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  • Psoriasis is a chronic inflammatory skin disease characterized by thick, raised lesions. Approximately 6.4 million people in the U.S. suffer from psoriasis. Historically, between 150,000 and 260,000 new cases are diagnosed each year in the U.S. It has been estimated that the annual cost of psoriasis outpatient care in the U.S. is between US$1.6 billion and US$3.2 billion, with an average annual cost per patient estimated between US$1,400 and US$6,700. At present, no known cure exists for psoriasis and current therapies have unsatisfactory efficacy and potentially unacceptable side effects.

acne Pictures acne Pictures Presentation Transcript

  • Overview of Psoriasis
    • Adam O. Goldstein, MD, MPH
    • Associate Professor
    • UNC Department of Family Medicine
    • Email: aog@med.unc.edu
  • Objectives
    • 1 . Differentiate psoriasis types
    • 2. Form differential dx
    • 3. Review tx guidelines
    • 4. Review new products
    • 5. Learn 2 additional patient education pearls
  • “ I am silvery, scaly. Puddles of flakes form wherever I rest my flesh.... Lusty, though we are loathsome to love. Keen-sighted, though we hate to look upon ourselves. The name of the disease, spiritually speaking, is…. Humiliation
  • Psoriasis: Incidence
    • 2-3% U.S. (6.4 million)
      • 200,000 new cases/year
      • 300,000 have >20% BSA
    • Median age dx: 30
      • Two peaks: 16-22, 57-60
    • Costs: $2 billion/year
      • Mean per patient costs $3000
    (Javitz, J Am Acad Dermatol , 2002)
  • Psoriasis: Quality of Life
    • 50% seek treatment
    • As debilitating as other chronic illnesses
    • > rates depression & alcohol abuse
    • (Sharma, J Dermatol , 2001)
  • Case
    • Bob- 34 yo insurance executive
      • history of psoriasis for 8 years
      • scalp, elbows, knees and trunk
      • Got topical steroid (Psorcon E, 60 gms) from dermatologist 3 years ago
      • helped with itching
      • Wants a renewal and wonders if needs to see a dermatologist
      • You estimate 5-10% involvement of skin with plaque psoriasis
  • Case
      • What is your treatment plan?
      • Do you refer him to a dermatologist ?
  • Psoriasis :
    • Definition
    • Chronic, remitting and relapsing
    • Scaly and inflammatory
    • Genetically influenced
  • Psoriasis :
    • Morphology : Circumscribed, thickened, plaques with secondary erythema and thick, silvery scales
  • Psoriasis: Pathogenesis
    • Hyperproliferation of the epidermis
      • Normal skin cell matures in 28-30 days
      • Psoriatic skin cell matures in 3-6 days
  • Psoriasis: Types
    • Plaque-type Localized or Generalized
    • Pustular Localized or Generalized
  • Psoriasis
    • Arthritis associated (5-7%)
  • Psoriasis: Distribution
    • (From Pardasan AG, et al. Am Fam Physician 2000)
  • Psoriasis: Distribution
    • Extensor
  • Psoriasis: Distribution
    • Extensor
  • Psoriasis: Distribution
    • Nails
  • Psoriasis: Distribution
    • Genitalia
  • Psoriasis: Distribution
    • Hands & feet
  • Psoriasis: Distribution
    • Pustular
  • Psoriasis: Distribution
    • Intertriginous/inverse - armpits, groin, under breasts (less thick “silvery”scale)
  • Psoriasis: Distribution
    • Guttate -small red dots (Gutta = drops)
    • Appears suddenly after a strep, URI, other infection, stress, medications
  • Psoriasis: Guttate
    • Appears after strep, URI, stress, medica-tions
  • Psoriasis: Distribution
    • Erythrodermic
    • Widespread erythema, itching, pain, edema
  •  
  • Psoriasis: Distribution
    • Sites of trauma (Koebner’s phenomenon)
  • Psoriasis : Diagnosis
    • Early on, may look like other diseases
    • Bx may be necessary
  • Psoriasis: Differential Diagnosis
    • Drug eruption
  • Psoriasis: Differential Diagnosis
    • secondary syphilis
  • Psoriasis: Differential Diagnosis
    • Seborrhea: Finer scale, central facial, scalp, central chest; Greasier; Sebopsoriasis
  • Psoriasis: Differential Diagnosis
    • dermatophyte infections (Tinea)
      • KOH negative
      • scale not as thick or silvery
  • Psoriasis: Differential Dx
    • intertriginous: diaper dermatitis/candidiasis
      • satellite pustules, beefy red, maceration; KOH positive for yeast in candidiasis; may coexist
  • Psoriasis: Differential Diagnosis
    • Eczema
    • Neuro-dermatitis/ lichen simplex chronicus
  • Psoriasis: Differential Dx
    • lichen planus
  • Psoriasis: Differential Diagnosis
    • lupus erythematosus
  • Psoriasis: Differential Diagnosis
    • pityriasis rosea
  • Psoriasis: Differential Diagnosis
    • Cutaneous T-cell lymphoma
  • Psoriasis: Principals of Treatment
    • Individualize treatment based on:
      • self-image, symptoms, interference with social interactions, expectations & scientific evidence
    • Patient education : Control, not cure
    • Pearl :
      • Combine products for better long-term control and fewer SE’s
    (Rees, J Am Acad Dermatol , 2003 )
  • Psoriasis: Treatment
    • Flares
      • skin injury (including dryness, scratching)
      • sunburn
      • infections (strep, HIV)
      • psychological stress
      • medications
  • Psoriasis: Treatment
    • Medications linked to psoriatic flares:
      • Lithium
      • Beta blockers
      • ACE inhibitors
      • Antimalarials
      • Indomethacin
  • Psoriasis Pearl
    • Avoid systemic corticosteroids
  • Psoriasis: Treatment
    • <5% sunlight + topical tx
    • 5-20% sunlight + topical tx +/- systemic
    • >20% systemic tx +/- light therapy
  • Psoriasis: Treatment
    • Sunlight
  • Evidence-based medicine
    • No good evidence that non-drug tx’s work
    • Topical tx’s effective in short-term (few comparative RCT’s)
    • RCT’s show UVB and PUVA effective short/long term (long term risk PUVA-SCCa)
    • Cyclosporin clears short term but toxic
    (BMJ, Clinical Evidence 2001)
  • Psoriasis: < 20% BSA Topical Therapies
    • 1. Emollients
    • 2. Keratolytic agents
    • 3. Topical steroids
    • 4. Calcipotriene
    • 5. Tazarotene gel
    • 6. Topical calcineurin inhibitors
    • 7. Anthralin
    • 8. Coal tar
    • ( BMJ 2001)
  • 1. Emollient cleansers and lotions/cream
    • Mild cleansers
    • Moisturizers
  • 2. Keratolytic Agents
    • WHEN THE SCALE IS REALLY THICK
      • Scalp: P & S liquid
      • Body: 2-10% salicylic acid qd- bid
  • 3. Topical Corticosteroids
    • Never treated-
      • start medium potency
      • follow up in 2 weeks
    • Previously treated
      • start high potency
      • 2-4 weeks, then taper
    • Always use lower potencies on face and intertriginous areas
  • 3. Topical Corticosteroids
    • Creams most body parts
    • Lotions/mousse hairy areas
    • Ultrapotent/potent BID 2-3 weeks to thick lesions
      • Taper to weekend use only or:
      • Taper to Class III for maintenance to avoid atrophy/striae
    • Educate on:
      • “ tolerance”, signs of atrophy, tapering & relapse
    • If topical steroids insufficient:
      • Steroids + occlusion (plastic wrap QHS- if no atrophy)
      • Steroids + calcipotriene cream/ointment or tazarotene gel
      • Coal tar products and/or Anthralin
      • ( Tristani-Firouzi, Cutis , 1998)
  • Intralesional injections
    • Isolated recalcitrant lesions
    • TAC 3-10mg/cc
    • in NS to plaques < 3 cm
  • 4. Calcipotriene 0.005% (cream, ointment, solution)
    • Calcipotriene (Dovonex)
      • simulates differentiation
      • inhibits proliferation
    • > effective as steroids, tar, anthralin
    • > irritation than steroids
    • Use cautiously if renal or calcium-related conditions, especially (< 60 gm/week)
    • Use > 4 wks to determine effectiveness
    ( BMJ 2001)
  • 4. Calcipotriene 0.005%
    • Use with potent topical corticosteroid (halobetasol) BID x 2-4 weeks
      • less potent topical corticosteroids for facial or groin use
      • may apply simultaneously
    • Continue calcipotriene use BID and taper corticosteroid use to weekends only
      • Helps prevent rebound flares
      • Helps avoid atrophy
    • Taper off steroid first, then calcipotriene
    • (Koo, Skin & Aging 2002)
  • 5. Tazarotene Topical Gel/ Cream
    • Tazarotene (Tazorac)
    • Mechanism of action not well defined
    • Vitamin A derived
    • Inhibits cornified envelope formation
    • Suppresses inflammation in the epidermis
  • 5. Tazarotene Topical Gel ( 0.05-0.1% )
    • Use with medium- high potency topical steroids QD-BID and Tazarotene gel QHS
    • (63% post-treat flare with steroids alone vs 14% steroids + tazarotene)
    • After 2-4 weeks, gradually decrease potent topical steroids to weekend use only
    • Continue or slowly taper tazarotene gel
    • (Koo, J Am Acad Dermatol 2000)
  • 5. Tazarotene Topical Gel/Cream
    • Educate
      • apply very small amount to center of plaques
      • initial increased erythema and scaling
      • confine application to plaques
      • do not “chase” erythema
      • Pregnancy = Do not use
      • Use for > 4-6 weeks before discontinuing
  • 6. Steroid Sparing
    • Topical calcineurin inhibitors
      • Tacrolimus ointment & Pimecrolimus cream
      • Facial and intertriginous areas
    • (Freeman, J Am Acad Dermatol , 2003)
  • Tacrolimus ointment & Pimecrolimus cream
    • Safety?
      • In 2005, FDA warnings about possible link between topical calcineurin inhibitors and cancer (? inc risk of lymphoma and skin cancers)
      • No definite causal relationship     
    • FDA recommends these agents only as second-line therapy in patients unresponsive to or intolerant of other treatments
      • Use for short periods of time and minimum amount
      • Avoid continuous use
  • 7. Anthralin
    • Antimitotic & reducing agent
    • Short-contact therapy
    • Creams:
      • Drithocreme 0.1%,0.25%,0.5%, 1%
      • Micanol 1%*
      • Psoriatec 1%
    • Ointment
      • Anthraderm 0.1%,0.25%,0.5%, 1%
    • * Micanol does not stain skin if rinsed with cool to lukewarm water
    • Use daily until skin is smooth (2-4 weeks)
    • (Koo, Skin & Aging , 2002)
  • 8. Coal Tar
    • Useful as an antimitotic agent
    • Folliculitis, Staining, Photosensitizer, Smell
    • Dozens of products
  • Algorithm for Treatment of Localized Psoriasis (From Pardasan AG, et al. Am Fam Physician 2000 )
  • Scalp Psoriasis
    • Medicated shampoos 5-10 minutes daily
      • keratolytics (salicylic acid)
      • coal tar based
    • Topical steroids in lotion or solution form
      • Class I to II lotion or scalp application, tapering to:
      • Class III lotion, solution, oil
    • Calcipotriene solution
      • Use qhs in addition to topical corticosteroids
    (Van der Vleuten, Drugs , 2001)
  • Scalp Psoriasis
    • Topical corticosteroids in mousse
      • BMV foam (Luxiq)-may be used on nonfacial/genital areas
      • Used qd-bid, less often with improvement
      • Foam superior efficacy & preferred by patients compared with lotion
    (Franz, Int J Dermatol 1999)
  • Genital Psoriasis
    • Mid potency steroids can be use cautiously and for limited time
      • short-term mometasone
    • Reduce to low-potency creams asap
      • desonide cream
    • Consider compounding hydrocortisone 2.5% cream and ketoconazole (Nizoral) cream ,
    • Cautious use of calcipotriene
    • Cautious use of anthralin
    • (Lebwoh, J Am Acad Dermatol 2001)
  • Nail Psoriasis
    • topical fluorouracil qhs
    • tazarotene gel 0.1% qhs
    • class I-II topical steroids
    • posterior nailfold intralesional Kenalog 5-10 mg/cc
    • methotrexate
    (Van Laborde, Dermatol Clin , 2000)
  • Topical Treatments
    • GIVE ENOUGH WITH REFILLS!
    • BE AWARE OF $$$$!
  • Generalized plaque-type psoriasis >20% BSA
    • Ultraviolet light: UVB or PUVA (oxpsoralens photosensitizer + UVA)
    • Methotrexate
    • Retinoids: Acitretin/ Etretinate
    • Sulfasalazine
    • Cylclosporine
  • Ultraviolet light: UVB
    • Indications :
      • guttate psoriasis
      • >20% BSA involved
      • unresponsive to topical therapies
    • Most effective wavelength of light for psoriasis (280-320 nm)
      • narrow band UVB (new)
      • not found in high enough concentrations in tanning salons
      • natural sunlight
  • Ultraviolet light: UVB
    • Risks : burns, especially corneal, conjunctivitis (Face can be shielded)
    • Very little toxicity involved
    • Home light therapy
    • Eximer laser
  • Ultraviolet light: PUVA
    • Indications :
      • severe or incapacitating psoriasis
      • previous failure of conventional topical therapy
      • previous failure of UVB therapy
      • rapid relapse after the above forms of therapy
    • Must be administered in dermatologist office
  • Ultraviolet light: PUVA
    • Contraindications :
      • photosensitive diseases
      • photosensitive drugs
      • previous or present skin cancers
      • previous x-ray therapy to the skin
      • cataracts
      • pregnancy
  • Ultraviolet light: PUVA
    • Increased risk of squamous cell carcinoma
    • Possible increased risk of melanoma (controversial)
    • Photoaging
  • Methotrexate
    • Indications :
    • psoriatic erythroderma
    • acute pustular psoriasis
    • localized pustular psoriasis
    • psoriatic arthritis
    • extensive psoriasis unresponsive to other, less toxic therapies
    • psoriasis in areas preventing the individual from obtaining gainful employment
    • psoriasis that is psychologically disabling
  • Methotrexate
    • Contraindications :
      • pregnancy
      • history of significant liver disease
      • excessive alcohol intake
      • abnormal liver function
      • poor renal function
      • leukopenia
      • active peptic ulcer
      • active, severe infectious disease
      • unreliable patient
  • Methotrexate
    • Test dose 2.5-5.0 mg once
    • Dosage 10-25 mg 1X/Week
    • Baseline labs: (cbc w/platelets, urinalysis, BUN, creatinine, liver functions, CXR)
    • Ongoing:
      • liver biopsy (0.5-1.5 grams)
      • wbc and PLT q wk x 4 weeks; 6 days after last dose
      • Hct, liver functions, urinalysis, serum creatinine every 3 months, at least 6 days after last dose
      • Folic Acid 1-5 mg/day for nausea
  • Acitretin (Soriatane)
    • New retinoid with shorter half-life than etretinate
    • 10, 25 mg capsules
    • Particularly useful in combination with light therapy
    • Many potential side effects
      • hepatotoxicity
      • elevation of triglycerides
      • dry eyes
      • hyperostosis
      • teratogenic
  • Biologics
        • Alefacet Amevive
        • Efalizumab Raptiva
        • Etanercept Enbrel
        • Infliximab Remicade
        • ximab = chimeric monoclonal antibody
        • zumab = humized monoclonal antibody
        • umab= human monoclonal antibody
        • cept = receptor-antibody fusion protein
  • Emerging Therapies
    • Oral Pimecrolimus
  • Alternative Therapies
    • Fish oil
    • Aloe vera
    • Oral Vit. D
    • Stress reduction
    • Lifestyle change
    • Antistrep tx
    • Thermal bath
    • Acupuncture
    (Guyette, Clin Fam Pract , 2002)
  • Alternative Therapies
  • Alternative Therapies
  • Case
    • Treatment plan:
      • Use moisturizer cream & sunlight daily
      • SCALP
      • Medicated shampoo
      • BMV foam (Luxiq) BID for 7 days
      • Calcipotriene solution qhs
      • BODY- Flexural
      • TAC 0.1% qd x seven days, followed by
      • H/C 2.5% qd prn
      • Calcipotriene cream qd
      • BODY- rest
      • 5% salicylic acid 1x/day thick areas 2 weeks
      • Fluocinonide cream 0.05% BID
      • See again in 2 weeks
      • Tazarotene gel/cream if stubborn plaques
      • or steroid dependent
      • Anthralin perhaps stubborn areas
  •  
  • Psoriasis: Patient Education
    • National Psoriasis Foundation , 6600 S. W. 92nd Avenue, Suite 300, Portland, OR 97223, 503-244-7404, Fax. 503-245-0626
    • http://www.psoriasis.org/
    • Patient ed brochure
    • http://www.aafp.org/afp/20000201/20000201d.html
    • Comprehensive WEB listing
    • http://www. edae . gr /psoriasis.html
  •  
  • Bibliography
    • Bruner CR, et al. A systematic review of adverse effects associated with topical treatments for psoriasis. Dermatol Online J 2003; 9(1): 2.
    • Lebwohl MG, Tan MH, Meador SL, Singer G. Limited application of fluticasone proprionate ointment, 0.005% in patients with psoriasis of the face and intertriginous area. J Am Acad Dermatol 2001; 44: 77-82.
    • Koo JY, Lowe NJ, Lew-Kaya DA, et al. Tazarotene plus UVB phototherapy in the treatment of psoriasis. J Am Acad Dermatol 2000; 43: 821-8.
    • Tausk F, Whitmore SE. A pilot study of hypnosis in the treatment of patients with psoriasis. Psychotherapy & Psychosomatics 1999; 68: 221-5.
    • Tristani-Firouzi P, Krueger GG. Efficacy and safety of treatment modalities for psoriasis. Cutis 1998; 61S: 11-21.
    • Jerner B, Skogh M, Vahlquist A. A controlled trial of acupuncture in psoriasis: no convincing effect. Acta Dermato-Venereol 1997; 77: 154-6.
    • Syed TA, Ahmad SA, Holt AH, et al. Management of psoriasis with Aloe vera extract in a hydrophilic cream: a placebo-controlled, double-blind study. Trop Med Internat Health 1996; 1: 505-9.
    • American Academy of Dermatology. Committee on Guidelines of Care, Task Force on Psoriasis. Guidelines of care for psoriasis. J Am Acad Dermatol 1993; 28: 632-7.
    • Gaston L, Crombez JC, Lassonde M, Bernier-Buzzanga J, Hodgins S. Psychological stress and psoriasis: experimental and prospective correlational studies. Acta Dermato-Venereol 1991; 156S: 37-43.
    • Fleischer AB Jr, Feldman SR, Rapp SR, et al. Alternative therapies commonly used within a population of patients with psoriasis. Cutis 1996; 58: 216-20.
    • Federman DG, Froelich CW, Kirsner RS. Topical psoriasis therapy. Amer Fam Physician 1999; 59: 957-62, 964.
    • Roenigk HH Jr, Auerbach R, Maibach H, Weinstein G, Lebwohl M. Methotrexate in psoriasis: consensus conference. J Am Acad Dermatol 1998; 38: 478-85.
    • Owen CM, Chalmers RJG, O'Sullivan T, Griffiths CEM. Antistreptococcal interventions for guttate and chronicplaque psoriasis. Cochrane Database of Systematic Reviews. Issue 1, 2001.
    • Pardasan AG, Feldman SR, Clark AR. Treatment of Psoriasis: An Algorithm-Based Approach for Primary Care Physicians. Am Fam Physician 2000; 61:725-733.
    • Sharma N, Koranne RV, Singh RK. Psychiatric morbidity in psoriasis and vitiligo: a comparative study. J Dermatol 2001; 28: 419-23.
    • Koo JY, Nguyen KD. Treating psoriasis patients: a topical therapy update. Skin and Aging 10: 35-39.
    • Van der Vleuten CJ. Management of scalp psoriasis: guidelines for corticosteroid use in combination treatment. Drugs 2001; 61(11): 1593-8.
    • Schon MP, Boehncke WH. Psoriasis. N Engl J Med 2005; 352: 1899-912 .