatologist
- Close monitoring for viral load and LFTs

Suppressive effects on reactivation of HCV.

- May be tolerated with close monitoring
 Biologics
TNF-alfa inhibitors
• HBV
- Not hepatotoxic
- Reactivation of HBV major risk
• HCV
- TNF-alfa inhibitors may be tolerated
- Etanercept improved clearing of HCV in
a study
 Ustekinumab, Secukinomab,
ixekizumab, brodalumab
- Long term data has not shown
increase risk of reactivation of HBV
and HCV.
- Not Hepatotoxic
 Aprelimast

• Not Hepatotoxic
• Risk of reactivation low
• Preferred Systemic therapy
 Methotrexate
- Reactivation of Virus causing
Fulminant liver failure
- Hepatotoxic
- Should not be prescribed
 Clinical scenario 2
• Management of
Psoriasis in HIV
patients
Coordinated care dermatologist
and infectious disease specialist

• Antiretroviral drugs along with

- Phototherapy with Topicals
- Acitretin with Topicals
- Aprelimast with Topicals
- Secukinumab with Topicals
 Less favourable options
• Cyclosporine
• Methotrexate
• Biologics (TNF alfa Blockers, ustekinumab)

• Only for refractory cases

• Use cautiously
• Status of HIV be monitored closely
 Clinical scenario 3
• Management concerns in
patients with Latent
Tuberculosis
 Special concerns
- Immunosuppressive treatment

- Biologics (TNF Blockers), methotrexate ,

cyclosporin may result in reactivation
of TB so screening for TB is
recommended before starting these.
Biologics in Latent Tuberculosis
• Full course of prophylactic TB can be
completed before initiating biologics

• Initiation of Biologic treatment after

one month of ATT treatment and
then continue with both biologics
and ATT.
 Preferred treatment in
tuberculosis
• Phototherapy
• Acitretin
• Aprelimast
• Secukinumab
 Clinical scenario 4
• Psoriasis and malignancy
 Psoriasis and malignancy

• Immunosuppressive effects of systemic

therapies are major safety concern in
patients with history of internal
malignancy

• Best approach depends upon severity of

psoriasis and type of malignancy
 Psoriasis and malignancy
• Methotrexate and cyclosporin may
increase the risk for lymphoproliferative
disorders

• TNF-Alfa inhibitors , ustekinumab,

Aprelimast do not appear to increase
risk for internal malignancy
 Psoriasis and malignancy
• Phototherapy and acitretin are safe
options

• In Patients with history of melanoma

or non melanoma skin cancers
phototherapy is contraindicated
 Clinical scenario 5
• Psoriasis in elderly
 Concerns
• Many medical, social, and economic
Comorbidities
• More attention to holistic care

• Increase risk of Adverse drug reactions

• Increase risk of Drug interactions

 Concerns
• Topicals and Phototherapy preferred

• Biologics

• Extra care in use of cyclosporin

methotrexate and acitretin due to lower
therapeutic index in elderly
 Clinical scenario 6
• Management issues of
Childhood Psoriasis
 Childhood Psoriasis
Need for Systemic Therapy

• BSA >20% , erythrodermic, pustular,

arthropathy , localized resistant,
severe psychologic morbidity
 Systemic Therapies
• Methotrexate: Preferred therapy

• Cyclosporin: Improvement rapid.

Duration should be limited

• Acitretin: Less effective for plaque

psoriasis
 Biologics
• Etanercept : (At least 4 years of age)

• Ustekinumab: ( At least 12 years of age)

• Serious adverse effects are rare.
 Childhood psoriasis
special considerations
• Topical calcineurin inhibitors for face and
intertriginous areas

• Vitamin D analogues alone or

combination with low to mid potency
steroids
 Childhood psoriasis
special considerations
• Oral Antibiotics
• Tonsillectomy
• Increased BSA in relation to weight
• Immature status of kidney and liver
 Childhood psoriasis
special considerations
• Active hematopoietic system
• Poor adherence to therapy
• Peer pressure
• Lifestyle modification
 Clinical scenario 7
• Management of Psoriasis
during pregnancy
 Psoriasis during pregnancy
NB UVB: Safe and effective if feasible

Exacerbation of melasma: Potential risk

 Systemic therapy

- Cyclosporin

- TNF Blockers
 Cyclosporin
• FDA category C

Risks
• Premature labour

• Low birth weight new born

 Biologics
• Anti TNF (category B)
• May be used safely
• Adalimubab , etanercept ,infliximab cross
placenta
• Drug discontinuation suggested at 30
weeks gestation
• Live vaccine to infant postponed till 7th
months of age
 Systemic therapy

Systemic steroids only in

Pustular psoriasis of
pregnancy.
 Contraindicated therapies

• Tazarotene category x
• Methotrexate category x
• Acetretin category x
 Less favourable options
• Topical calcineurin inhibitors ( category C)

• Coal Tar (Category C)

• Calcipotriol (Category C)
• Anthralin risks unknown
• PUVA (category C)
 Less favourable options
• Sulfasalazine (Category B)
• Ustekinumab ( Category B)
• Interleukin 17 inhibitors and aprelimast
(no published reports)
• Fumaric acid esters ( Limited data)
 Psoriasis and pregnancy
special considerations
• Better to plan pregnancy when in remission

• Methotrexate: 3 months interval for both

men and women after stopping the drug

• Acitretin: 3 years interval for women. No

precaution for men
 Take Whom Message
for managing psoriatic patients in
special circumstances

• Evaluating the patient for comorbidities

and thorough understanding of risks,
benefits, drug interactions and
contraindications of treatment modalities
is of utmost important.
 A N K YO U
TH