Rheumatology Nurse Practitioner University of Washington School of Nursing Affiliate Assistant Professor Seattle WA Dr Dewing has no conflicts of interest to disclose Please complete the preactivity survey ID: 775437
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Slide1
Slide2Faculty
Kori Dewing, ANP-BC, DNP, ARNPRheumatology Nurse PractitionerUniversity of Washington School of NursingAffiliate Assistant ProfessorSeattle, WA
Dr. Dewing has no conflicts of interest to disclose.
Slide3Please complete the
pre-activity survey.
Slide4This program is supported by educational funding provided by Novartis Pharmaceuticals and Amgen.
Slide5To download a pdf of the slides, please visit:
http://www.cmecorner.com/PDF/psor-psaCES.pdf
Slide6Learning Objectives
Upon completion of this educational activity, participants should be able to:
Summarize the epidemiology and pathophysiology of psoriasis and
PsA.
Describe the diagnosis, disease classification, and assessment associated with psoriasis and
PsA.
Incorporate patient preferences and shared decision making into tailored treatment plans for patients with psoriasis and
PsA.
Evaluate the efficacy and safety of recently available therapies for the management of psoriasis and
PsA.
Slide7Psoriasis
Slide8Psoriasis
Chronic, immune-mediated skin diseaseMost common autoimmune diseaseCorrelation between skin and systemic inflammationHigh comorbidity burdenAffects almost 8 million Americans
Rachakonda
TD, et al.
J Am
Acad
Dermatol
. 2014;70(3):512-516; Eder L, et al.
Arthritis
Rheumatol
. 2016;68(4):915-923;
Helmick CG, et al.
Am J Prev Med
. 2014;47(1):37-45;
Nestle FO, et al.
N
Engl
J Med
. 2009;361(5):496-509.
Slide9Psoriasis
Tollefson
MM, et al. J Am Acad Dermatol. 2010;62(6):979-987; Icen M, et al. J Am Acad Dermatol. 2009;60(3):394-401; Rachakonda TD, et al. J Am Acad Dermatol. 2014;70(3):512-516; Helmick CG, et al. Am J Prev Med. 2014;47(1):37-45.
Psoriasis in Adults (n=2564)
Pediatric incidence: 40.8/100,000 population
Adult incidence: 78.9/100,000 population
Slide10Impact of Psoriasis on
QoL
Emotional and Physical Impact of Psoriasis
Psoriasis Patients (%)
Adapted by Lilian McVey from Armstrong AW, et al. PLoS One. 2012;7(12):e52935. Used with permission.
~80% to 90% of psoriasis patients experience significant impairment of
QoL
and work productivity
Slide11Pathogenesis
Ainsworth C.
Nature
. 2012;492(7429):S52-S54. Used with permission.
Slide12Psoriasis Types
Photos courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP. Used with permission.
Erythrodermic
Nail psoriasis
Scalp
Genital/Inverse
Plaque
Plaque
Slide13Psoriasis Assessment: Types
Plaque psoriasisWell-defined erythematous plaquesElbows, knees, scalp, lower trunkScalp psoriasisPresentation ranges from slight scaling to thick, crusted plaques that cover the scalpNail psoriasisNail pitting and crumbling, separation of nail plate from bed with white discoloration, nail thickeningInverse psoriasisShiny, erythematous plaques with minimal scalingGroin and/or other intertriginous areas (eg, under breasts, in abdominal skin folds)
Young M, et al.
J Am
Assoc
Nurse
Pract
.
2017;29(3):157-178.
Slide14Psoriasis Assessment: Types (cont’d)
Pustular psoriasisEruption of sterile pustulesGeneralized and extensive or localized to existing plaquesPalmoplantar pustular psoriasisYellow-brown sterile pustules on hands and feetMay include scaling and severe pruritisErythrodermic psoriasisGeneralized exfoliative dermatitis, often with hair loss and nail dystrophyAffects large body surface area (BSA); ≥80%Guttate psoriasisSmall, scattered, pink, oval-shaped papules w/silvery scalingAffects trunk and extremities
Young M, et al.
J Am
Assoc
Nurse
Pract
.
2017;29(3):157-178.
Slide15Psoriasis Assessment
Comprehensive examMedication historyAssess for comorbidityPsoriatic arthritis (PsA) and other arthropathiesDiabetesHyperlipidemiaObesityCardiovascular diseaseMalignancyDepression
Differential diagnosesEczemaContact dermatitisSeborrheic dermatitisDrug eruptionTinea infectionsPityriasis roseaLichen planusCandidal intertrigoOnychomycosis
Psoriasis can be difficult to diagnose…When in doubt, REFER!
Young M, et al.
J Am
Assoc
Nurse
Pract
.
2017;29(3):157-178.
Slide16Clinical Pearls for Diagnosis
Distribution
Eczema common on flexors
Psoriasis common on extensors
Auspitz
sign
Well-defined
vs eczema with diffuse border
Consider treatment secondary infection
Inverse psoriasis vs candidiasis vs
intertrigo
Skin biopsy if unsure (punch biopsy)
Slide17Psoriasis Assessment: Severity
Scoring tools:
PASI: Psoriasis Area and Severity Index
BSA: Body Surface Area
DLQI: Dermatology Life Quality Index
Remember:
Severity ≠ amount of area affected
Consider
Area(s) of involvement
Palms, genitals, soles, scalp, nails
Interference with
QoL
Slide18US Perspectives: MAPP Survey
Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) surveyN=1,005 patients, 101 dermatologists, and 100 rheumatologistsKey findingsBoth psoriasis and PsA remain undertreated in patients with moderate-to-severe diseaseGaps in care include screening, assessing, diagnosing and treating psoriasis patients with symptoms of PsA
Lebwohl
MG, et al.
Am
J
Clin
Dermatol
. 2016;17(1):87-97.
Slide19US Perspectives: MAPP Survey
Key findings (cont’d)Widespread dissatisfaction with current treatment optionsLack of efficacyLong-term safety unknownAdministration challengesCostDifference in perceptions of severity, treatment impact in patients vs clinicians
Lebwohl
MG, et al.
Am
J
Clin
Dermatol
. 2016;17(1):87-97.
Slide20Perceptions of Disease Severity: MAPP Survey
Perceptions of disease severity differ between patients and clinicians
Adapted by Lilian McVey from Lebwohl MG, et al. Am J Clin Dermatol. 2016;17(1):87-97. Used with permission.
Respondents (%)
36.1
11.9
21.8
76.2
8.3
4.0
11.4
4.0
5.4
0.0
Most important factors contributing to disease severity in psoriasis, as reported by patients and clinicians
Slide21Psoriatic Arthritis
Slide22PsA in Psoriasis Patients
Up to 30% of individuals with psoriasis will develop PsA (higher than previously thought)Risk factorsSevere psoriasisPsoriatic nail pittingUveitis
Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923.Karreman MC, et al. Arthritis Rheumatol. 2016;68(4):924-931.Photos courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP.Used with permission.
Slide23PsA
Inflammatory arthritisSkin disease typically precedes joint diseaseVariable disease courseFlares and remissionSevere disease is associated with:Progressive joint damageIncreased mortalityIncrease in cardiovascular risk
Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923.Gladman DD. Clin Exp Rheumatol. 2008;26(5 Suppl 51):S62-S65.Arumugam R, McHugh NJ. J Rheumatol Suppl. 2012;89:32-35.Photo courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP. Used with permission.
80%
20%
Slide24Diagnosis of PsA
High prevalence of undiagnosed PsA (~10%-15%)Patients with PsA report a mean interval of 12.4 years between onset of skin symptoms and onset of joint symptomsArthritis symptoms precede skin involvement in 13% to 17% of patients15% of patients have undiagnosed or unrecognized psoriasis
1. Villani A, et al. J Am Acad Dermatol. 2015;73(2):242-248.2. Karreman MC, et al. Arthritis Rheumatol. 2016;68(4):924-931.3. Gottlieb A, et al. J Am Acad Dermatol. 2008;58(5):851-864.
Joint symptoms represent DESTRUCTIVE,
IRREVERSIBLE DISEASE.
Early diagnosis is critical for preventing progression.
Slide25Diagnosis of PsA
Common signs and symptoms Musculoskeletal (32.1%)Joint symptoms (88.2%)Tendon symptoms (50.4%)DactylitisLow back pain (73.9%)Peripheral arthritis Psoriatic nail dystrophy (15.5%) Enthesitis (4.6%-7.0%) Uveitis Plaque psoriasis
Karreman
MC, et al.
Arthritis
Rheumatol
.
2016;68(4):924-931.
Slide26Diagnosis of PsA
2 primary patternsPeripheral joint disease (~95% of PsA patients)Axial involvement only (~5% of PsA patients)Diagnosis is typically made in a patient with psoriasis and inflammatory arthritis in a PsA-type patternPatients with psoriasis may have other types of arthritis including RA, OA, gout, reactive arthritis, and arthritis of IBD
Gottlieb A, et al.
J Am
Acad
Dermatol
. 2008;58(5):851-864.
Slide27Diagnosis Is Made Clinically
HistorySkin diseaseJoints involvedEnthesitis, dactylitis, eye disease, inflammatory back pain (age <40, worse at night with AM stiffness, better with activity)Family historyPhysical examLaboratory testingCBCBUN, creatinine, uric acid, and UAESR and CRP (elevated in 40% of patients)RF (2%-10%), anti-CCP (8%-16%) and ANA (low titer 50%)HLAB27 (50%)
ArthrocentesisTo rule out septic arthritis, gout and CPPDImagingPlain film, ultrasound, MRICo-existence of erosive changes and new bone formation, which may occur in same joint or within same digit
Menter A, et al. J Am Acad Dermatol. 2011;65(1):137-174; Alenius GM, et al. Ann Rheum Dis. 2006;65(3):398-400; Johnson SR, et al. Ann Rheum Dis. 2005;64(5):770-772; Eder L, et al. Ann Rheum Dis. 2012;71(1):50-55.
Diagnosis can be
challenging
:
REFER
Slide28ClASsification Criteria for Psoriatic ARthritis (CASPAR)
Valuable in clinical trials, can be used for diagnosisLimited to peripheral arthritis, axial disease, and enthesitisSpecificity of 98.7% and sensitivity of 91.4%Advantages over Moll and Wright Criteria*High specificity and sensitivityIncludes family history of psoriasisIncludes inflammatory articular diseaseIncludes RF status
*To meet the Moll and Wright 1973 classification criteria for psoriatic arthritis, a patient with psoriasis and inflammatory arthritis who is seronegative for RA must present with 1 of 5 clinical subtypes: polyarticular, symmetric arthritis;
pligoarticular
(less than 5 joints), asymmetric arthritis; distal interphalangeal joint predominant; spondylitis predominant; or arthritis
mutilans
.
Taylor W, et al.
Arthritis Rheum
. 2006;54(8):2665-2673;
Congi
L,
Roussou
E.
Clin
Exp
Rheumatol
. 2010;28(3):304-310; Gottlieb A, et al.
J Am
Acad
Dermatol
. 2008;58(5):851-864.
Slide29PsA is diagnosed when ≥3 points below are assigned in the presence of inflammatory articular disease (joint, spine, or entheseal)CategoryDescriptionPointsCurrent or personal history of psoriasisPsoriatic skin or scalp disease confirmed by dermatologist or rheumatologist; history of psoriasis from patient, family physician, dermatologist, rheumatologist, or other qualified practitioner 2 Family history of psoriasisPatient-reported history of psoriasis in first- or second-degree relative1Psoriatic nail dystrophy on current physical examIncludes onycholysis, pitting, and hyperkeratosis1Negative for RFEnzyme-linked immunosorbent assay or nephelometry preferred (no latex) using local laboratory reference range1Current dactylitis or history of dactylitis documented by a rheumatologistSwelling of entire digit1Radiographic evidence of juxta-articular new bone formationIll-defined ossification near joint margins excluding osteophyte formation on plain X-rays of hand or foot1
CASPAR
Taylor W, et al
.
Arthritis Rheum
. 2006;54(8):2665-2673.
Slide30Treatment of Psoriasis and
PsA
Treatment of Psoriasis
Type of treatmentRecommended forCommentsTopical Therapy(emollients, corticosteroids, vitamin D analogues, calcipotriene, tazarotene, calcineurin inhibitors, anthralin)Mild disease (standard)Limited by poor adherence ratesUltraviolet (UV) Light(UVB radiation, narrow-band UVB, photochemotherapy [PUVA]) Moderate-to-severe diseaseAssociated with accelerated photodamage and increased risk of malignancy; will not treat PsAMethotrexateModerate-to-severe diseaseMost widely used systemic treatment; inexpensive; pregnancy category XCyclosporinePsoriasis flaresUsed as a bridging agent during induction of other maintenance agents or for flaresAcitretinModerate-to-severe diseaseLow toxicity and no immunosuppression; can be used in patients with infection, malignancy, or HIV; need to monitor LFTs and triglycerides; contraindicated if considering pregnancy Biologic Agents(infliximab, etanercept, adalimumab, ustekinumab, secukinumab, tofacitinib, apremilast)Moderate-to-severe diseaseMay be used as first-line systemic agent depending on comorbidities and other considerations; highly efficacious; expensive
Menter A, et al.
J Am
Acad
Dermatol
. 2011;65:137-174.
Slide32Treatment Considerations
Age
Pregnancy/lactation (current or future)
Patient/family medical history
Malignancies
Multiple sclerosis or CHF
Inflammatory bowel disease
Depression or suicide
Chronic infections
Other autoimmune diseases (ie, lupus)
Exposure to fungus or TB
History of HCV, HBV, HIV or high risk behavior
Social – alcohol consumption
Slide33Psoriasis Treatment Algorithm
Psoriasis
+
PsA
Anti-TNF +/- MTX*
Extent of disease
TopicalsTargeted phototherapy
UVB/PUVA SystemicBiologic
Effective
Not Effective†
Mild
(limited)
No
Moderate/Severe
(extensive)
Yes
*Patients with nondeforming
PsA
without any radiographic changes, loss of range of motion, or interference with tasks of daily living should not automatically be treated with tumor necrosis factor (TNF ) inhibitors. It would be reasonable to treat these patients with a nonsteroidal anti-inflammatory agent or to consult a rheumatologist for therapeutic options. †Patients with limited skin disease should not automatically be treated with systemic treatment if they do not improve, because treatment with systemic therapy may carry more risk than the disease itself.
Adapted by Lilian McVey from Menter A, et al.
J Am
Acad
Dermatol
. 2008;58(5):826-850. Used with permission.
Slide34Treatment of Mild-to-Moderate Psoriasis
Topical therapyCorticosteroids, vitamin D derivatives, tazarotene, anthralin, tacrolimus, pimecrolimus, newer tar formulationsMust be prescribed appropriately and used consistently for weeks to months for clinical improvementPotential AEsCutaneous atrophyTelangiectasiasHypothalamic-pituitary axis suppression
Stein Gold LF.
Semin
Cutan
Med Surg
. 2016;35(2
Suppl
2):S36-S44.
Koyama G, et al.
Int
J
Pharm
Compd
. 2015;19(5):357-365.
Slide35Treatment of Mild-to-Moderate Psoriasis
Topical therapy (cont’d)Primary limitation is medication adherenceStrategies to optimize adherence:Consider dosage/schedule, choice of vehicleFixed-combination gels, foamsAddress patient preference about treatmentAddress concerns about treatment-related toxicitiesManage patient expectationsAssess patient response and know when to refer!Up to 80% of psoriasis patients receive no treatment or only topical therapy
Stein Gold LF.
Semin
Cutan
Med Surg
. 2016;35(2
Suppl
2):S36-S44.
Lebwohl
MG, et al.
Am J
Clin
Dermatol
. 2016;17(1):87-97.
Slide36Treatment of Moderate-to-Severe Psoriasis
Refer to dermatologyPrimary care:Emphasize need for long-term follow-up and adherence to prescribed therapyEncourage lifestyle changesSmoking cessationDecreased alcohol consumptionHealthy diet and increased physical activityMonitor for AEsConsider early screening/intervention for CVD and metabolic disease
TreatmentPotential AEsPhototherapySquamous cell carcinoma, photoagingMethotrexateHepatotoxicity, bone marrow suppression, pneumonitisCyclosporinImpaired renal function, hypertension, lymphoma, cutaneous malignanciesAcitretinMucocutaneous side effects, dyslipidemiaBiologicsTuberculosis, and latent infections, hepatitis, CNS complications, cytopenia, multiple sclerosis, CHF
Aldredge
LM, et al.
J
Dermatol
Nurses Assoc
. 2016;8(1):14-26.
Menter
A, et al.
J Am
Acad
Dermatol
. 2008;58(5):826-850.
Slide37Treatment of PsA
Treatment is guided by disease severity and symptoms
Treat to target (T2T) approach
Comorbidities may limit options (diabetes, metabolic syndrome, fatty liver, CAD)
Screening
CV risk factors (BP, lipids, smoking)
Weight loss counseling
Ultrasound of liver with elevated LFTs
Hepatitis screening
Tuberculosis screening –
quantiferon
gold TB is standard (or PPD skin test)
Vaccinations
Slide38Treatment of PsA
NSAIDs
Intra-articular injections
Nonbiologic DMARDsmethotrexate, sulfasalazine, leflunomide, cyclosporin,
Biologic DMARDsanti-TNF, PDE4 inhibitors, anti-IL-12/23, anti-IL-17A
Adapted by Lilian McVey from
Gossec L, et al. Clin Exp Rheumatol. 2015;5 (Suppl 93):S73-S77. Used with permission.
Will not affect plaque psoriasis
Can also treat
plaque psoriasis
Slide39Biologic Agents for Psoriasis/PsA
DrugTargetFDA-Approved for PsoriasisFDA-Approved for PsAEtanerceptTNF-receptorXXInfliximabTNF-alphaXXAdalimumabTNF-alphaXXUstekinumabAnti-IL-12/-23XXBrodalumabIL-17 receptorXIxekizumabIL-17AXSecukinumabIL-17AXXApremilastPhosphodiesterase 4 (PDE4)XXTofacitinibJanus Kinase (JAK-STAT pathway)XGolimumabTNF-alphaXCertolizumabTNF-alphaX
Alwan
W, Nestle FO.
Clin
Exp
Rheumatol
. 2015;33(5
Suppl
93):S2-S6.
Slide40Biologic Agents in PsA
Benefits
Induce a durable long-term response56% improvement in tender joint counts70% improvement in swollen joint counts64% improvement in CRP level36% improvement in overall disease activity score (DAS) Improve Health Assessment Questionnaire (HAQ) scoresLong-term safety confirmed
Drawbacks
Potential AEsInjection site reactionsSerious infectionsPossible association with increase of some malignanciesLack of sustained response to TNF inhibitors in some PsA patientsIntravenous dosing of some medicationsCost
Coates LC, et al.
Ann Rheum Dis
. 2008;67(5):717-719.
Cawson
MR, et al.
BMC
Musculoskelet
Disord
. 2014;15:26.
Bissonnette
R, et al.
J
Cutan
Med Surg
. 2009;13(
Suppl
2):S67-S76.
Slide41Treatment of PsA
Mild arthritisNSAIDsModerately severe arthritis or resistant to NSAIDMethotrexateLeflunomideApremilastSevere peripheral arthritis/adverse prognosisTNF inhibitorEtanerceptInfliximabAdalimumabGolimumabCertolizumab pegolOther biologic DMARDsSecukinumab Ustekinumab
Axial diseaseNSAIDsBiologic DMARDEnthesitisNSAIDsBiologic DMARDDactylitisNSAIDsDMARD
.
Slide42Stay Tuned
American College of Rheumatology and the National Psoriasis Foundation Guideline for the Management of Psoriatic Arthritis
Anticipated completion 2018
Slide43Monitoring
National Psoriasis Foundation (NPF) treatment targets for plaque psoriasisAcceptable: Either BSA ≤3% or BSA improvement ≥75% from baseline at 3 months after treatment initiationTarget: BSA ≤1% at 3 months after treatment initiationMonitor at least every 3 to 6 months during maintenance therapyReassess if skin symptoms or arthritis not under control
Armstrong
AW, et al
.
J Am
Acad
Dermatol
.
2017;76(2):290-298.
Slide44Comorbidities Established in Psoriasis and PsA
Cardiovascular disease (CVD)Metabolic syndrome ObesityDyslipidemiaDiabetes
Mood disordersInflammatory bowel diseaseMalignancyUveitisAlcohol and addictive behaviors
Abuaara
K, et al.
Br J
Dermatol
. 2010;163(3):586-592; Armstrong AW, et al.
J
Hypertens
. 2013;31:433-442; discussion 442-443;
Azfar
RS, et al.
Arch
Dermatol
. 2012;148(9):995-1000;
Gelfand
JM, et al.
JAMA
. 2006;296(14):17351-741;
Gelfand
JM, et al.
J Invest
Dermatol
. 2006;126(10):2194-2201; Kurd SK, et al.
Arch
Derm
. 2010;146:891-895;
Langan
SM, et al.
J Invest
Derm
. 2012;132(3 Pt 1):556-562; Li W, et al.
Am J
Epidemiol
. 2012;175(5):402-413; Ma C, et al.
Br J
Dermatol
. 2013;168(3):486-495; Mehta NN, et al.
Eur
Heart J
. 2010;31(8):1000-1006;
Najarian
DJ, et al.
J Am
Acad
Dermatol
. 2003;48(6):805-821;
Yeung
H, et al.
JAMA
Derm
. 2013;149(10):1173-1179.
Slide45Emerging Comorbidities
Callis
Duffin
K, et al.
J Am
Acad
Dermatol
. 2009;60(4):604-608;
Wakkee
M, et al.
J Am
Acad
Dermatol
. 2011;65(6):1135-1144; Van der
Voort
ET, et al.
J Am
Acad
Dermatol
. 2014;70:517-524; Yeung H, et al.
JAMA
Derm
. 2013;149(10):1173-1179; Yang YW, et al.
Br J
Derm
. 2011;165(5):1037-1043.
Slide46Risk of Cardiometabolic Disease in Patients with More Severe Psoriasis
Clinical significance:Increased risk of MI, stroke, CV death, and diabetes5 years shorter life expectancy10-year risk of major CV event attributable to psoriasis = 6%Risk of CV disease in patients with severe psoriasis similar to risk conferred by diabetesPatients treated for severe psoriasis are 30 times more likely to experience MACE (attributable to psoriasis) than to develop a melanoma
MI = myocardial infarction, MACE = major adverse cardiac events, RR = relative risk.
1.
Abuaara
K, et al.
Br. J.
Dermatol
. 2010;163(3):586-592; 2.
Gelfand
JM, et al.
JAMA
. 2006;296(14):1735-1741.
3.
Gelfand
JM, et al.
J Invest
Derm
. 2009;129(10):2411-2418; 4. Mehta NN, et al.
Eur
Heart J
. 2010;31(8):1000-1006.
5. Mehta NN, et al.
Am J Med
. 2011;124(8):775.e1-6. 6.
Azfar
R, et al.
Arch
Derm
. 2012;148(9):995-1000.
Slide47Cardiovascular Comorbidity in PsA
PsA patientsIR/1000 PYsNon-PsA patients IR/1000 PYsRates of incident CVD – All12.89.6Rates of MACE4.63.5
Rates of CVD and MACE are higher in patients with PsA compared to those without PsA
IR = incidence rate, PY = person-years.
Li L, et al.
J
Clin
Rheumatol
. 2015;21(8):405-410.
Slide48Case Study28-year-old female nurse being followed in rheumatology clinic for fibromyalgia diagnosed 5 years prior presents c/o worsening back and hand pain over the last several months.
HistoryInflammatory back painSomewhat responsive to NSAIDs, h/o gastric ulcerNo h/o psoriatic diseasePhysical examScalp psoriasisDactylitis right second finger
Laboratory
ANA 1:40
Neg RF, anti-CCP
ESR 35, CRP 7
HLAB27 positive
Slide49Case Study
Diagnosed with psoriasis and
PsA
after review of labs and films
Treatment considerations
Negative hepatitis and TB screening
History of gastric ulcer
Considering pregnancy in the next year
Options
Methotrexate
Unable to tolerate: GI distress and hair loss
TNF inhibitor
Etanercept
At 3-month follow-up,
dactylitis
absent, scalp psoriasis clear, AM stiffness 30 minutes, back pain improved though not gone
Slide50Case Study
Two years later, stopped etanercept with pregnancy confirmation
Back pain worse during pregnancy
At 2 months postpartum
Scalp psoriasis worse, patches on elbows and hands
Joint pain and stiffness in hands and knees
Difficulty with ADLs
Resumed etanercept with reduction in symptoms
Slide51Primary Care Pearls
Take a good history from the patient
Complete a thorough skin examination
Assess for joint signs and symptoms
Monitor patients for comorbidities sooner than the general population
Monitor for side effects and treatment complications
Slide52Primary Care Pearls
Assess for adherence to therapy
Ensure all a
ge-appropriate screening
Assess for
QoL
and ADLs
Assess for psychosocial
Patients on biologics or immunosuppressants
Do not give live vaccines
Notify specialist (dermatology or rheumatology) if patient develops
Serious signs or symptoms of infection
Change in medical condition
Slide53Please complete the
post-activity survey and the activity evaluation.
Slide54Q&A