cpg psoriasis 2011

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  • 72

    (Psoriasis)

  • 73

    Clinical Practice Guideline for Psoriasis +,- +./

    +,01/234 256

    +, .7+879

    +,01++, -:2/;6

    +,0122+27.,

    +,015?3 68

    +,01986 @2892

    +,01.7= 26

    +,+=6 .5/5

  • 74

    9A

    (psoriasis) !"#$%!"&!'()" *+",-. "/$! '$'()"! 0 &1*) ! 2! " ( "3"45"###67 8 97 *)+ *## :7( "3"45"#&;!!"# (psoriatic arthritis), inflammatory bowel disease, 3"410+0(+;!I22"*79);0+61;9);! J; 9

    $%!" 2 ( '6&!##KL1;"* . 9); !"# 7("# 0#76"(&!M+'()"('6 :

    3#J; -;!*+ 1-2 &!: "%) 3#J;1:$%!: 6 !"6 7 ""%3P: *0+3P)/ 2 PQ, 9'L;R(*2. ( 2,400 * 3#( T9 2 :7($!:7(! *1;!* (22.5 W) 0+! *1 (55 W)(1, 2) 'L;R(*0! &!6"%067! *1;!*23#( 10&! (7 +17'L;R(*! *1 0+3#! 9!#"(2;(* 06.

    *"J7 # )6107:" 2 )+"X 9I221#" #(7 7 22 )+ *I22"*7(" J;07 3"41 ##KL1;"0+I22"*61;K *! -B> Plaque psoriasis +",-'$'()"3##7!*1 -;!*+ 80-90 &!'L;R(*"%) !*+",-

    '$0) &!#&6:" ) &1* & 6"%067 1 M66&Q%J 3##7!*#(-)"P, +. 6"( ;0+0&& "%!&; *[3 #(- extensor :7 &;!P! &7 6; -;!*+ 80 &!'L;R(*( 10;!*TQ + 3*;!*+ 20 7 "%( 10 + TQ $!!*"(7 * (7 ;!*+ 10 &!3$%'(7 *"%) )$!!*96. 0)7. "/ :7 $! ; ); 0+!("*(3P 6; Guttate psoriasis !*6170 &1* (fine scale) 617& +J7 1 M66 #(-+. 6"( 6;0& 6;& 3#J;;!*(7 ;!*+ 10-20 &!'L;R(*"%) 'L;R(*"! *1;!*(7 30 W 0+! 2("6 6:$%! ) *927(# *[3 group A beta-hemolytic streptococci . 7! - 2-3 " )5 ! 2! "%0&!'L;R(* )$! . #9'L;R(* plaque psoriasis ! J;

  • 75

    Pustular psoriasis !*+",-617)! 0#7J;

    - Generalized pustular )$! acute generalized variant (von Zumbusch variant) :10617)! 2 *"('()" !"#0

    - Localized pustular variant "3##(- fR $! fR ; *! 2 plaque psoriasis 7(;(*J; Erythrodermic psoriasis '$!*+",-0$!#"(3$%'("%)&!7 * -&1*0667 "J ! 23"g 2 plaque psoriasis )$!J;" !2 %! 23# J&;L !7!3+* ) (" 0+ L/*%. 0+697 * (dehydration and hypoalbuminemia) 7(;(*J; Inverse psoriasis $!'$!*9#(-M!3"#&!7 * J;07 "0; #(-!("*(3P & )# 0+

    96; ( 6; $!2 #(-)+7 %( :17:$%!*L70+;( 2Q3#&1*)$!J7 Psoriatic nails ( '6&!+# T3#7(;(*91K 3#%($!J;;!*+ 50 9&-%(; 3#J;;!*+ 35 &!'L;R(*"%) ( '6J;07 pitting, onycholysis, subungual hyperkeratosis 0+ oil-drop sign . )"#+17&;!!"# (psoriatic arthritis) "( '6+#7(;(*J;TQ;!*+ 90 Psoriatic arthritis &;!!"# $! !"#&!&;!2 MQ( . "/$!2 !"#&!&;!9". 9); 3 'LJ;#7!* !1#"6 0667 " 6 +17'L;R(*. PQ, &;!L+3#J;;!*+ 1-40 &!'L;R(* 8K2 ! P"*("60+ 6(27 *)+" 2?/

    26 1.'$$%!" 2.! 22)$!J7! " 3.# *("6!#"( 4.'$! 2. #J;K *)+"K (6:$%! ( * )$!)+"J;"#* # : :7 lithium, antimalaria, beta-blocker, NSAIDS 0+ alcohol

  • 76

    68L

    02 '$) 0 &!#:"2+1;(*&1*MQ3#J;)+ *+",- ! &1*) & (+; * MQ T&L!!J;7 * 0+$!&L&1*!!)221+$!!!#!*'$ (Auspitzns sign) &1*& (+!* &1*)+$!'$! 2#!*0'+T+!)$!!*0'+'7 6" (Koebner phenomenon) : 3#)+1(pitting) +#7!(onycholysis) + *+#) &1*96;+# (subungual hyperkeratosis) )$! 21%. 6 +96;+#(oil spot) B> !"#&!!0+&;!MQ! 2J;"%&;!9)/7 &;!+ &;!*( )$! )+ *&;! *7(9)/7 !"# distal interphalangeal joint T$!+",-2. 3 &!&;!!"#0+! 22&;!3 6 )+" !"#$%!"

    99.B>

    The Psoriasis Area and Severity Index (PASI) ( 10&!'$2 body surface area involvement, erythema, induration and scaling &!'$97(67 8&!7 * *"(J( PASI 7! ", )(7 ", 0+%1 ", ( *+!* . (-) PASI score "K '()

    Body surface area (BSA) ( 10&!'$*L3$%&!'()" (4 ("*9:;fR $!&!'L;R(*$!(". )9); 1 fR $!&!'L;R(*;!*+ 1 &!3$%'()""%)

    Dermatology Life Quality Index (DLQI) 1-K 3:(6&!'L;R(*'()"(2) ( *+!*"K '()

    :L9.B>2=V

    Mild psoriasis ) *TQ ( 10;!* *L2 3$%!* < 10% body surface area (BSA), PASI 10, DLQI> 10

    XY=YZ:0 9X> ("%!("*(3P 0;3$%&!!*2;!*(7 10% 067) 7'+67!1-K 3:(6&!'L;R(*22"!*L79+17 moderate to severe psoriasis

  • 77

    680>[:26 68+7 3* 4K 3&!'$2+",-[3 067J72. 6;!. 6(21 * ! 2. 3$!:7(*9 (2["*0* 3$!*$*" (2["*0+:7(*(2["*9-I/) 686L>@=VX>AK+=Y9=> 0X>B>:L5=V

    1.*;!"0+3 :$%!0#* T; 617)! 2.T; ! &;!!"#(76(2 "0+6(2) rheumatoid factor 3$!0* rheumatoid arthritis 3.9 *! 10 [*#3+")$!I22"** (2 anti HIV antibody

    680=YL92: (Medical comorbidities associated with psoriasis ) Metabolic syndrome: +17!#;(* obesity, diabetes mellitus, dyslipidemia

    (hypertriglyceridemia and low high-density lipoprotein) 0+ hypertension 3#(7 'L;R(*!1#"6 metabolic syndrome (7 'L;R(*J70+. JL7 cardiovascular disease 67! (3-8)""%2Q(6(27 * ("( " :"%. )" ("7(L 3$! BMI 0+2

    +$! J;07 fasting blood sugar, lipid profiles 3$!) 9+17 metabolic syndrome 9'L;R(*

    Autoimmune diseases: &;!L+967 P 3#!1#"6 Crohnns disease 0+ ulcerative colitis 9'L;R(* 3.8-7.5 7 $!*#*#"#: "(J(9) !2 % PQ, 3# multiple sclerosis L&Q%9!#"( "#1(7 ( "3"45 3"41)(7 "+7 ((10)

    Lymphoma PQ, 9P!"{, 3#!1#"6 lymphoma 9'L;R(*L&Q% 3 7 $!*#*#"#+17(#1! *1 0+3P9+;*"(11) 2?

    $!2 $%!"*"J7 # )61:"2 ", 2Q '' (4 )+ )+ * (combination therapy) 03*5'L;", 2. 6;! #&;!&;!* 0+4K 3&!067+(4 *+$!9:;9067+- 0+ )1(*(4 ", (rotational therapy) 3$!)++*0++'+&; *2 9:;* 067+K 1. ", 6 6X (Standard treatment)

    1.1. * K *! 1.2. * "#

  • 78

    1.3. 9:;00* (Phototherapy, Photochemotherapy) 1.4. * [+17:(K 3

    2. ", "#! (Supportive treatment) 3. "#! 2692 (Psychotherapy) Z09=Y2:L16 (Education)

    - $%!" ! 7 '()"!"# J7 T", ) *& J;067 T(#1J; 9# -! 2'$6+!:(6 0+! 2 . #:7(8 J;

    - J7667! - ()++*I22"*61;9);. #:7 $)+; L##1) 0 0+#(

    '()"9+",-67 8 '(J);02 00 0+ ( * (stress) 6; - 6:$%!. 9);. #&Q%J; - * # : :7 * 6; + * * +( "+)6+17 beta-blocker, * lithium T61;

    9);. #J; - (4 ", )+ *(4 MQ067+(4&;! '+&; * 4K 3 0+&;!(("0667 "

    2? (Topical therapy) * 9:;9PJ*I221#" J;07

    1. Corticosteroids 2. Tar 3. Dithranol (Anthralin) 4. Calcipotriol 5. Calcineurin inhibitor 6. Salicylic acid

    .L96>>, (Topical steroids) @>>^7_

    - + !"# 0++ 0#76"(&!M+'()" *2"#"# glucocorticoid receptors 7=Z5

    - * +176!!*5 )+ *"#( 0&! !!{4}9);+$!9:; +$!9:;* :9"%(32 - 2 6. 0)7&!!* * {4}!7!2J;'+ ", ;!*(7 :{4}0(7 067* {4}029:;J;# #(-&!7 * 0+(9:;9:7("%87 "%

    - * {4}!7!! 2 ("+ 1-2 "%1("

  • 79

    - * {4}0( ("+ 2 "%67!$!"J7 2 " )5 )+"2 "%! 2 ("(;(" )$!" )5+ 1-2 "% 3$!(#1

    7-+ $!", 0## monotherapy * "#( 0 + 2J;4K 3 ", 1 . )"#* {4}024K 39:7( 2 " )50&! ", (12, 13) (1-K 3)+"X "# 1 "#. 0. "# A)

    B=B>2

    - '()"# + - !*06&!'()" (Striae) MQ6;!("!*7 *#(-"0; & )# 0+M!; 67 8 - * TLLMQ&; L70+$! . &!67!)(J6 ) 9:;#(-(; 67!$!

    (7 2 " )5 - 9:;* 667!"(+ 2. 9);4K 3&!* ++ (Tachyphylaxis)(14) - 9:;* topical steroid class I 67!$!"J7( 667!" 2-4 " )5 0+J7(9:;

    - 50 "67!" )5(15)

    VA92 (Tars) (1-K 3)+"X "# 2 "#. 0. "# B) @>>^7_

    - ; DNA 9:"%)". 3; - +! !"#

    7=Z5 9:;%. "!*7 *(

    - Tar bath 9:; coal tar solution '%. 9);'L;R(*0:7 10 - ;(* Tar cream )$! ointment #'$ MQ6;!(" *$!#(-&;!3"#0+ #(-!("*(

    3P (genital area) - )"P, ;(* Tar shampoo

    9:;%. "7("# ", !$ - 9:;7("#* !566*!*5 - 0:7 tar bath 15-30 6 ;(* [ * UVB )$!! #0 - ", 0## Goeckerman $! 9:;%. " "%6"( %J(; - 8-12 :"( 0+;(+; * !!

    6 ;(* [ * UVB 7-+ 9);'+ ", (7 $!*#*#"# placebo(16)

  • 80

    B=B>2 - L&1&!"# (folliculitis) - '()" *$! (irritant contact dermatitis) - '()"!"#2 03; (allergic contact dermatitis) - !!$%!'; 0++) - %. " ! 2 7! (9:;;(*( "("$!9:;7("# ", '$ MQ'+67!

    :7 UVB, PUVA

    Anthralin (Dithranol) (1-K 3)+"X "# 3 "#. 0. "# C) @>>^7_

    - 0#76"(&!M++5:"%)". 3; 7=Z5

    - ", 0## short contact $! anthralin %J(; 15-30 T; J7! *$!9);3 ( &;&;&Q%J;$!*8 0+;(:!!;(*%. "!T; 9:;9L0##&%'Q% ) 9:;* 9L T9:;%. +7 +; !!J;

    - ", 0## Ingram $!9:;%. " #(-'$0+;(6 ;(* [ *" UVB 0+ anthralin 7!!

    7-+ ", 0## short contact therapy T. 9);!*&Q%;!*+ 10-72(17)

    B=B>2

    - *$!&!'()" - !!$%!'; - . 9);!*0+'()"6+%. &;&Q%

    .L9 Vitamin D3 analogues (calcipotriol,calcitriol, tacalcitol, maxacalcitol) (1-K 3)+"X "# 1 "#. 0. "# A) @>>^7_

    - 2"#"# vitamin D receptors - . 9); differentiation &!M++5+"#L7K (6

    7=Z5 9:; Calcipotriol !*7 *(

    - . )"#'$ psoriasis : plaque ("+ 2 "%

  • 81

    - ()++*'$); 0+#(-&;!3"# 9:;7("# ", !$

    - 9:;7("#* !566*!*52:7(*+ *$!2 calcipotriol 0+4K 3&! ", 067); 9(+ *("

    - 9:; 7("# UVB )$! PUVA 7-+ '+ ", 8 " )5 &!'L;R(*!9 9"#TQ (18)

    B=B>2

    - '()" *$! - K ( hypercalcemia J;(19) ""%J7(9:; 100 "/" )5

    Calcineurin inhibitors (tacrolimus, pimecrolimus) (1-K 3)+"X "# 2 "#. 0. "# B) @>>^7_

    - 2"#"# FK506-binding protein '+. 9);+ ; cytokine . 9); !"# 7=Z5

    - #(-!* 2 "%67!(" J;'+[3 !*#(-9#); 0+M!3"#67 8 J;'+J7. )"#:'$) (plaque type)

    7-+ 9 ", facial and flexural psoriasis 9);'+ ", 9"#L(7 +179:;* )+!(20, 21)

    B=B>2 - *$!#(- * - (9:;!*7 "("9'L;R(*! *16. (7 2 W

    Salicylic acid ( 9:;7("#* !$9);L)+"X 6 6 1); 22) @>>^7_

    -. 9); )+1+!&!M++5'()" 7=Z5

    - Salicylic acid "'7("#* :!$8 MQ2. 9);'+ ", &Q%$!2 . 9); MQ'7 &!* :!$'7 &; '()"&Q% 9:; #(-!*("+ 1-2 "%

    B=B>2

    - ) - (7 ;!*+ 20 &!3$%'("(7 *! LMQ&; L77 *7!9);3,J; *[3 9'L;R(*6"#0+J6

  • 82

    - Salicylic acid 7![ *0UVB 2+4K 3&! [ *0+ - J7(9:;9

    2?=Y>>^7_2YL (Systemic therapy) 9I221#"* )+ *:TL. 9:;", 0#7+17J;"% * +17)+"

    1. Methotrexate 2. Retinoid 3. Cyclosporine

    * +17!

    1. Sulfasalazine 2. Hydroxyurea