overview of psoriasis
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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 - PowerPoint PPT PresentationTRANSCRIPT
Overview of Psoriasis
Adam O. Goldstein, MD, MPH
Associate Professor
UNC Department of Family Medicine
Email: [email protected]
Objectives1. 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. Keen-sighted, though we hate to look upon ourselves. The name of the disease, spiritually speaking, is….HumiliationHumiliation
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:DefinitionDefinition
• 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 days28-30 days
– Psoriatic skin cell matures in 3-6 days3-6 days
Psoriasis: Types
• Plaque-typeLocalized or Generalized
• PustularLocalized 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, medica-tions
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
• Neuro-dermatitis/ 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% BSATopical Therapies
1. Emollients2. Keratolytic agents3. Topical steroids 4. Calcipotriene5. Tazarotene gel6. Topical calcineurin
inhibitors7. Anthralin8. 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 treatmentsUse for short periods of time and minimum
amountAvoid 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
(From Pardasan AG, et al. Am Fam Physician 2000)
Algorithm for Treatment of Localized Psoriasis
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 5-10 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
MethotrexateIndications:• 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 Amevive• Efalizumab Raptiva• Etanercept Enbrel• Infliximab 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
Case• Treatment plan:
• Use moisturizer cream & sunlight daily SCALP• Medicated shampoo• BMV foam (Luxiq) BID for 7 days • Calcipotriene solution qhsBODY- 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 brochurehttp://www.aafp.org/afp/20000201/20000201d.html
• Comprehensive WEB listing
http://www.edae.gr/psoriasis.html
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