n CASE HISTORY

10 z Prescriber December 2013 prescriber.co.uk

Working as a concierge in a four-starhotel had become increasingly

stressful for this 30-year-old overweightman with psoriasis, not least becausethe requisite black uniform highlightedthe thick scale that flaked from his scalp,the unpredictable hours made regularapplication of creams almost impossibleand smoking breaks were the onlychance to leave the building in an 18-hour shift.

This environment only served to makehis psoriasis worse. The itchy, burgundy-coloured, indurated plaques congregatedaround his shins and forearms with athick, yellowing scale.

However, the area that caused himthe most distress was his hands: theangry, erythematous palms with tensepustules, with scattered erythematousplaques on the dorsum, had begun toattract comments at work and hadstopped him from socialising alltogether due to embarrassment. Hehad been using beclometasone 0.1 per

cent ointment and emollients with sali-cylic acid, but had experienced littlerelief.

He had also been recently diag-nosed with psoriatic arthritis particularlyaffecting his knees and hips and hadbeen reviewed by rheumatology whohad recommended methotrexate.Unfortunately, his liver function wasderanged and therefore this option wasexcluded. He was seen in the dermatol-ogy clinic at which point his PsoriasisArea Severity Index (PASI) was 14.5 andDermatology Life Quality Index (DLQI)16, suggesting a significant skin involve-ment and impact of the psoriasis on hisquality of life.

He was unable to attend photother-apy due to work commitments and waseligible for biological agents. He wastherefore commenced on adalimumab(Humira). Three weeks after initiatingtreatment both his psoriatic plaques andjoint pains had significantly improved. Hecontinues to be monitored and six

An embarrassing rash

His hands were attracting comments at work and he was avoiding social situations due to their appearance

months on his symptoms are well con-trolled with only small, persistent plaqueson his shins.

Psoriasis is an inflammatory condi-tion histologically characterised by epi-dermal hyperproliferation and abnormalkeratinocyte differentiation. There isalso neoangiogenesis within theaffected plaques and cell turnover isincreased from the normal three to fourweeks to three to four days. It has aprevalence of around 2 per cent inadults within the UK and displays a vari-ety of clinical phenotypes, most com-monly plaque psoriasis.1

It is an immune-mediated conditionand TNF-alpha, dendritic cells and T-cellshave been identified in the pathogenesis.There is a complex genetic component tothe aetiology with multiple loci associatedwith the condition, and also environmen-tal factors such as acute stress, beta-haemolytic streptococcal infections, localtrauma, smoking and alcohol playing arole. For the majority of patients with psor -iasis no obvious cause is found. In mostcases sunlight improves psoriasis, but forsome it can make it worse, particularlyafter sunburn.1

The main cause of morbidity withpsor iasis is the stigma that may be asso-ciated with the appearance of the lesions.This can significantly affect patients’ qual-ity of life. Psoriasis can lead to avoidanceof social interaction due to fear of rejec-tion from others due to their appearance,and in some the psychological impact hasbeen suggested to negatively impact theirresponse to treatment.2

Psoriasis has no cure but there aretherapies to help relieve the features.Treatment options include topical agents,phototherapy, immunomodulatory med-ications and biologics.3

Common topical treatments are vita-min D analogues, steroid ointments, tarpreparations, salicylic acid and vitamin Aanalogues. Dithranol is effective in somecases, but it causes staining of all sur-faces it touches and skin irritation and istherefore rarely used now. Topical cal-cineurin inhibitors may also be used incertain areas such as the face, folds orgenitals.

Phototherapy may be administered asUVA with psoralen tablets, or as UVB. This

requires hospital sessions usually threetimes per week with gradually increasingdoses administered.

Immunomodulatory medicationssuch as acitretin, methotrexate, hydroxy -carbamide (unlicensed use) or ciclosporinmay be considered if the disease issevere or extensive. They have an arrayof side-effects and require blood monitor-ing, and patients may need to continuetopical treatment in addition.

Biological infusions such as adal -imumab, etanercept (Enbrel), ustek-inumab (Stelara) and infliximab(Remicade) are used for severe or resist-ant forms of psoriasis and have showngood results.3 They are, however, associ-ated with a myriad of side-effects andpatients are carefully selected to max-imise benefit and minimise the risks oftreatment.

The choice of treatment should beguided not only by the severity of dis-ease but also by the likely impact of thetreatment: it is pointless if the chosentherapy is more unbearable than the dis-ease itself. The main goal in the treat-ment of psoriasis is to amelioratepatient discomfort, choosing treatmentsthat target the areas affected andimprove the individual’s overall qualityof life.4

References1. Mason AR, et al. Topical treatments forchronic plaque psoriasis. Cochrane DatabaseSyst Rev. 2013 Mar 28;3:CD005028. doi:10.1002/14651858.CD005028.pub3.2. Fortune DG, et al. Arch Dermatol 2003;139(6):752–6.3. British Association of Dermatologists patientinformation leaflet: Psoriasis – an overview.May 2012.4. Camp RDR. Psoriasis. In: Champion RH, etal eds. Textbook of dermatology. Oxford:Blackwell Science,1992:1391 –458.

By Dr Sophie Paget, an ST2 in medicineat Bristol Royal Infirmary

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n CASE HISTORY l Psoriasis

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