April W. Armstrong, MD, MPH, prepared useful practice aids pertaining to psoriasis management for this CME activity titled "Stories From the Psoriasis CaseBook: Overcoming Challenges in Diagnosis and Treatment for Family Physicians." For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at http://bit.ly/2n9Pfxg. CME credit will be available until August 9, 2019.

1. Access the activity, “Stories From the Psoriasis CaseBook: Overcoming
Challenges in Diagnosis and Treatment for Family Physicians,” at
www.peerview.com/UEY40.
Overcoming Challenges in the
Diagnosis and Treatment of
Psoriasis: A Case-Based Guide
for Family Physicians
PRACTICE AID
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.
• Erythematous plaques
covering scalp, torso, arms,
and lower extremities
Patient Presentation
Identifying the Type of Psoriasis
Case 1:Tommy (46 years)
Plaque psoriasis1
• Most common form of psoriasis
• Appears as raised, red patches covered with a silvery white
buildup of dead skin cells
• Patches or plaques most often show up on the scalp, knees,
elbows, and lower back
• Often itchy and painful, and can crack and bleed
• Psoriasis had been well-controlled with
topical steroids; however, over the past year
it progressed and now involves large areas
of torso, genitalia, and lower extremities
• Current estimated BSA of involvement: ~12%
Patient Presentation
Psoriasis Treatment Considerations
Case 2: Samantha (48 years)
Psoriatic arthritis2
• According to current guidelines, the presence of psoriatic
arthritis is the first branching point in the treatment algorithm
that guides therapeutic selection for psoriasis
Diagnosis
Key Treatment Considerations

2. Access the activity, “Stories From the Psoriasis CaseBook: Overcoming
Challenges in Diagnosis and Treatment for Family Physicians,” at
www.peerview.com/UEY40.
Overcoming Challenges in the
Diagnosis and Treatment of
Psoriasis: A Case-Based Guide
for Family Physicians
PRACTICE AID
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.
BSA: body surface area; IL-17: interleukin 17; OR: odds ratio; TNF: tumor necrosis factor.
1. https://www.psoriasis.org/about-psoriasis#type. Accessed July 17, 2018. 2. Menter A et al. J Am Acad Dermatol. 2008;58:826-850. 3. Armstrong AW et al. J Am Acad Dermatol. 2013;68:654-656.
• Has had psoriasis since he was a teenager
– Involves nails, elbows, and knees
• During the past year, noticed stiffness
and pain in his back lasting 45 minutes
in the morning
Patient Presentation
Optimizing Therapeutic Selection
Case 3: Larry (38 years)
TNF inhibitors
• Adalimumab; etanercept; infliximab; certolizumab pegol
Anti–IL-17 therapies
• Secukinumab; ixekizumab
• Presents for annual visit
• Blood pressure: 142/74 mmHg; also appears
to have a large waist circumference
Patient Presentation
Cardiovascular Monitoring
Case 4: Steve (52 years)
More than double3
• Compared with the general population, patients with psoriasis
have a higher prevalence of metabolic syndrome
(pooled OR = 2.26; 95% CI, 1.70-3.01)
• Patients with more severe psoriasis have greater odds of
metabolic syndrome than those with milder psoriasis
Addressing Axial Disease in PsA
Risk of Metabolic Syndrome

3. Access the activity, “Stories From the Psoriasis CaseBook: Overcoming
Challenges in Diagnosis and Treatment for Family Physicians,” at
www.peerview.com/UEY40.
Patient Handout: Screening
Tool for Psoriatic Arthritis1,2
PRACTICE AID
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.
a
This validated screening tool was approved for use by the National Psoriasis Foundation (NPF). For more information on psoriasis and psoriatic arthritis, and to learn about NPF’s Patient Navigation Center
and the many services it offers, visit www.psoriasis.org.
1. https://www.psoriasis.org/sites/default/files/screening_tool_for_psoriatic_arthritis.pdf. Accessed July 17, 2018. 2. Ibrahim GH et al. Clin Exp Rheumatol. 2009;27:469-474.
Psoriatic arthritis is a form of arthritis that can affect almost one-third of people with psoriasis and
lead to lasting damage to your joints and bones. But getting diagnosed and treated as soon as
possible can prevent that damage and help you stay healthy.
Answer the following five questions to find out if you are at risk for psoriatic arthritis.a
Then put a checkmark next to the places on the diagram where your body feels tender or sore.
Bring this handout with you to your doctor’s appointment.
1. Have you ever had a swollen joint (or joints)?
£ Yes £ No
2. Has a doctor ever told you that you have arthritis?
£ Yes £ No
3. Do your fingernails or toenails have holes or pits?
£ Yes £ No
4. Have you had pain in your heel?
£ Yes £ No
5. Have you had a finger or toe that was completely
swollen and painful for no apparent reason?
£ Yes £ No
¢ Neck
¢
Upper back
¢
Lower back
¢
Knee
¢
Hand/Fingers
¢
Hand/Fingers
Thumb ¢
Wrist ¢
¢ Thumb
¢ Wrist
Elbow ¢ ¢ Elbow
Shoulder ¢
¢
Knee
Ankle
¢
Ankle
¢
¢
Foot/Toes
¢
Foot/Toes
¢ Shoulder

4. Access the activity, “Stories From the Psoriasis CaseBook: Overcoming
Challenges in Diagnosis and Treatment for Family Physicians,” at
www.peerview.com/UEY40.
Non-Biologic Systemic Treatments1-3
Treatment Considerations
Methotrexate
• Antimetabolite
• Effective in 40% of patients and overall safe for PsO when used short-term
at low doses and properly monitored
Cyclosporine
• Commonly used in combination with biologics
• Associated with several side effects and toxicity issues
• Calcineurin inhibitor
• Useful as a “rescue drug” for patients who need rapid response with
symptomatic relief
• Associated with many side effects (specifically renal toxicity); limit use to
short-term therapy
Acitretin
• Oral retinoid
• Modest efficacy against plaque psoriasis
• Commonly used to treat palmoplantar psoriasis
• Has been used in combination with UVB and PUVA therapy, resulting in more
effective treatment
• Contraindicated in women of childbearing age (very potent teratogen)
Apremilast
• Phosphodiesterase-4 inhibitor
• Substantially less efficacious compared with biologics, but offers an alternative
for patients who prefer an oral agent
• Minimal toxicity
Treatment Options
for Psoriasis
PRACTICE AID
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.

5. Access the activity, “Stories From the Psoriasis CaseBook: Overcoming
Challenges in Diagnosis and Treatment for Family Physicians,” at
www.peerview.com/UEY40.
Treatment Options
for Psoriasis
PRACTICE AID
This Practice Aid has been provided as a quick reference to help learners apply the information to their daily practice and care of patients.
AE: adverse event; IBD: inflammatory bowel disease; IL-12: interleukin 12; IL-17A: interleukin 17A; IL-17RA: interleukin 17 receptor A; IL-23: interleukin 23; PsO: psoriasis; PUVA: psoralen and ultraviolet A;
TNFα: tumor necrosis factor alpha; UVB: ultraviolet B.
1. https://www.psoriasis.org/sites/default/files/systemics_booklet.pdf. Accessed July 5, 2018. 2. West J et al. PLOS One. 2016;11:e0153740. 3. Lee CS, Koo J. Expert Opin Pharmacother. 2005;6:1725-1734.
4. Humira (adalimumab) Prescribing Information. http://www.rxabbvie.com/pdf/humira.pdf. Accessed July 5, 2018. 5. Enbrel (etanercept) Prescribing Information. http://pi.amgen.com/united_states/
enbrel/derm/enbrel_pi.pdf. Accessed July 5, 2018. 6. Remicade (infliximab) Prescribing Information. https://www.remicade.com/shared/product/remicade/prescribing-information.pdf.
Accessed July 5, 2018. 7. Cimzia (certolizumab pegol) Prescribing Information. https://www.cimzia.com/sites/default/files/docs/Prescribing_Information.pdf. Accessed July 5, 2018. 8. Campanati A et al.
Expert Opin Biol Ther. 2017;17:387-394. 9. Stelara (ustekinumab) Prescribing Information. https://www.stelarainfo.com/pdf/prescribinginformation.pdf. Accessed July 5, 2018. 10. Cosentyx (secukinumab)
Prescribing Information. https://www.pharma.us.novartis.com/sites/www.pharma.us.novartis.com/files/cosentyx.pdf. Accessed July 5, 2018. 11. Taltz (ixekizumab) Prescribing Information. http://uspl.lilly.
com/taltz/taltz.html#pi. Accessed July 5, 2018. 12. Siliq (brodalumab) Prescribing Information. https://siliqrems.com/SiliqUI/rems/pdf/resources/SILIQ_REMS_Prescribing_Information.pdf. Accessed July 5,
2018. 13. Tremfya (guselkumab) Prescribing Information. https://www.tremfyainfo.com/shared/product/tremfya/prescribing-information.pdf. Accessed July 5, 2018. 14. Ilumya (tildrakizumab) Prescribing
Information. http://www.sunpharma.com/Media/Press-Releases/ILUMYA%20US%20Prescribing%20Information.pdf. Accessed July 5, 2018.
Biologic Therapies
Agent
Approved
for PsA
Target
Route of
Admin.
Safety Considerations
Adalimumab4
P TNFα SubQ
• Black box warning: serious infections, malignancy
• AEs: infections, injection-site reactions,
headache, rash
Etanercept5
P TNFα SubQ
• Black box warning: serious infections, malignancy
• AEs: infections, injection-site reactions
• Approved for pediatric psoriasis
Infliximab6
P TNFα IV
• Black box warning: serious infections, malignancy
• AEs: infections, infusion-related reactions,
headache, abdominal pain
Certolizumab7,8
P TNFα SubQ
• Black box warning: serious infections, malignancy
• AEs: infections, injection-site reactions,
headache, rash
Ustekinumab9
P IL-12/23 SubQ • AEs: infections, headache, fatigue
Secukinumab10
P IL-17A SubQ • AEs: infections, diarrhea, IBD
Ixekizumab11
P IL-17A SubQ • AEs: injection-site reactions, infections, nausea, IBD
Brodalumab12
– IL-17RA SubQ
• Black box warning: suicidal ideation and behavior
• AEs: arthralgia, headache, injection-site reactions,
infections, IBD
Guselkumab13
– IL-23 SubQ
• AEs: infections, headache, injection-site reactions,
arthralgia
Tildrakizumab14
– IL-23 SubQ
• AEs: upper respiratory infections, injection-site
reactions, diarrhea