Overview of Psoriasis

Adam O. Goldstein, MD, MPH

Associate Professor

UNC Department of Family Medicine

Email: aog@med.unc.edu

Objectives1. 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….HumiliationHumiliation

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:DefinitionDefinition

• 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 days28-30 days

– Psoriatic skin cell matures in 3-6 days3-6 days

Psoriasis: Types

• Plaque-typeLocalized or Generalized

• PustularLocalized 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% BSATopical Therapies

1. Emollients2. Keratolytic agents3. Topical steroids 4. Calcipotriene5. Tazarotene gel6. Topical calcineurin

inhibitors7. Anthralin8. 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 treatmentsUse for short periods of time and minimum

amountAvoid 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

(From Pardasan AG, et al. Am Fam Physician 2000)

Algorithm for Treatment of Localized Psoriasis

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

MethotrexateIndications:• 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 qhsBODY- 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 brochurehttp://www.aafp.org/afp/20000201/20000201d.html

• Comprehensive WEB listing

http://www.edae.gr/psoriasis.html

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psoriasis. Dermatol Online J 2003; 9(1): 2.• Lebwohl MG, Tan MH, Meador SL, Singer G. Limited application of fluticasone proprionate

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• 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.

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• 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.

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• 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

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