management of psoriasis in low income countries · management of psoriasis in low income countries...
TRANSCRIPT
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MANAGEMENT OF PSORIASIS IN LOW INCOME COUNTRIES
An overview of Psoriasis management, situation analysis in the Middle East & Africa May 9th, 2014
Mahira Hamdy El Sayed
Professor of Dermatology and Venereology Ain Shams University
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Goeckerman
“The comparative frequency with which psoriasis occurs demands that not only the specialist but the general
practitioner should be familiar with effective therapeutic measures directed against it.”
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Psoriasis isn’t contagious , but awareness is.
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• Overview of Psoriasis
• Psoriasis in the Middle East & Africa (Egypt)
• Challenges and gaps
• Suggestion of a national strategy
Key Points
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06 page
30 page
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• Management of psoriasis with limited resources 3 46 page
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Overview of Psoriasis
Psoriasis Patients
New concept
Burden of psoriasis
Psoriasis causes
Variants of psoriasis
Clinical types Of psoriasis
Psoriasis march
QOL
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Multifactorial 1-3% of the world
population
Psoriasis Patient
Systemic
Finger nail pit
Polygenic
Hyperproliferative
Chronic Disabling Relapsing
Total body skin
involvement
Disabling
Arthritis
Comorbidities
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Psoriasis
Psoriasis
Traditional
Concept
New Concept
Cutaneous disease
No comorbidities
(Ps Arthritis)
Systemic Disease
Comorbidities
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Cutaneous Polymorphism
One or several
Diseases?
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The burden of Psoriasis
• Ocular inflammation
(Iritis/Uveitis/Episcleritis)
• Crohn’s disease • Ulcerative colitis
• Psoriatic arthritis • Spondyloarthropathies
• Nail Psoriasis
Psychosocial burden
• Reactive depression
• Higher suicidal ideation
• Alcoholism
Metabolic syndrome
• Arterial hypertension
• Dyslipidaemia
• Insulin resistant diabetes
• Obesity
• Higher CVD risk
Plaque psoriasis and other forms
• Generalized psoriasis
• Palmoplantar pustulosis
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Immune response
What causes Psoriasis
Environmental
Genetic
Stress
Injury to skin Emotional stress
Infections
Drugs
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Smoking increases the
incedince of psoriais Psoriasis patients smoke
more as a coping
mechanism
Obesity increases the
incidence and the
severity of psoriasis
Psoriasis patients eat
more as a coping
mechanism
Alcohol
Consumption
Obesity Smoking
Additional factors
Alcohol consumption
increases the incidence
and the severity of
psoriasis
Psoriasis patients drink
more as a coping mechanism
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Variants of Psoriasis
Erythrodermic Arthritis Pustular
Psoriasis
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Psoriasis in children
Incidence of psoriasis in children is
increasing, estimated by 20% in
Egypt.
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Clinical types Of psoriasis
Plaque
Guttate
Scalp
Palms and soles
Oral.
Flexural
Nail
Geographic
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Arthritis
1 in 4 patients develop arthritis
Disfiguring & mutilating
Early intervention Inflammatory sero-ve arthritis
associated with psoriasis. Enthesitis,dactylitis &axial disease
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Genetic factors drive disease specific process
Comorbidity results from chronic inflammation
Triggered by environmental factors involving innate &adaptive immunity
.
Leading to disease expression
Genetic
factors
Environment
al factors Expression Comorbidity
How the march of psoriasis unfolds from gene to clinic
Griffiths &Barker (2007)lancet
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Impact of Psoriasis on QOL
Significant impact on QOL
Negative physical impact.
Negative psychological impact
Stigmatized
Insensitive reactions from
people
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QOL
Withdrawal, anxiety and depression
Very low QOL, worse than patients with stroke, COPD, heart disease & diabetes
Survey by the US National Psoriasis Foundation Psoriasis has a moderate to large Impact on QOL in 75% of Psoriasis patients
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Disease severity
Age of onset
Gender
Location
Factors
affecting QOL
QOL
Underestimated by disease severity score .
Weak association between PASI score and impaired QOL
Lesions located on visible body parts
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QOL
Scalp psoriasis is visible , persistent
& inconvenient so it is the most
difficult aspect of the disease, with
marked negative Impact on the QOL.
Psoriasis doesn’t
have to be severe
to impair the
quality of life!
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Cumulative Life Course Impairment “CLCI “
Cumulative impairment acquired by the psoriasis patient over a life time.
Reflects chronic nature of the disease .
Repercussions including stigmatization physical &psychological comorbidities
Factors playing a moderating role making patient less vulnerable.
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Cumulative Life Course Impairment “CLCI “
Supportive environment
Coping strategies
Personality Style
External Factors
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Cumulative Life Course Impairment “CLCI “
Personality traits
Coping Strategies
Stigma Psychological comorbidities
Physical comorbidities
Personality traits
Patients reported psoriasis had an important influence on major life decisions
Choice of work & career
Education
Marriage and having children
Early retirement
Bhatti et.al 2009,2010,2011
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Comorbidities
↑ risk of cardiovascular disease (Hypertension & Heart Failure),metabolic syndrome, diabetes & obesity compared with non-psoriatic skin diseases
Psoriasis is an independent risk factor for coronary artery calcification, MI & stroke .
The risk associated with psoriasis is greatest in young patients with severe disease and increases with age.
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Management of Psoriasis
Climatotherapy Light Therapy
exercise Stop smoking
Healthy Diet
Management of Psoriasis
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1925 1953 1967 1974 1982 1994 1996 1998 2000 2014
2000’s
Monoclonal
Antibodies
Fusion
Proteins
1982
Retinoids
1952-53
Hydrocortisne
Anthralin
.
2014++
FUTURE
1967
MTX
1996
Cyclosporine
1998
NBUVB.
1994
Vit D
Analogues
1974
PUVA
1900-1925
UVB ,Coal
Tar
Breakthroughs in Psoriasis therapy
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Treatment of Psoriasis
Topical treatment Systemic treatment
Steroids. Methotrexate.
Emollients. Cyclosporin.
Anthralin. Acitretin.
Tar. PUVA.
Vit D analogues. NBUVB.
Salicylic acid. Biologics
Retinoids
Tazarotene
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Long term management
Individualization of therapy
Patient’s Perception of
severity
Reconciling extent of disease
Potential side effects of specific
treatments
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Guidelines
German
Spanish South African
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Psoriasis in the Middle East & Africa.
Limited literature
Egyptian Experience
The Egyptian study
Studies in the Middle East on QOL
Different Cases
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Limited literature
Literature regarding
psoriasis & its
management in the
geographically
large, culturally
diverse &
heterogeneous
regions of the
Middle East & Africa
is limited, compared
with the large
volume of data from
the western World.
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Studies in the Middle East & Africa on Incidence of psoriasis
2 small single centre studies in Saudi Arabia 2004,2005
1.5% in South Western SA.
3.4% in Eastern SA.
Shelleh et al SMJ 2004, Alakloby et al SMJ 2005
Larger study across 5 hospitals in Johannesburg SA .
9.6% in Indian patients.
Hartshorne Clin Exp Derm 2003
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Studies in the Middle East on QOL
Kuwait, Iran & Tunisia.
Same findings as Western countries .
Psoriasis affected physical activities and social relationships in ≥ 50% & sexual activity in 33% of 330 Kuwaiti outpatients as measured by the Dermatology QOL scale.
Al-Mazeedi et al.2006 Int.J.Derm
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Egyptian Experience
Psoriasis Clinic..
Department of Dermatology Ain Shams University.
International Psoriasis Network.
Registry.
Protocol for treatment .
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Objectives
Griffiths et al.(2007) BJD,Mallbris et al.(2005)JID, Stuart el al.(2002)Arch.Derm.Res.
Classification and clinical characterisation of psoriasis in Egyptian patients (phenotypes)
Multicentre studies
Protocol for treatment
Difficult cases (HCV) Egypt Fact: Population 85 million 40% under poverty line
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Psoriasis Questionnaire
Patient's name: -Telephone no.: File number:- Date of Consultation: -New Case: Yes No Age (years): -Sex: M F
Residence: -Marital status: Single Married Divorced Widow
Children: no. -Age of youngest Height of the patient in cm: -Weight of the patient in Kg: Waist Circumference in cm: -Phototype (according to Fitzpatrick classification)
Age of onset of psoriasis: -Family history of psoriasis: yes no does not know
Personal history Diabetes mellitus -gout -hypertension -hyperlipidemia -Atopy -IBD -renal insufficiency -gastro-duodenal ulcer -vitiligo -smoking: -skin cancer -viral hepatitis Location of psoriasis at onset: -Upper extremities -Scalp -Lower extremities -Genitalia -Trunk -Palms -Face -Soles -Folds -Nails
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Psoriasis Questionnaire
Evolution: -Continuous -Flare-ups and complete remissions -Flare-ups and incomplete remissions
Extension of the lesions during the worst episode: -Limited (<10% body surface area) -moderately extensive (10-30% body surface area) -Generalized (>30% body surface area)
Clinical aspect of the lesion during the worst episode: -Erythematosquamous plaques -Erythrodermic -Pustular
Provoking Factors: -Stressful events -Mechanical factors (Koebner phenomenon) -Change of season -Infectious disease -Weight increase -Medication intake
Effect of environmental factors: Sun ± sea: -worsens -improves -clears -no effect
Treatments received: Yes No
If Yes: -Local treatments -Systemic treatments (Methotrexate-Cyclosporine-Acitretin- PUVA) -Physical treatments -Alternative medicine
Efficiency of treatment: yes no
Which was the most efficient:
Longest remission period: -<1 month -1-3 months -3-6 months -6-9 months -9-12 months -≥ 1 year
Approximate cost of treatment per month:
Actual Situation of Psoriasis
1-Patient under treatment: Yes No
2-Location -Upper extremities -Lower extremities -Scalp -Face - Genitalia -Palms -Soles -Nails
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Psoriasis Questionnaire
Clinical Type of psoriasis at presentation: - Psoriasis vulgaris -Guttate psoriasis -Pustular psoriasis -Erythrodermic psoriasis -Scalp psoriasis -Nail psoriasis Symptoms: Pruritus Yes No If Yes: -Limited to plaques -on unaffected skin Rheumatological manifestations: Yes No -Oligoarthritis -Polyarthritis Involvement of distal interphalangeal joint -Axial involvement (spondylitis and /or sacroiliitis) -Arthritis mutilans -Dactylitis -Enthesopathy
Clinical aspect of the actual episode: -Nummular plaques -Large plaque -Drops -Mixed -Erythrodermic -Pustular -Nail: Yes No
PASI score:
Alteration of Quality of Life:
-no impact -minimal side effects easily coped with -alteration of everyday life -alteration of appearance and socialization -major personal and social handicap
Treatment the patient is receiving now:
-Local -Systemic –Physical - Others Echo abnormalities: yes no Lab. Abnormalities: yes no Lipid profile -Liver function test -Renal function tests -CBC ,ESR,HCV,HBV
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Study population
Overall 1181 questionnaires were completed at university hospitals.
SPSS was performed on all patients except those presenting single episode of psoriasis (n=97 patients) and those with missing data or inaccurate history data (n=44 patients).
181 subjects were excluded from the typology development.
Some dermatologists reported erythroderma not only for total body area involvement but even for limited lesions. Thus erythroderma data were also excluded from the analysis
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Description of personal and family history among study cases
Maximum Minimum ±SD Mean
81.0 1.0 18.0 41.1 Age
70.4% 732 Male Gender
29.6% 308 Female
27.9% 290 Yes Smoking
72.1% 750 No
2.9% 30 Yes Alcoholism
97.1% 1010 No
21.0% 218 Yes Personal antecedents of atopy
79.0% 822 No
14.6% 152 Yes Familial antecedents of psoriasis
85.4% 888 No
8.1% 84 Yes Familial antecedents of psoriasis arthritis
91.9% 956 No
5.8% 60 Yes Familial antecedents of atopy
94.2% 980 No
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Description of personal and family history among study cases
Males represented the
majority of cases
(70.4%), smokers and
alcoholics represented
about 28% and 3% of
cases respectively.
70%
Males
79%
Personal History of Atopy
28%
Smokers
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History & Disease Course
14
7.8
5.7
0
2
4
6
8
10
12
14
16
Family History
Psoriasis Psoriatic Arthritis Atopy
81%
19%
Continous Discontinous
Clinical Course
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Age of onset
50%
30%
20%
< 30 years 30 - 49 years ≥ 50 years
The mean age among
study cases was 41.1
± 18 ranging
between 1-81 years.
Data
73%
Psoriatic Arthritis
52%
Pruritus
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Description of medical characteristics (comorbidities) among study cases
14.6
9.2
6
3.9
0
2
4
6
8
10
12
14
16
Comorbidities
HTN DM Hepatic disease Lipid Disorder
The table showed that HTN was the commonest co morbidity among cases (14.6%) while lipid disorder was the least frequent among cases (4%)
% N
4.0% 42 Yes Lipid disorder
96.0% 998 No
14.6% 152 Yes High blood pressure 85.4% 888 No
9.2% 96 Yes Diabetes
90.8% 944 No
6.0% 62 Yes Hepatic disease 94.0% 978 No
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Different Cases
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Different Cases
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Different Cases
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Different Cases
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Different Cases
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Different Cases
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Management of psoriasis with limited resources
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Where do we stand
Weekly clinic
Follow up of patients
No Governmental funding
Non governmental funding Charities, Pharmaceutical industry,NGOs
Generic treatment
Phototherapy
Difficulty in obtaining newer drugs
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Challenges & gaps
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Challenges and gaps
Severe social & economic burden of the disease.
Co-morbidities.
Unmet needs facing the dermatologists with limited resources.
Lack of resources .
HCV.
Ministry of Health budgets.
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HCV in Egypt 2008
0
5
10
15
20
25
30
35
40
45
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
HCV RNA HCV antibody
2008 Egypt Demographic Health Survey Results DHS survey 2008, in collaboration with NCCVH
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Suggestion of a national strategy
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National Strategy including all health care sectors in
Egypt.
National registry.
Larger epidemiological studies to know the true size
& impact of the problem.
Awareness program to all health care providers
&primary health physicians.
Specalized referral centres.
Suggestion of a national Strategy
4
1
2
3
5
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Patients advocacy groups.
Fill the research gaps.
Management of Co-morbidities.
Research and clinical trials in special population
groups.
Guidelines &treatment protocols implementing
changes to current management practice.
Suggestion of a national Strategy
9
6
7
8
10
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Collaboration with international experts
Modelling studies for cost-effective treatment .
Media Campaigns.
Long term research data so governments recognize
psoriasis as a disabling disease needing early
diagnosis &treatment .
Involve stake holders for support.
Suggestion of a national Strategy
14
11
12
13
15
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Conclusion
“Early management of psoriasis is more cost
effective to avoid long term morbidity & complications.”
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Conclusion
“Psoriasis is at once both a common and complex
disease.
Psoriasis usually does not take lives, but it does ruin
them.