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Psoriasis
Christopher Betts (PGY I)
What is Psoriasis?
• Papulosquamous proliferative skin condition that is generally chronic and inflammatory in nature and often associated with systemic manifestations.
• Characterized as erythematous scaly papules and plaques with additional involvement of the nails and joints; pustular and erythrodermic eruptions can occur.
• Contributed w/ trauma (Koebner’s phenomenon)
Psoriasis: Epidemiology
• Affects about 2-3% of US adults • Prevalence ranges from 0.1% to 3% in various
populations• Prevalence equal in males and females• Onset commonly around the ages 15-30, but
also can occur at any age
Psoriasis: Risk factors & Etiology• Immune-mediated disease with genetic predisposition
– Approximately 1/3rd of pts w/ psoriasis have a first-degree relative w/ psoriasis
• Many stressful physiologic and psychological events and environmental factors a/w onset and worsening of the condition
• Lesions tend to develop in areas of trauma (Koebner's phenomena)• Strep throat infection is an example of a trigger and exacerbating
factor• HIV infection (more seen as an exacerbating factor)• Other risk factors, but not shown to be clearly causative, include
smoking, obesity, and alcohol use
Psoriasis: Clinical presentation• Holds much weight in diagnosis, but skin bx is definitive• Typically as a erythematous, scaly patch or plaque which can be
itchy or painful• A scale in psoriasis is typically white and thin and when removed,
leaves pinpoint foci of bleeding (Auspitz sign). • The plaques and micaceous scales are easily recognizable in light-
skinned pts but to a lesser degree in dark-skinned pts and more difficult to discern.
• 90% of patients present with well-defined round or oval plaques that differ in size and often coalesce and situated over the extensor surfaces of extremities, scalp, buttocks, and trunk (plaque psoriasis).
Psoriasis: Non-cutaneous involvement
• Psoriatic onchodystrophy seen in 80-90% of patients w/ psoriasis over the lifetime (fingernails > toenails) – Pitting (most common), – Subungual hyperkeratosis (abnl keratinization of
the distal nail bed; accumulation of scales under distal nail plate)
– Onycholysis (separation of nail from its bed).
onycholysis
pitting
Subungual keratosis
Psoriasis: Clinical presentation
Guttate psoriasis• More common in patients younger than 30 yo• Truncal distribution• Comprises 2% of psoriasis cases• 1- to 10-mm pink papules w/ fine scaling• Can present several weeks after a Grp A beta-
hemolytic strep URI.
Psoriasis: Atypical presentations
• Inverse psoriasis: less scaly; occurs in skin folds and flexor surfaces; distribution includes perineal, inframammary, axillary, inguinal, and intergluteal areas; contributed by heat, trauma, and infection
Psoriasis: Atypical presentations
• Erythrodermic psoriasis: widespread and generalized erythema and associated w/ systemic symptoms; may be slow and incidious in chronic psoriasis or eruptive and abrupt in pts w/ mild psoriasis.
Psoriasis: Atypical presentations
• Pustular psoriasis: pustules over palms and soles w/o plaque formation.
Psoriatic arthritis
• Prevalence ranges from 6-42% of pts w/ psoriasis; male to female ratio 1:1
• Seronegative inflammatory arthritis w/ various clinical presentations
• On average, develops 12 yrs after the onset of skin symptoms.
Classification Criteria for Psoriatic ArthritisSpecificity of 98.7% and sensitivity of 91.4%
Psoriasis: Comorbid conditions• Association based on either pathophysiology, shared risk factors, or adverse
effects from treatments• Significant social morbidity• One survey conducted on patients w/ diagnosed psoriasis, 79% of them
thought that the disease negatively affected their lives by causing problems w/ work, activities of daily living, and socialization.
• Social isolation may contribute to incr risk of medical conditions that are mediated and prevented by exercise and lifestyle modifying practices.
• Incr disease severity a/w lower income, higher number of consultations w/ multiple physicians, and reduced satisfaction w/ treatment.
• Younger and female patients are most affected by psoriasis.• One survey found that more than one half of patients w/ severe psoriasis
thought physicians could do more to help, and 78% reported frustration w/ the effectiveness of treatment.
Psoriasis: Comorbid conditions
Psoriasis: Management
Psoriasis: Management – overview
• Treatment goals include improvement of skin, nail, and joint lesions plus enhanced quality of life.
• Based on level of severity – in this case amt of BSA covered
• … and how systemic the condition is– Skin only vs. Skin + joint +/- other extra-dermal sites
• Major modalities of Tx: topical, phototherapy, systemic/biologic agents
• Management of compound co-morbidities (previous slide)
Psoriasis: Management – overview
• Severity: Mild/moderate or Severe
– Mild/Moderate is <5% BSA affected• Genitals, hands, feet, face usually spared
– Severe is 5% or greater of BSA affected
Psoriasis: Management – overview
• If Mild/Moderate, is the patient needing prn therapy or continuous therapy?– PRN/intermittent therapy: • Topical corticosteroids, • Vitamin D analogs, • Tazarotene (Tazorac) (SORT A)
– Continuous therapy: Calcineurin inhibitors• Tacrolimus, Pimecrolimus
Psoriasis: Management – overview
• If Severe, is the BSA affected greater or less than 20%?– <20% BSA affected calls for Vitamin D analogs w/
phototherapy– >20% BSA affected calls for more systemic therapy
w/ phototherapy (SORT A)• Systemic tx: Methotrexate, Acitretin, Cyclosporine
– Any arthritic involvement calls for biologic therapy (not necessarily the same as systemic tx)• Adalimumab, Infliximab, Etanercept (SORT A)
Psoriasis: Topical Tx’s in general• Ointment vs. cream vs. gel vs. lotion?? • Level of penetration: Lotion, gel < cream < ointment• The choice of formulation depends on area to cover, examples:
– Lotion for scalp– Cream for moist weeping lesions– Ointment for dry, lichenified, scaly lesions
• Emollients are ointments or thick creams that are used to reduce scaling and irritation.
• Ointment emollient example is Aquaphore• Thick cream emollient examples include Cerave, Nivea, Eucerin• Overall, individualized and based on a personal preference, level of
compliance, and dermatologic factors like skin type and plaque thickness.• Twice daily application
Psoriasis: Topical Corticosteroids
• These, combined with emollients, are the most common and effective treatment to limited plaque psoriasis.
• Anti-inflammatory, ant proliferative, and immunosuppressive effects
• Twice daily application• The greater the potency the greater the improvement
in symptoms, based on systematic reviews• Common localized adverse effects are poor wound
healing, skin atropy, and irritation.
Psoriasis: Topical Corticosteroids• Extended use of high potency steroids, although topical, can bring
about systemic effects similar to those from oral steroid use.• Children have a high ratio of BSA to weight, hence are most
vulnerable to adverse effects of steroid use in general. • Once symptoms improve, recommend to taper.• Tachyphylaxis of topical steroids is not uncommon and is either
related to genuine tolerance to long-term treatment or low adherence.
• Expense: a 60 g tube can be as high as $80. Foam and spray forms are new-type of formulations for better adherence but are also expensive. Generic forms available are shown below.
Psoriasis: Topical Corticosteroids• US-graded potency scale ranges
– Grade I (most potent) to VII (least potent)• Some are the same name in different classes but varied in
potency based on formulations – Betamethasone: ointment (I) > cream (II) > lotion (III)
• The more sensitive or thinner the skin (i.e. face, intertrigous areas) the lower the potency called for (grades VI-VII)
• The thicker and angrier the lesion in areas of thicker skin (i.e. extremities) the higher the potency called for (grades I-III)
• Can be used in sequence for tapering effect.
Psoriasis: Topical CorticosteroidsMost commonly used ones for psoriatic plaques
– Hydrocortisone topical 2.5% (VII)– Triamcinolone topical 0.025% and 0.1% (IV and VI)– Fluocinonide topical 0.05% (II to III)– Halobetasol topical 0.05% (I)– Betamethasone Diproprionate topical 0.05% - Grade I to V
Three-dollar list ones: – Betamethasone diproprionate 0.05% cream (I,II), – Betamethasone valerate 0.01% cream (V) and ointment (III), – Fluocinolone soln 0.01% (VI), – Fluocinonide cream 0.05% (II), – Hydrocortisone cream 1% and 2.5% (VI, VII), – Triamcinolone cream 0.025% (VI), 0.1% (IV), 0.5% (III), – Triamcinolone 0.1% ointment (III)
Psoriasis: Topical Vitamin D analogs
• Hypoproliferative effect on keratinocytes; questionable immunomodulating effect; inactivated by UVA light
• Monotherapy < combination therapy either w/ phototherapy or topical steroid; combined emollient use also common
• Slower onset of action (6-8 wks) but longer disease-free interval than topical steroids
• Adverse effects: hypercalcemia, PTH suppression– High risk: pts w/ supratherapeutic doses and those w/ renal
insufficiency
Psoriasis: Topical Vitamin D analogs
• Calcipotriene (Dovonex) 0.005% ($)– Twice a day application; generic form as well– Available in all types of formulations
• Calcitriol (Vectical) – 3 mcg/g ($$)– Only in ointment form; originally was available only in Europe;
demonstrated in one systematic review study to have less skin irritative effects compared to calcipotriene
– One 52-wk open labeled study in 2009 demonstrated less hypercalcemic adverse effects
• Both are well tolerated agents; safe for pediatric use; both are expensive
Psoriasis: Topical Vitamin D analogs
• Combination Vit D + topical steroids available but very expensive– Calcipotriene + Betamethasone diproprionate
0.064% (Talconex) = $400 for 60g tube
Psoriasis: Tazarotene• Chemically related to Vitamin A; regulate epithelial growth• Topical retinoid 0.1% and 0.05%: cream, foam, gel (pediatric use)• Two RVCT double-blind study (Amer J of Derm, 2003) of 1303 pts w/
psoriasis using 0.1% and 0.05% creams qd for 12 weeks: – Significant reductions in severity of clinical signs of psoriasis– Therapeutic effect maintained during post-treatment period
(unspecified duration)– 0.1% cream w/ more skin irritative effects than 0.05% cream
• As effective as potent topical corticosteroids in alleviating symptoms of psoriasis and a/w longer disease-free intervals
• Approved for psoriasis in patients older than 18 yo and tx of acne in pts > 12 yo
Psoriasis: Tazarotene
• Adverse effect: perilesional itching and burning (common); teratogenic
• Regimen of alternating days w/ topical corticosteroid and moisturizers
• One multicentre, non-controlled study in 2006 studying short-term tazarotene therapy in 43 pts w/ psoriasis vulgaris– Results showed that short-term treatment (20 min of
application followed by washing) was just as effective as traditional treatment
Psoriasis: Calcineurin inhibitors• Tacrolimus > Pimecrolimus• From two RCTs in 2004: Effective in facial and intertriginous
psoriasis• Approved for use in patients > 2 yo • FDA approved?: Mainly approved for therapy for mod-severe
atopic dermatitis.• A considered alternative to chronic topical steroid use over
sensitive areas• Improve symptoms w/ less skin atrophy than topical
corticosteroids• Boxed warning: skin malignancy and lymphoma (FDA report 2005)
Psoriasis: Calcineurin inhibitors
• In 2004, 8 wk double-blind RVCT study of 167 pts >16 yo with intertriginous and facial psoriasis applying twice a day 0.1% tacrolimus ointment; results showed more patients achieving clearance of lesions or excellent improvement compared to placebo (65% to 32%)
• Second study in 2004, RVCT of 57 pts w/ mod-to-severe inverse psoriasis for 8 weeks of bid usage pimecrolimus: 1% cream is an effective tx for inverse psoriasis w/ rapid onset of action, safe, well-tolerated
Psoriasis: Phototherapy
• Mainly for refractory and/or severe psoriasis
Psoriasis: Systemic therapiesMethotrexate• MTX used for patients of severe psoriasis (BSA >5%)• used to treat psoriatic disease for >50 yrs• Administered weeklyCyclosporine• Rapid alleviation of symptoms• multiple adverse effects and drug interactions preclude long-term
use• often used for suppressing crises and as bridge therapy during
initiation of slower-onset maintanence therapies.• Both MTX and cyclosporine are not approved for treating severe
psoriasis in children
Psoriasis: Systemic therapies
Acitretin• Oral retinoid w/ slow onset of effect (up to 6
mo)• teratogenic, causes mucocutaneous lesions,
hyperlipidemia, and elevated LFTs• more effective when combined w/
phototherapy.
Psoriasis: Biologic therapy• Increasingly used in treating moderate-to-severe psoriasis
and in psoriatic arthritis• Tumor necrosis factor inhibitors (Humira, Enbrel, Remicade)• Etanercept (Enbrel) commonly combined w/ MTX for
effective use.• Infliximab (Remicade) reported in clinical trials to have the
most rapid and sustained response• Risk of infection: Usage of any TNF inhibitor contrainidcates
for live vaccine usage and calls for a baseline PPD tuberculin skin test.
Psoriasis: Management
Psoriasis: Management
Questions and critics welcomed…
Resources:• AAFP article: Psoriasis (May 2013)• http://www.psoriasis.org/• http://www.guideline.gov/content.aspx?id=12
505• Medscape Reference, Up To Date, Epocrates
online