Model Answer
0 min readIntroduction
Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 1-3% of the global population. Characterized by well-defined, erythematous plaques with silvery scales, it significantly impacts quality of life. While genetic predisposition plays a role, environmental factors can trigger or exacerbate the condition. Accurate diagnosis and a tailored treatment plan are crucial for managing symptoms and improving patient outcomes. This response outlines a comprehensive approach to treating a gentleman presenting with suspected Psoriasis Vulgaris, acknowledging the need for individualized care based on disease severity and patient factors.
I. Diagnostic Approach
Before initiating treatment, a definitive diagnosis is essential. This involves:
- Detailed History: Gather information on onset, duration, family history of psoriasis or autoimmune diseases, triggering factors (stress, infection, trauma), and impact on quality of life.
- Physical Examination: Thoroughly examine the skin, noting the distribution, morphology, and extent of lesions. Assess nail involvement (pitting, onycholysis) and scalp involvement.
- Skin Biopsy: A skin biopsy is often crucial, especially in atypical cases or when diagnosis is uncertain. Histopathological findings characteristic of psoriasis include acanthosis, parakeratosis, Munro’s microabscesses, and dilated capillaries in the dermal papillae.
- Differential Diagnosis: Rule out other conditions mimicking psoriasis, such as seborrheic dermatitis, eczema, lichen planus, and pityriasis rosea.
II. Treatment Plan
Treatment is tailored to disease severity, measured by the Psoriasis Area and Severity Index (PASI) score and the impact on quality of life.
A. Topical Therapies (Mild to Moderate Psoriasis)
These are the first-line treatment for localized psoriasis.
- Emollients: Regular use of emollients helps hydrate the skin and reduce scaling.
- Topical Corticosteroids: Varying potencies are available. Higher potency corticosteroids are used for thicker plaques, but prolonged use can lead to side effects like skin atrophy and telangiectasias.
- Vitamin D Analogues (Calcipotriol, Calcitriol): These modulate immune function and reduce epidermal proliferation. Often used in combination with topical corticosteroids.
- Topical Retinoids (Tazarotene): Help normalize epidermal differentiation. Can cause irritation.
- Calcineurin Inhibitors (Tacrolimus, Pimecrolimus): Useful for sensitive areas like the face and intertriginous regions.
B. Phototherapy (Moderate to Severe Psoriasis)
Involves exposure to ultraviolet (UV) light.
- UVB Phototherapy: Narrowband UVB (NB-UVB) is preferred due to its efficacy and reduced side effects compared to broadband UVB.
- PUVA (Psoralen + UVA): Psoralen is a photosensitizing agent taken orally, followed by UVA exposure. More effective than UVB but carries a higher risk of long-term side effects, including skin cancer.
C. Systemic Therapies (Severe Psoriasis)
Reserved for patients with extensive disease or those unresponsive to topical and phototherapy.
- Methotrexate: A folate antagonist that suppresses immune function. Requires regular monitoring of liver function and blood counts.
- Cyclosporine: An immunosuppressant. Effective but can cause nephrotoxicity and hypertension.
- Acitretin: An oral retinoid. Teratogenic – strict contraception is essential.
- Biologics: Target specific components of the immune system (TNF-alpha, IL-17, IL-23). Highly effective but expensive and associated with increased risk of infections. Examples include Adalimumab, Etanercept, Infliximab, Secukinumab, Ixekizumab, and Guselkumab.
- Apremilast: A phosphodiesterase 4 (PDE4) inhibitor. Oral medication with a different mechanism of action than biologics.
III. Monitoring & Follow-up
Regular follow-up is crucial to assess treatment response, monitor for side effects, and adjust the treatment plan as needed. This includes:
- PASI score assessment every 3-6 months.
- Monitoring for adverse effects of systemic therapies (blood tests, liver function tests, renal function tests).
- Patient education on disease management, adherence to treatment, and lifestyle modifications (stress reduction, smoking cessation).
Conclusion
Managing psoriasis requires a holistic and individualized approach. The treatment plan should be tailored to the severity of the disease, patient preferences, and potential side effects. A combination of topical therapies, phototherapy, and systemic medications may be necessary to achieve optimal control. Ongoing monitoring and patient education are essential for long-term management and improved quality of life. The emergence of newer biologic therapies offers promising options for patients with severe psoriasis who have failed conventional treatments.
Answer Length
This is a comprehensive model answer for learning purposes and may exceed the word limit. In the exam, always adhere to the prescribed word count.