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Psoriasis

Slide3

What are the most common symptoms?

Erythematous lesions with loose, silvery-white scalesRemoving scale can induce punctate bleeding: Auspitz signPapules can coalesce in pruritic patches / plaques Nails and joints may be affected

A. Extensive, well-demarcated erythematous plaques of abdomen

Slide4

B. Erythematous plaque of elbowC. Erythematous, scaling plaques of abdomen

Slide5

What is the differential diagnosis?

PlaqueEczema; dermatophyte infection; superficial squamous / basal cell CA; subacute cutaneous lupus

Guttate

Secondary syphilis;

pityriasis

rosea

Erythrodermic

Pityriasis

rubra

pilaris

; drug eruptions

Pustular

Candidiasis

; acute generalized

exanthematic

pustulosis

Inverse

Intertrigo

;

cutaneous

T-cell lymphoma

Slide6

Which areas of the skin are most commonly affected?

In chronic plaque psoriasisExtensor surfaces (elbows and knees)Lumbosacral areaIntergluteal cleftScalp

In

i

nverse

psoriasis

Intertriginous

areas

Slide7

How often are the nails involved?

Up to 55% with psoriasis have nail involvementOccurs in any subtype<5% of nail disease occurs in those lacking other cutaneous findings of psoriasis≤90% with psoriatic arthritis have nail involvement Fingernail involvement in 50% of cases Toenail involvement in 30% of cases

Requires

aggressive treatment:

intralesional

steroid injections

Slide8

How often are joints affected by psoriasis? Which ones?

Psoriatic arthritis occurs in up to 30%

Inflammatory,

seronegative

spondyloarthropathy

Stiffness, pain, swelling of joints, ligaments, tendons

Hands more likely involved than feet

Polyarticular

peripheral joint involvement common

About 5% have only axial involvement

Up to 50% have both spine & peripheral joint involvement

Slide9

Enthesitis

: inflammation where tendon, ligament, or joint capsule fibers insert into bone

Dactylitis

:

enthesitis

of tendons and ligaments +

synovitis

of an entire digit

Slide10

When should joints be tapped to diagnose PsA?

Use clinical observationsSymmetrical joint stiffness (hands, feet, large joints) for ≥30 minutes in morning or after long periods of inactivityUse radiologic observationsJoint erosions, joint-space narrowingBony proliferation, spur formationOsteolysis with “pencil-in-cup” deformities

Arthrocentesis

is

not

recommended

Slide11

Aside from skin and joints, what else should be examined when considering a diagnosis of psoriasis?

Psoriasis: systemic inflammatory disorderInflammation cascade promotes endothelial dysfunction and oxidative stress

I

ncreases

risk for:

Atherosclerosis-based CV disease

Hypertension

Obesity

and the metabolic syndrome

Diabetes

Smoking

Slide12

What triggers or unmasks psoriasis?

Bacterial and viral infections URI associated with guttate psoriasisEspecially Streptococcus pyogenes

Stress Often first outbreak traced to stressful eventLesions can be induced locally in areas of physical trauma, i.e., vaccination, tattoos, sunburn, excoriation

Certain medications Lithium, interferon, antimalarials, β-blockers, ACE inhibitors, NSAIDs, withdrawal of oral corticosteroids

Cold weather with low humidity

Slide13

Are there any specific diagnostic tests for psoriasis?

NoDiagnosis is clinical

For initial work-up:

Total body skin evaluation, including nails and scalp

? Joint symptoms (stiffness, swelling, pain, decreased

ROM

)

? Personal or family history of autoimmune diseases

Slide14

Which blood tests are abnormal in psoriasis, and how specific are they to the diagnosis?

Rarely needed for diagnosis

Rapid plasma

reagin

:

to distinguish from syphilis

Antinuclear antibody, anti-Ro, and anti-La: confirms

Dx

if

subacute

cutaneous

lupus suspected

CRP levels: occasionally elevated in

PsA

Uric acid levels: may be elevated, especially

in

erythrodermic

psoriasis

Slide15

What is the role of skin biopsy in making the diagnosis?

Histologic

confirmation

Classic findings of psoriasis

Epidermal hyperplasia

Parakeratosis

Thinning of granular layer

Neutrophil

+ lymphocyte infiltration in epidermis and dermis

Increased prominence of dermal papillary vasculature

Slide16

CLINICAL BOTTOM LINE: Diagnosis and Evaluation…

Diagnosis most often made clinically

Psoriasis papules, patches, or plaques: sharply demarcated,

erythematous

, scaly,

pruritic

Concomitant joint and nail involvement

Histologic

and lab abnormalities not required

Triggers: infection, trauma, stress, and certain drugs

Psoriasis increases risk for CV disease and events

If diagnosis uncertain, consult dermatologist

Slide17

Topical therapiesCorticosteroidsVitamin D analoguesTopical retinoidsCalcineurin inhibitorsSalicylic acid AnthralinCoal tarPhototherapy

Systemic therapies MethotrexateCyclosporine AOral vitamin A derivatives

Biological therapies AdalimumabAlefaceptEtanerceptGolimumabInfliximabUstekinumab

What drug therapies are used in treatment?

Slide18

How should a clinician choose between topical and systemic drug therapy?

Determine disease severityMeasure affected body surface area≤3%: mild3%-10%: moderate≥10% or serious adverse affect on QOL: severeDetermine the location of lesionsConsider affect on QOL

Mild disease: topical therapies

Moderate-to-severe disease: systemic and topical therapies; biologics if

systemics

fail / can’t be used

Slide19

What is the role of phototherapy?

For widespread disease or when disease substantially affects QOL

Efficacious and cost-effective

Not immunosuppressive like systemic drugs

Affects

Langerhans

cells directly

,

cytokines indirectly

Don’t use with photosensitive disorders

Slide20

Is there a role for combination drug therapy and phototherapy?

Improves efficacy and decreases toxicity of a potentially hazardous combination agent

Phototherapy can be combined with:

Anthralin

or coal tar

MTX

Retinoids

Biological therapies

Slide21

What alternative therapies are shown to improve quality of life and outcomes?

Salicylic acid Combine with other topical therapies

Dead Sea

Unique UVA-UVB ratio + high water salinity improves psoriasis

May increase risk for

nonmelanoma

skin cancer

Slide22

How should psoriasis be treated in pregnant patients?

Consider therapy benefits vs. potential fetal risk

First-line treatment:

t

opical

agent or

photo

therapy

Alternative to phototherapy:

TNF-α blocker

(

Category B)

Severe

psoriasis:

cyclosporine A (

Category C)

Contraindicated

:

retinoids

, MTX, o

ral vitamin A derivatives

Slide23

When is it necessary to hospitalize patients with psoriasis?

Erythrodermic psoriasisInflammation of ≥75% BSA +/- presence of exfoliationTriggers: steroid withdrawal, sun exposure, drug reactions, emotional stress First-line: adjuvant topical treatment + CSA or infliximabHospitalize for hypothermia or hyperthermia, protein loss, dehydration, infection, renal failure, hi-output cardiac failure

Acute episodes of generalized

pustular

psoriasis

Pinhead-sized pustules on

erythematous

background

Pustules may dry out, exfoliate, and redevelop

Triggers: corticosteroid withdrawal for plaque psoriasis

Retinoids

uniquely effective treatment

Hospitalize for systemic symptoms

Slide24

When should patients be referred to a dermatologist?

Recalcitrant diseaseModerate-to-severe diseaseDisease that significantly impairs quality of life

Dermatologist can initiate

Phototherapy

Systemic therapy

Combination therapy

Slide25

When should patients be referred to a rheumatologist?

When PsA is diagnosedMajority have psoriasis years before joint symptoms develop

Rheumatologist guides treatment to

Alleviate pain and swelling

Inhibit structural damage

Improve quality of life

Slide26

When should patients be referred to a psychiatrist?

Screen for psychosocial aspectsPsychosocial morbidity + decreased occupational functionClinical severity may not reflect extent of emotional impact

Order a consultation if psychiatric disorder suspected

Slide27

What is the role of the PCP in treating psoriasis?

Identify conditions associated with psoriasis

Help prevent

comorbid

conditions

Provide counsel regarding lifestyle modifications

Consult specialists (dermatology, rheumatology)

Slide28

How often should patients be followed by a dermatologist?

Topical steroids: every 6-12 monthsMore frequently if using more potent topical steroids

Systemics: Follow more frequentlyMTX/CsA: Examine for response and skin cancer

Regularly to assess: Disease severityCompliance and medication toxicityQuality-of-life issues

Phototherapy: annually

C

heck

for

photoaging

, pigmentation, skin cancer

Slide29

Should patients be routinely followed by other specialists?

Mild PsA: PCPTreat with NSAIDs or intra-articular steroid injections

Moderate-to-severe

PsA

:

rheumatologist / dermatologist

Risk for structural damage

More aggressive therapy required

Slide30

CLINICAL BOTTOM LINE: Treatment and management…

Mild-to-moderate psoriasis

Topical therapy: steroid, vitamin D analogue, retinoid,

calcineurin

inhibitor

Moderate-to-severe psoriasis

Traditional systemic medications, biological agents, or phototherapy + topical therapy

For

PsA

, start treatment early to avoid structural damage

Mild disease:

NSAIDs

More severe systemic disease: biological agent, MTX, or a combination of the two

Slide31

How should patients be educated about psoriasis pathophysiology and genetics?

Normal skin cells: mature + fall off body in 28 daysPsoriasis skin cells: mature in just 3 to 4 days + pile up into lesions instead of shedding

Requires both inheritance + environmental trigger≥10% of general population inherits ≥1 predisposing geneBut only 3% of population develops psoriasis

If both parents have psoriasis, offspring incidence up to 50%

If 1 parent affected, offspring incidence 16%

If only a sibling affected, incidence 8%

Slide32

What should patients be told about preventing exacerbations?

Avoid common triggers

Adhere to prescribed treatments

Use occlusive agents, emollients, and humectants

Provide and retain moisture in the skin

Enhance efficacy of topical corticosteroids and exert a steroid-sparing effect

Prevent disease exacerbation

Inhibit the

Koebner

response

Slide33

What should patients be told about the risks of topical or systemic steroids?

Don’t use systemic steroids for psoriasis

Topical steroid side effectsAtrophy, telangiectasia, striae, acneMay exacerbate pre- / co-existing dermatosesCan cause contact dermatitisMay lead to rebound

Limit

superpotent

topicals

(

≤2x/d for ≤4wks, ≤50

g

/wk)

Replace or combine with vitamin D analogues,

retinoids

, and

calcineurin

inhibitors

I

ncreases

efficacy with less steroid exposure

Slide34

What behavior modifications can ameliorate the effects of psoriasis?

Stopping tobacco use

Reducing alcohol use

Maintaining ideal body weight

Slide35

CLINICAL BOTTOM LINE: Patient Education…

Essential to optimizing treatment

Genetic + environmental factors contribute to psoriasis

Smoking, alcohol, obesity = more severe symptoms

Counsel patients on lifestyle modification

Individualized treatment regimen promotes adherence, improves treatment outcomes, and avoids toxicity