How to treat psoriasis how to manage psoriasis difficult cases of psoriasis diagnosis of psoriasis cure of psoriasis how to handle psoriasis how to diagnose psoriasis biological therapy of psoriasis nail psoriasis psoriasis icd 10

1. Dr. Arun Sharma

2.  Psoriasis is moderate to severe in approximately 20% to 25% of
patients
 It has physical and psychosocial burdens
 It is important to screen patients for level of disease & presence of
comorbidities when considering biologics
 Mild disease: < 3% BSA
 Moderate disease: 3% to 10% BSA
 Severe disease: >10% BSA
National Psoriasis Foundation. Statistics. 2019
Am J Clin Dermatol. 2018 Feb;19(1):1-13

3.  42 year old man with a 12 year history of plaque psoriasis
 Disease during first 10 years was mild, located on knees and elbows
 Being treated with topical agents prescribed by Primary Care Physician (PCP)
 In the past 2 years his psoriasis increased to affect 12% to 15% of BSA
 PCP referred him to dermatology

4.  Obesity: BMI = 30.7
 Hyperlipidemia, well controlled on a statin
 T2DM: controlled on oral medication
 Currently a non-smoker
 Alcohol intake: 3 to 6 drinks per week, on weekends primarily

5.  Involvement of scalp, nails, elbows,knees, and trunk

6.  Patient considerations
 Cardio-metabolic disease
 Risk for PsA
 Nail disease
 Scalp psoriasis

7.  Psoriasis is a disease of systemic inflammation
 Associated with increased risk of comorbidity
 Diabetes
 Hypertension
 Dyslipidemia
 Obesity
 Cardiovascular disease

8.  Adapt risk score to account for additional risk of systemic
inflammation in patients with psoriasis that affects >10% BSA or who
otherwise qualify for systemic therapy
 Framingham score to predict the 10-year mortality: multiply score by
1.5 to get the new risk score

9.  Psoriasis is highly correlated with diabetes
 Mild-moderate psoriasis adjusted OR: 3.137, 95% CI 2.675-3.68, P = .00001)
 Severe psoriasis (41%) OR: 3.77, 95% CI 2.60-5.47, P = .00001)
 Psoriasis is associated with dyslipidemia
 Mild or moderate disease: adjusted OR 3.379 (95% CI 2.631-4.34, P = .00001)
 Severe psoriasis, adjusted OR: 5.55 (95% CI 3.49-8.83, P = .00001)
 Patients at increased risk for developing CVD
Am Acad Dermatol. 2019;80:1073-1113.
Puig L Intl Mal Sci. 2017;19:pii:E58.
Eur Heart 2010;31:1000-1006.

10.  Patients with psoriasis require a team-based approach
 Patient-care needs extends beyond dermatology
 Rheumatology, cardiology, and primary care are needed to manage components of
psoriasis
Curr Opin Rheumatol. 2008;20:381-383.
Rheumatology (Oxford). 2017;56:1829-1831.

11.  > 10% BSA
 Level of nail involvement points to possible presence of PsA

12.  Approximately 30% of patients with psoriasis have PsA
 Cutaneous disease usually precedes joint disease by approximately 10 years
 Screen for PsA
 Ask about joint pain, swelling, and stiffness
 Examine all fingers and toes for local swelling or dactylitis
 Palpate for tenderness
J Am Acad Dermatol. 2013;69:729-735.

13.  Approximately 50% of patients with psoriasis have nail involvement
 Associated with physical impairment and pain
 Most common findings
 Pitting and onycholysis
 Subungual hyperkeratosis
 Nail bed discoloration
 Nail plate abnormalities
J Am Acad Dermatol. 2007;57:1-27.

14.  Physical affects
 Itching
 Bleeding
 Koebner phenomenon: scratching causes lesions to spread
 Psychological stress
 Embarrassment
 Impaired QoL
Dermatol Ther. 2018;31:e12589
Am J Clin Dermatol. 2017;18:17-43.

15.  Approximately 45% to 56% of individuals with psoriasis have scalp involvement
 Number of lesions increases with the duration of psoriatic disease
 Biologic agents effective against scalp psoriasis
 TNF inhibitors: adalimumab, etanercept, infliximab
 IL-12/23 inhibitor: ustekinumab
 IL-23 inhibitor: guselkumab
 IL-17 inhibitors: brodalumab, ixekizumab, secukinumab
Clin Exp Dermatol. 2016;41:486-489
Dermotol Ther. 2018;31:e12589
Expert Opin Pharmacother. 2018;19:561-575
J Am Acad Dermatol. 2019 (Epub ahead of print)

16.  Disease severity: 12% to 15% BSA
 Warrants treatment with a systemic or biologic agent
 Treatment selection depends on whether joint involvement is found
 TNF inhibitors are preferred as first-line treatment
 IL-17 inhibitors
 IL-12/23 inhibitors
 IL-23 inhibitors
J Am Acad Dermatol. 2019 (Epub ahead of print)
Am J Clin Dermatol. 2018;19:1-13

17.  TNF inhibitors: adalimumab, certolizumab, etanercept, and infliximab
 IL-12/23 inhibitor: ustekinumab
 IL-17 inhibitors: secukinumab, ixekizumab, brodalumab
 IL-23 inhibitors: guselkumab or tildrakizumab
 Oral systemic agents: apremilast, methotrexate
J Am Acad Dermatol. 2019 (Epub ahead of print)

18.  May prescribe medications
 Conduct patient education regarding injections
 Review administration of agents
 Initial management of side effects
 Triage urgent appointments

19.  26-year-old woman with psoriasis that began in adolescence
 Lesions on her face, neck, and scalp
 Currently being treated with adalimumab
 Unhappy with the minimal improvement seen over the past year
 Her goal is to be clear of lesions

20.  Acceptable response at 3 months: BSA 3% or 75% improvement in BSA
 Target response at 3 months: BSA < 1%
 Target response during maintenance treatment: BSA 5 1% at every 6 month interval
J Am Acad Dermatol. 2017;76:290-298.

21.  Medical history: appendectomy in childhood
 Medications: oral birth control and over-the-counter allergy medication
 Relationship status: recently began a serious relationship
 Profession: accountant
 Alcohol use: rarely drinks
 Physical activity: cycling and hiking enthusiast

22.  Visible lesions on scalp and neck
 Patches between eyebrows, at hairline
 Reluctantly admits to lesions in her genital area

23.  Her reaction to being asked about genital psoriasis is understandable
 Estimates of prevalence of genital psoriasis ranges from approximately 30% to
60%
 Have not been studied extensively
 Genital psoriasis is often untreated
Dermatol Ther. 2018;31:e12589
Acta Derm Venereol. 2011;91:5-11
Am Acad Dermatol. 2019; 80:1073-1113

24.  A study of 1485 psoriasis patients examined internalized stigma associated with
psoriasis
 High levels of internalized stigma were found in patients with greater disease
severity, lesions in genital region
 Genital psoriasis has a significant negative effect on QoL and sexual health
J Dermatol. 2017;44:885-891

25.  Pain during sexual intercourse
 Itch
 Pain
 Burning sensation
 Pain Can result in reduced frequency of intercourse
J Am Acad Dermatol. 2015;72:978-983

26.  Increased depression, anxiety, and suicidal ideation
 Feelings of shame, anger, and worry/embarrassment
 Impairments in activities of daily living and social life
Can Fam Physician. 2017;63:278-285.
Eur Acad Dermatol Venereol. 2014;28:333-337.
Am Acad Dermatol. 2019;80:1073-1113.

27.  Over the past 2 weeks, how often have you been bothered by having little interest
or pleasure in doing things?
 Over the past 2 weeks, how often have you been bothered by feeling down,
depressed, or hopeless?
 Answers are scored 0 (not at all) to 3 (nearly every day)
 A combined score 3 is considered positive for depressive disorder
Br Gen Pract. 2007;57:144-151.

28.  Good efficacy seen with secukinumab, ixekizumab, and brodalumab
 Patients achieving PASI 90
 Approximately 60% to 70% of patients who received IL-17 targeted treatments at week 12
J Am Acad Dermotol. 2019 [Epub ahead of print]
N Engl J Med. 2014;37:1326-338.
N Engl J Med. 2016;37:5345-356.
Br J Dermatol. 2016;175:273-286.

29. • SCULPTURE
trial at 4
years: PASI
90 = 66%
Secukinumab
• UNCOVER-3
OLE at 5
years: PASI
90 = ~96%
Ixekizurnab
• AMAGINE-2
trial at 1
year: PASI
90 = 58%
Brodalumab
J Eur Arad Dermatol Venereal 2018;32:1507-1514.
Acta Derm Venereol. 2018;98:98-102
Br J Dermatol 2019;180:306-314
Psoriasis Area and Severity Index (PASI). PASI 90 indicates a 90% or
greater reduction in PASI scores from baseline and is indicative of
excellent disease improvement.

30.  High PASI 90 rates in the short term pivotal trials
 PASI 90 for guselkumab: Approximately 64% to 73% at week 16
 PASI 90 for tildrakizumab: Approximately 35% to 39% at week 121d
 Rate of PASI 90 response increases over time
J Am Acad Dermatol. 2017;76:405-417.
J Am Acad Dermatol. 2017;76:418-431.
Lancet. 2017;390:276-288.

31.  Guselkumab
 VOYAGE 1 at year 2
 PASI 90 = 82%
 Tildrakizumab
 reSURFACE 2 at year 1
 PASI 90 = 74% to 84%
J Drugs Dermatol. 2018;17:826-832
Cision PR. (2019) [Press release]

32.  Palmoplantar psoriasis
 Adalimumab, guselkumab, ixekizumab, secukinumab, and ustekinumab showed good
efficacy
 Scalp psoriasis
 Etanercept, infliximab, adalimumab, ustekinumab, and secukinumab showed good
efficacy
 Nail psoriasis
 Etanercept, infliximab, adalimumab, ustekinumab, and secukinumab showed good
efficacy
Dermatol Ther (Heidelb). 2017;7:425-446.
J Am Acad Dermatol. 2017;76:70-80
J Am Acad Dermatol 2019 [Epub ahead of print]
J Am Acad Dermatol. 2017;76:667-674

33.  Patient is getting married in 3 months
 Agent with fast onset of action
 IL-17 inhibitors have a fast onset of action
 Brodalumab
 70% achieved PASI 90 at week 12
 89% PASI 100 rate at 1 year
N Engl J Med. 2015;373:1318-1328
Br J Dermatol. 2017;176:741-751

34.  Management for each patient needs to be individualized
 Consider comorbidities
 Assess for PsA
 Important to establish treatment goals
 Goals for treatment success will change over time as newer agents become
available

35.  AE = adverse event
 BMI = body mass index
 BSA = body surface area
 IL = interleukin
 NP = nurse practitioner
 PASI = Psoriasis Area Severity Index
 PCP = primary care physician
 PsA = psoriatic arthritis
 QoL = quality of life
 TNF = tumor necrosis factor
 UV = ultraviolet