overview of psoriasis

1. Overview of Psoriasis Adam O. Goldstein, MD, MPH Associate Professor UNC Department of Family Medicine Email: aog@med.unc.edu

2. Objectives 1. Differentiate psoriasis types 2. Form differential dx 3. Review tx guidelines 4. Review new products 5. Learn 2 additional patient education pearls

3. “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….

4. 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 Psoriasis is a chronic inflammatory skin disease characterized by thick, raised lesions. Approximately 6.4 million people in the U.S. suffer from psoriasis. Historically, between 150,000 and 260,000 new cases are diagnosed each year in the U.S. It has been estimated that the annual cost of psoriasis outpatient care in the U.S. is between US$1.6 billion and US$3.2 billion, with an average annual cost per patient estimated between US$1,400 and US$6,700. At present, no known cure exists for psoriasis and current therapies have unsatisfactory efficacy and potentially unacceptable side effects.Psoriasis is a chronic inflammatory skin disease characterized by thick, raised lesions. Approximately 6.4 million people in the U.S. suffer from psoriasis. Historically, between 150,000 and 260,000 new cases are diagnosed each year in the U.S. It has been estimated that the annual cost of psoriasis outpatient care in the U.S. is between US$1.6 billion and US$3.2 billion, with an average annual cost per patient estimated between US$1,400 and US$6,700. At present, no known cure exists for psoriasis and current therapies have unsatisfactory efficacy and potentially unacceptable side effects.

5. Psoriasis: Quality of Life 50% seek treatment As debilitating as other chronic illnesses > rates depression & alcohol abuse (Sharma, J Dermatol, 2001)

6. 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

7. Case What is your treatment plan? Do you refer him to a dermatologist?

8. Psoriasis: Definition Chronic, remitting and relapsing Scaly and inflammatory Genetically influenced

9. Psoriasis: Morphology: Circumscribed, thickened, plaques with secondary erythema and thick, silvery scales

10. Psoriasis: Pathogenesis Hyperproliferation of the epidermis Normal skin cell matures in 28-30 days Psoriatic skin cell matures in 3-6 days

11. Psoriasis: Types Plaque-typeLocalized or Generalized PustularLocalized or Generalized

12. Psoriasis Arthritis associated (5-7%)

13. Psoriasis: Distribution (From Pardasan AG, et al. Am Fam Physician 2000)

14. Psoriasis: Distribution Extensor

15. Psoriasis: Distribution Extensor

16. Psoriasis: Distribution Nails

17. Psoriasis: Distribution Genitalia

18. Psoriasis: Distribution Hands & feet

19. Psoriasis: Distribution Pustular

20. Psoriasis: Distribution Intertriginous/inverse- armpits, groin, under breasts (less thick “silvery”scale)

21. Psoriasis: Distribution Guttate-small red dots (Gutta = drops) Appears suddenly after a strep, URI, other infection, stress, medications

22. Psoriasis: Guttate Appears after strep, URI, stress, medica-tions

23. Psoriasis: Distribution Erythrodermic Widespread erythema, itching, pain, edema

25. Psoriasis: Distribution Sites of trauma (Koebner’s phenomenon)

26. Psoriasis: Diagnosis Early on, may look like other diseases Bx may be necessary

27. Psoriasis: Differential Diagnosis Drug eruption

28. Psoriasis: Differential Diagnosis secondary syphilis

29. Psoriasis: Differential Diagnosis Seborrhea: Finer scale, central facial, scalp, central chest; Greasier; Sebopsoriasis

30. Psoriasis: Differential Diagnosis dermatophyte infections (Tinea) KOH negative scale not as thick or silvery

31. Psoriasis: Differential Dx intertriginous: diaper dermatitis/candidiasis satellite pustules, beefy red, maceration; KOH positive for yeast in candidiasis; may coexist

32. Psoriasis: Differential Diagnosis Eczema Neuro-dermatitis/ lichen simplex chronicus

33. Psoriasis: Differential Dx lichen planus

34. Psoriasis: Differential Diagnosis lupus erythematosus

35. Psoriasis: Differential Diagnosis pityriasis rosea

36. Psoriasis: Differential Diagnosis Cutaneous T-cell lymphoma

37. 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

38. Psoriasis: Treatment Flares skin injury (including dryness, scratching) sunburn infections (strep, HIV) psychological stress medications

39. Psoriasis: Treatment Medications linked to psoriatic flares: Lithium Beta blockers ACE inhibitors Antimalarials Indomethacin

40. Psoriasis Pearl Avoid systemic corticosteroids

41. Psoriasis: Treatment <5% sunlight + topical tx 5-20% sunlight + topical tx +/- systemic >20% systemic tx +/- light therapy

42. Psoriasis: Treatment Sunlight

43. 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

44. Psoriasis: < 20% BSATopical Therapies 1. Emollients 2. Keratolytic agents 3. Topical steroids 4. Calcipotriene 5. Tazarotene gel 6. Topical calcineurin inhibitors 7. Anthralin 8. Coal tar ( BMJ 2001)

45. 1. Emollient cleansers and lotions/cream Mild cleansers Moisturizers

46. 2. Keratolytic Agents WHEN THE SCALE IS REALLY THICK Scalp: P & S liquid Body: 2-10% salicylic acid qd- bid

47. 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

48. 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)

49. Intralesional injections Isolated recalcitrant lesions TAC 3-10mg/cc in NS to plaques < 3 cm

50. 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

51. 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)

52. 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

53. 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)

54. 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

55. 6. Steroid Sparing Topical calcineurin inhibitors Tacrolimus ointment & Pimecrolimus cream Facial and intertriginous areas (Freeman, J Am Acad Dermatol, 2003)

56. 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 treatments Use for short periods of time and minimum amount Avoid continuous use

57. 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)

58. 8. Coal Tar Useful as an antimitotic agent Folliculitis, Staining, Photosensitizer, Smell Dozens of products

59. Algorithm for Treatment of Localized Psoriasis

60. 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

61. 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

62. 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)

63. Nail Psoriasis topical fluorouracil qhs tazarotene gel 0.1% qhs class I-II topical steroids posterior nailfold intralesional Kenalog 5-10 mg/cc methotrexate

64. Topical Treatments GIVE ENOUGH WITH REFILLS! BE AWARE OF $$$$!

65. Generalized plaque-type psoriasis >20% BSA Ultraviolet light: UVB or PUVA (oxpsoralens photosensitizer + UVA) Methotrexate Retinoids: Acitretin/ Etretinate Sulfasalazine Cylclosporine

66. 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

67. Ultraviolet light: UVB Risks: burns, especially corneal, conjunctivitis (Face can be shielded) Very little toxicity involved Home light therapy Eximer laser

68. 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

69. Ultraviolet light: PUVA Contraindications: photosensitive diseases photosensitive drugs previous or present skin cancers previous x-ray therapy to the skin cataracts pregnancy

70. Ultraviolet light: PUVA Increased risk of squamous cell carcinoma Possible increased risk of melanoma (controversial) Photoaging

71. Methotrexate Indications: 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

72. 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

73. 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

74. 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

75. 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

76. Emerging Therapies Oral Pimecrolimus

77. Alternative Therapies Fish oil Aloe vera Oral Vit. D Stress reduction Lifestyle change Antistrep tx Thermal bath Acupuncture

78. Alternative Therapies

79. Alternative Therapies

80. Case Treatment plan:

82. 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 brochure http://www.aafp.org/afp/20000201/20000201d.html Comprehensive WEB listing http://www.edae.gr/psoriasis.html

84. Bibliography Bruner CR, et al. A systematic review of adverse effects associated with topical treatments for psoriasis. Dermatol Online J 2003; 9(1): 2. Lebwohl MG, Tan MH, Meador SL, Singer G. Limited application of fluticasone proprionate ointment, 0.005% in patients with psoriasis of the face and intertriginous area. J Am Acad Dermatol 2001; 44: 77-82. Koo JY, Lowe NJ, Lew-Kaya DA, et al. Tazarotene plus UVB phototherapy in the treatment of psoriasis. J Am Acad Dermatol 2000; 43: 821-8. Tausk F, Whitmore SE. A pilot study of hypnosis in the treatment of patients with psoriasis. Psychotherapy & Psychosomatics 1999; 68: 221-5. Tristani-Firouzi P, Krueger GG. Efficacy and safety of treatment modalities for psoriasis. Cutis 1998; 61S: 11-21. Jerner B, Skogh M, Vahlquist A. A controlled trial of acupuncture in psoriasis: no convincing effect. Acta Dermato-Venereol 1997; 77: 154-6. 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.

85. 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. Federman DG, Froelich CW, Kirsner RS. Topical psoriasis therapy. Amer Fam Physician 1999; 59: 957-62, 964. 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. Pardasan AG, Feldman SR, Clark AR. Treatment of Psoriasis: An Algorithm-Based Approach for Primary Care Physicians. Am Fam Physician 2000; 61:725-733. Sharma N, Koranne RV, Singh RK. Psychiatric morbidity in psoriasis and vitiligo: a comparative study. J Dermatol 2001; 28: 419-23. 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 treatment. Drugs 2001; 61(11): 1593-8. Schon MP, Boehncke WH. Psoriasis. N Engl J Med 2005; 352: 1899-912 .