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  1. 1. Overview of Psoriasis Adam O. Goldstein, MD, MPH Associate Professor UNC Department of Family Medicine Email: aog@med.unc.edu
  2. 2. Objectives 1. Differentiate psoriasis types 2. Form differential dx 3. Review tx guidelines 4. Review new products 5. Learn 2 additional patient education pearls
  3. 3. “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…. HumiliationHumiliation
  4. 4. 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)
  5. 5. Psoriasis: Quality of Life • 50% seek treatment • As debilitating as other chronic illnesses • > rates depression & alcohol abuse (Sharma, J Dermatol, 2001)
  6. 6. 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
  7. 7. Case What is your treatment plan? Do you refer him to a dermatologist?
  8. 8. Psoriasis: DefinitionDefinition • Chronic, remitting and relapsing • Scaly and inflammatory • Genetically influenced
  9. 9. Psoriasis: • Morphology: Circumscribed, thickened, plaques with secondary erythema and thick, silvery scales
  10. 10. Psoriasis: Pathogenesis • Hyperproliferation of the epidermis – Normal skin cell matures in 28-30 days28-30 days – Psoriatic skin cell matures in 3-6 days3-6 days
  11. 11. Psoriasis: Types • Plaque-type Localized or Generalized • Pustular Localized or Generalized
  12. 12. Psoriasis • Arthritis associated (5-7%)
  13. 13. Psoriasis: Distribution (From Pardasan AG, et al. Am Fam Physician 2000)
  14. 14. Psoriasis: Distribution • Extensor
  15. 15. Psoriasis: Distribution • Extensor
  16. 16. Psoriasis: Distribution • Nails
  17. 17. Psoriasis: Distribution • Genitalia
  18. 18. Psoriasis: Distribution • Hands & feet
  19. 19. Psoriasis: Distribution • Pustular
  20. 20. Psoriasis: Distribution • Intertriginous/inverse- armpits, groin, under breasts (less thick “silvery”scale)
  21. 21. Psoriasis: Distribution • Guttate-small red dots (Gutta = drops) • Appears suddenly after a strep, URI, other infection, stress, medications
  22. 22. Psoriasis: Guttate • Appears after strep, URI, stress, medica- tions
  23. 23. Psoriasis: Distribution • Erythrodermic • Widespread erythema, itching, pain, edema
  24. 24. Psoriasis: Distribution • Sites of trauma (Koebner’s phenomenon)
  25. 25. Psoriasis: Diagnosis • Early on, may look like other diseases • Bx may be necessary
  26. 26. Psoriasis: Differential Diagnosis • Drug eruption
  27. 27. Psoriasis: Differential Diagnosis • secondary syphilis
  28. 28. Psoriasis: Differential Diagnosis • Seborrhea: Finer scale, central facial, scalp, central chest; Greasier; Sebopsoriasis
  29. 29. Psoriasis: Differential Diagnosis • dermatophyte infections (Tinea) – KOH negative – scale not as thick or silvery
  30. 30. Psoriasis: Differential Dx • intertriginous: diaper dermatitis/candidiasis – satellite pustules, beefy red, maceration; KOH positive for yeast in candidiasis; may coexist
  31. 31. Psoriasis: Differential Diagnosis • Eczema • Neuro- dermatitis/ lichen simplex chronicus
  32. 32. Psoriasis: Differential Dx • lichen planus
  33. 33. Psoriasis: Differential Diagnosis • lupus erythematosus
  34. 34. Psoriasis: Differential Diagnosis • pityriasis rosea
  35. 35. Psoriasis: Differential Diagnosis • Cutaneous T-cell lymphoma
  36. 36. 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 )
  37. 37. Psoriasis: Treatment • Flares – skin injury (including dryness, scratching) – sunburn – infections (strep, HIV) – psychological stress – medications
  38. 38. Psoriasis: Treatment • Medications linked to psoriatic flares: – Lithium – Beta blockers – ACE inhibitors – Antimalarials – Indomethacin
  39. 39. Psoriasis Pearl • Avoid systemic corticosteroids
  40. 40. Psoriasis: Treatment • <5% sunlight + topical tx • 5-20% sunlight + topical tx +/- systemic • >20% systemic tx +/- light therapy
  41. 41. Psoriasis: Treatment • Sunlight
  42. 42. 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)
  43. 43. 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)
  44. 44. 1. Emollient cleansers and lotions/cream • Mild cleansers • Moisturizers
  45. 45. 2. Keratolytic Agents • WHEN THE SCALE IS REALLY THICK Scalp: P & S liquid Body: 2-10% salicylic acid qd- bid
  46. 46. 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
  47. 47. 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)
  48. 48. Intralesional injections •Isolated recalcitrant lesions TAC 3-10mg/cc in NS to plaques < 3 cm
  49. 49. 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)
  50. 50. 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)
  51. 51. 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
  52. 52. 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)
  53. 53. 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
  54. 54. 6. Steroid Sparing • Topical calcineurin inhibitors – Tacrolimus ointment & Pimecrolimus cream – Facial and intertriginous areas (Freeman, J Am Acad Dermatol, 2003)
  55. 55. 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
  56. 56. 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)
  57. 57. 8. Coal Tar • Useful as an antimitotic agent • Folliculitis, Staining, Photosensitizer, Smell • Dozens of products
  58. 58. (From Pardasan AG, et al. Am Fam Physician 2000) Algorithm for Treatment of Localized Psoriasis
  59. 59. 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)
  60. 60. 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)
  61. 61. 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)
  62. 62. 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)
  63. 63. Topical Treatments • GIVE ENOUGH WITH REFILLS! • BE AWARE OF $$$$!
  64. 64. Generalized plaque-type psoriasis >20% BSA • Ultraviolet light: UVB or PUVA (oxpsoralens photosensitizer + UVA) • Methotrexate • Retinoids: Acitretin/ Etretinate • Sulfasalazine • Cylclosporine
  65. 65. 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
  66. 66. Ultraviolet light: UVB • Risks: burns, especially corneal, conjunctivitis (Face can be shielded) • Very little toxicity involved • Home light therapy • Eximer laser
  67. 67. 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
  68. 68. Ultraviolet light: PUVA • Contraindications: – photosensitive diseases – photosensitive drugs – previous or present skin cancers – previous x-ray therapy to the skin – cataracts – pregnancy
  69. 69. Ultraviolet light: PUVA • Increased risk of squamous cell carcinoma • Possible increased risk of melanoma (controversial) • Photoaging
  70. 70. 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
  71. 71. 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
  72. 72. 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
  73. 73. 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
  74. 74. 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
  75. 75. Emerging Therapies • Oral Pimecrolimus
  76. 76. Alternative Therapies • Fish oil • Aloe vera • Oral Vit. D • Stress reduction • Lifestyle change • Antistrep tx • Thermal bath • Acupuncture (Guyette, Clin Fam Pract, 2002)
  77. 77. Alternative Therapies
  78. 78. Alternative Therapies
  79. 79. Case • Treatment plan: se moisturizer cream & sunlight daily CALP Medicated shampoo MV foam (Luxiq) BID for 7 days alcipotriene solution qhs DY- Flexural AC 0.1% qd x seven days, followed by C 2.5% qd prn alcipotriene cream qd ODY- rest % salicylic acid 1x/day thick areas 2 weeks luocinonide cream 0.05% BID ee again in 2 weeks azarotene gel/cream if stubborn plaques r steroid dependent nthralin perhaps stubborn areas
  80. 80. 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
  81. 81. 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.
  82. 82. • 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 .

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