A Textbook of Clinical Pharmacology and Therapeutics

PSORIASIS 415

Emollients

Improving?

Continue as necessary

Yes

Yes

Yes

No

No

No

Salicylic acid topically,

or

Coal tar topically, or

Dithranol topically

Improving?

Improving?

Consider topical/systemic steroids

Consider topical vitamin D 3 analogues

Consider PUVA

Consider oral retinoids (e.g. acetretin)

SPECIALISTS

ONLY

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-αinhibition TNF-αinhibition
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 Medicine2005; 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.