Transcript Overview of Psoriasis Adam O. Goldstein, MD, MPH Associate Professor UNC Department of Family Medicine Email: [email protected] Objectives 1.

Overview of Psoriasis
Adam O. Goldstein, MD, MPH
Associate Professor
UNC Department of Family Medicine
Email: [email protected]
Objectives
1. 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. Keensighted, though we hate to
look upon ourselves. The
name of the disease,
spiritually speaking,
is….
Humiliation
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:
Definition
• 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 days
– Psoriatic skin cell matures in 3-6 days
Psoriasis: Types
• Plaque-type
Localized or
Generalized
• Pustular
Localized 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,
medications
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
• Neurodermatitis/
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% BSA
Topical 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)
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 treatments
 Use for short periods of time and minimum amount
 Avoid 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
Algorithm for Treatment of Localized Psoriasis
(From
Pardasan AG,
et al. Am Fam
Physician
2000)
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 510 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
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
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
• Efalizumab
• Etanercept
• Infliximab
•
•
•
•
Amevive
Raptiva
Enbrel
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
• Treatment plan:
Case
• Use moisturizer cream & sunlight daily
SCALP
• Medicated shampoo
• BMV foam (Luxiq) BID for 7 days
• Calcipotriene solution qhs
BODY- 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 brochure
http://www.aafp.org/afp/20000201/20000201d.html
• Comprehensive WEB listing
http://www.edae.gr/psoriasis.html
Bibliography
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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.
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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 .