Guttate Psoriasis

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Guttate psoriasis is often a form that begins in childhood or early adulthood. A variety of conditions have been known to precipitate guttate psoriasis including infections, such as streptococcal infections, as well as stress, injury to the skin, or certain medications. Strep throat is a common trigger, and can be associated with flares as well, even if the infection is not clinically evident. Guttate psoriasis appears as an eruption of scattered 0.1-1 cm "drop" shaped, erythematous, scaling papules of the trunk and extremities primarily (Fig. 9.1B). This type of psoriasis often has a more rapid response to therapy than other forms of psoriasis.

Table 9.1. Summary of biologics used for psoriasis

Alefa-cept

Etaner-cept

Efalizu-mab

Infliximab

Adali-mumab

Moderate to severe chronic plaque psoriasis

RA, polyar-ticular-course RA, AS, psoriatic arthritis, moderate to severe psoriasis

Chronic moderate to severe plaque psoriasis

RA, Crohn's disease, AS, moderate to severe plaque psoriasis, psoriatic arthritis, and ulcerative colitis

RA, psoriatic arthritis

Inhibits T-cell activation and proliferation; induces selective T-cell apo-ptosis

Dimeric TNF-a receptor antagonist competitively inhibits interaction of TNF with cell-surface receptors

Monoclonal antibody which binds CD11a, blocking interaction with ICAM-1 resulting in decreased T-cell activation, adhesion, and trafficking

Chimeric monoclonal antibody which binds with high affinity to free and membrane bound TNF, and inhibits its binding to its receptors

Monoclonal antibody which binds and inhibits TNF-

15 mg intramuscular injection once weekly for 12 weeks

50 mg twice weekly by subcutaneous injection for 3 months followed by reduction to maintenance dose of 50 mg weekly

First dose 0.7 mg/ kg, then 1.0 mg/kg subcutaneous injection once weekly

Studies examining infliximab for psoriasis have dosed using 3 or 5 mg/kg intravenous infusion at weeks 0, 2, and 6

40 mg subcutaneous injection every other week

PASI-75 results of phase IIIIM study: 33 % patients on alefa-cept 15 mg/week vs. 13 % receiving placebo (at any time)

PASI-75 in one phase III study on 50 mg twice weekly: 47% vs. 4% in placebo after 12 weeks; after 24 weeks, PASI-75 in 50 mg twice weekly group was 54%

At 12 weeks of therapy, a phase III study found that 27% of patients receiving efalizumab achieved PASI-75 vs. 4% in placebo

Aphase III studyfound at 10 weeks, 80% of subjects achieved PASI-75 on 5 mg/kg (weeks 0, 2, and 6 dosing) vs. 3% in placebo

53 % of patients in a phase II study achieved a PASI-75 with 40 mg every other week compared to 4% in placebo

Similar to placebo, injection site pain/inflammation; no increased incidence of infections

Well tolerated in clinical trials: extended use does not result in cumulative toxici-ties. Most common adverse event is injection site reaction. Avoid in patients with demyelinating disease, congestive heart failure and active, significant infection, e.g., tuberculosis

Most common include headaches, myalgia, pain, and fever

Well tolerated. Headache, nausea, upper respiratory infections seen. Avoid in patients with deymyelinating disease, congestive heart failure and active, significant infection, e.g., tuberculosis

Rates of adverse events comparable between adalimumab and placebo. Avoid in patients with deymyelinating disease, congestive heart failure and active, significant infection, e.g., tuberculosis

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