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Effective diagnosis & management


administered by subcutaneous or intravenous injections. Patients are screened for TB, hepatitis and HIV and baseline anti-nuclear antibody (ANA) is usually taken before commencement of therapy. Although these therapies are very effective, the long-term side effects are not yet clear. In the short term, it appears to be safe. Many patients require rotation of therapy to ensure maximum efficacy. – Etanercept, adalimumab and infliximab inhibit tumour necrosis factor (TNF) alpha, a cytokine that mediates the inflammatory reaction that causes psoriatic plaques.10


Administration of


anti-TNFs range from once every week to once every eight weeks.


– Ustekinumab is a humanised antibody against the p40 subunit found in cytokines IL-12 and IL-23.10


the T-cell pathway involved in the pathogenesis of psoriasis.10


It is administered once every three months.


Psychological intervention The management of psoriasis consists of medical intervention and psychological support. It is common for psoriasis patients to suffer from distress, anxiety and low self-esteem.1


These can influence the


effectiveness of conventional treatment and have an impact on the patient’s quality of life.1


It is important to identify susceptible patients and offer psychological interventions, such as psoriasis-specific cognitive behavioural therapy.1


Typical patient pathway A patient who presents with psoriasis in primary care settings should be given verbal and written information and support to understand their disease, the treatment options, the correct way to apply their treatments and strategies to deal with the impact of psoriasis on their daily lives.18


Treatments offered must be based


on the patient’s preference and health goals, taking into account the patient’s age, individual circumstances and past medical history.18


Benefits and risks of the treatments and the importance of compliance with the treatments should be discussed with the patient.18


The


assessment of a patient should include determining the severity of the disease using an assessment tool (such as PASI or BSA), its impact on the patient’s life, presence of comorbidities and whether they have psoriatic arthritis.18


The patient 10


then should be offered topical therapy as the first-line treatment and referred to a specialist if they need phototherapy,


www.hospitalpharmacyeurope.com This blocks


systemic or biologic therapy.18


A DLQI


score of ten or more indicates severe disease, which requires admission, phototherapy or second-line therapy.9


Role of pharmacists


Pharmacists have a crucial role in giving advice to patients on how to take their medications correctly and in preventing errors in prescribing medications. Previous treatment with the same medication should not deter pharmacists from verifying a patient’s understanding through questions and feedback.19 Pharmacists also have a role in making coal tar preparations and need to work closely with physicians to ensure consistent quality of formulations. In conclusion, effective diagnosis and management of psoriasis involves a multidisciplinary team including the pharmacists. It needs clear updated guidelines based on recent medical evidence. The management of psoriasis should be patient centered and more efforts should be made to increase the patient’s understanding of their disease and use of the different treatments. ●


References 1. Pathirana D et al. European S3 guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009;23 Suppl 2:1–70.


2. National Institute for Health and Care Excellence. NICE clinical guideline 153. Psoriasis: The assessment and management of psoriasis. www. nice.org.uk/nicemedia/live/13938/61190/61190. pdf. Accessed January 2014.


3. DermNet NZ. PASI score. New Zealand Dermatological Society Incorporated.www. dermnetnz.org/scaly/pasi.html. Accessed January 2014.


4. Finlay AY, Khan GK. Quality of Life: Dermatology Life Quality Index. www.dermatology.org.uk/quality/ dlqi/quality-dlqi.html. Accessed January 2014.


5. Mattei PL, Corey KC, Kimball AB. Psoriasis Area Severity Index (PASI) and the Dermatology Life Quality Index (DLQI): the correlation between disease severity and psychological burden in patients treated with biological therapies. J Eur Acad Dermatol Venereol 2013; Feb 21 [Epub ahead of print].


6. Scottish Intercollegiate Guidelines Network.


Guideline 121: Diagnosis and management of psoriasis and psoriatic arthritis in adults. www. sign.ac.uk/guidelines/fulltext/121/section5.html. Accessed January 2014.


7. Recommendations for the initial management of psoriasis. British Association of Dermatologists & Primary Care Dermatology Society [updated Jan 2010]. London [cited 22 July 2013]. Available from: http://www.eguidelines.co.uk/eguidelinesmain/ guidelines/summaries/skin/bad_pcds_psoriasis. php#.UgQgVNKce8A. Accessed January 2014.


8. Nast A et al. S3 – Guidelines on the treatment of psoriasis vulgaris (English version). Update. Journal der Deutschen Dermatologischen Gesellschaft. 10(Suppl. 2):S1–S95.


9. British Association of Dermatologists website. Available from: http://www.bad.org.uk. Accessed January 2014.


10. Fitzpatrick JE, Morelli JG. Dermatology Secret Plus: (4th edition). Philadelphia: Elsevier;2011.


11. Levin C, Maibach HI. Topical Corticosteroid- Induced Adrenocortical Insufficiency. Am J Clin Dermatol 2002;(3)3:141–7.


12. Warren RB, Griffiths CEM. Systemic therapies for psoriasis: methotrexate, retinoids, and cyclosporine. Clinics Dermatol 2008;(26)5:438–47.


13. Methotrexate Summary of Product Characteristics July 2012.


14. Montaudié H et al. Methotrexate in psoriasis: a systematic review of treatment modalities, incidence, risk factors and monitoring of liver toxicity. J Eur Acad Dermatol Venereol 2011;25. s2:12–18.


15. Neotigason Summary of Product Characteristics, March 2013.


16. Fallah Arani S et al. Treatment of psoriasis with non-registered fumaric acid esters in The Netherlands: a nationwide survey among Dutch dermatologists. J Eur Acad Dermatol Venereol 2013;Available from: MEDLINE, Ipswich, MA. Accessed January 2014.


17. Thaçi D et al. Efficacy and safety of fumaric acid esters in patients with psoriasis on medication for comorbid conditions – a retrospective evaluation (FACTS). Journal Der Deutschen Dermatologischen Gesellschaft 2013;11(5):429– 35. Available from: MEDLINE, Ipswich, MA. Accessed January 2014.


18. National Institute for Health and Care Excellence. NICE Pathways: Psoriasis. Oct 2012. http://pathways.nice. org.uk/pathways/psoriasis. Accessed January 2014.


19. Arnet I, Bernhadt V, Hersberger KE. Methotrexate intoxication: The Pharmaceutical Care process reveals a critical error. J Clin Pharm Ther 2012;37(2):242–4. PHEM/IMM/0613/0002c


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