PsoriasisJ. Scott Kennedy, DO, FAAD

Beatrice Keller Clinic, Sun City West, AZ

Disclosures

• I have no disclosures

Objectives

• Be able to identify Psoriasis and it’s variants

• Formulate a treatment plan based on location of disease and severity

• Identify comorbidities of Psoriasis

Epidemiology

• 2% of World Population

• 2-5% in the US

• Two Peaks of onset 20-30 and 50-60

• Can appear at any age

Genetics• 35% -90% have family history

• HLA -Cw6 RR of 13, Psors1 Gene

• Psoriasis susceptibility genes

• Skin specific

• Innate immunity

• Interface between innate and adaptive immunity

• Adaptive Immunity

Dermatology Fig 8.1 Courtesy, Dr Paola DiMeglio.

Triggering Factors

• External

• Koebner Phenomenon: Psoriasis developing in areas of cutaneous injury

• 25% of patients

• also sunburn, viral exanthem, drug eruption

Koebner Phenomenon

• Isomorphic response

Andrews’ Fig.10-11

Koebner Phenomenon

Psoriasis in an HIV patient with after Herpes ZosterFig. 10.45, Courtesy Vikash Oza, MD.

Triggering Factors

• Systemic

• Infections

• factor in up to 45% of cases

• streptococcal pharyngitis most common

• guttate psoriasis

Andrews’ Diseases of the SkinFig 10.42

Dermatology.van de Kerkhof, Peter C.M.; Nestle, Frank O…

Systemic Factorscont.

• HIV can flare psoriasis

• Endocrine

• Hypocalcemia: pustular psoriasis

• Pregnancy: 50% report improvement

• impetigo herpetiformis (form of pustular psoriasis)

Systemic Factors cont.• Psychogenic stress

• Initial presentation or flare of disease

• plays significant role in roughly half of patients

• Drug

• Lithium, IFN’s, B-Blockers, anti-malarial, calcium channel blockers, captopril, glyburide, G-CSF, interleukins, lipid-lowering drugs

• anti-malarial: erythrodermic flares

• doxycycline or mefloquine if this is appropriate coverage for region, otherwise better to cover with appropriate prophylaxis

• Oral steroids: rebound or pustular flares with removal

Psoriasis Variants

• Chronic Plaque

• Symmetric

• Scalp, Elbows, Knees, Lumbosacral, Hands and Feet

• Genitals involved in 45%

Dermatology, Fig 8.3Courtesy, Lorenzo Cerroni, MD

Andrews’ Fig. 5-15Nummular Eczema

Andrews’ Fig.32-2CTCL

Andrews’ Fig 29-24Bowen’s Disease

Psoriasis Variants• Guttate

• More common children/adolescents

• Preceded by URI

• elevated ASO titer, DNase-B or streptozyme titer is found >50%

• rapidly responsive to UVB therapy

Andrews’ Diseases of the SkinClinical Atlas

??

Andrews’ Fig. 11-4

Andrews’ Fig. 11-3

Andrews’ Fig. 11-2, PRP

Psoriasis Variants

• Erythrodermic Psoriasis

• Severe itching, fevers, chills

• Extensive TEWL

• Secondary infections

• High output cardiac failure, ARDS, capillary leak syndrome, mortality as high as 7%

Andrews’ Fig 10-10

Erythroderma• DDX is long: 60%+ pre-existing disease (atopic

dermatitis, psoriasis, chronic actinic dermatitis, seborrheic dermatitis, PRP, ICD/ACD.

• medications, mycosis fungoides, pemphigus foliaceous, internal malignancies (paraneoplastic erythroderma)

• Requires biopsy and many cases remain idiopathic.

• Pre-existing psoriasis, classic nail changes and central facial sparing.

Psoriasis Variants

• Pustular Psoriasis

• Pregnancy (impetigo herpetiformis)

• Rapid taper of steroids or systemic medication

• Hypocalcemia

• Infection

Dermatology Fig. 8.8Courtesy, Julie V. Schaffer, MDAndrews’ Fig. 10-9

Von Zumbusch, Generalized Pustular Psoriasis

Dermatology Fig. 21-7Dermatology Fig.

Pustular Psoriasis

• von Zumbusch

• culprit medicines

• coal tar, terbinafine, minocycline, hydroxychloroquine, salicylates, acetazolamide

• Acitretin drug of choice for treatment

Andrews’ Fig. 10-7

Pustular psoriasis

• Annular pattern of pustular psoriasis

• erythema and scaling with pustulation at the advancing edge.

Dermatology Fig. 8.9A. Marieke M B Geyer, MD

B. Julie V Schaffer, MD

Special Locations• Scalp

• One of most common sites

• Well demarcated unless total scalp involved

• Pityriasis amiantacea: asbestos like appearance adhering to shafts of hair

• Tinea, Atopic Derm, Seborrheic Dermatitis

Dermatology Fig. 8.12

• Seborrheic Dermatitis

• “Sebo-psoriasis”

Andrews’ Fig 10.3

Inverse (Flexural) Psoriasis

• Generally lack the typical scale of psoriasis

• Axillae, inframammary, inguinal crease, gluteal crease, retroauricular

• Often fissured

• Localized infection can be trigger: dermatophyte, candida, bateria

Dermatology, Fig. 8.13Courtesy, Luis Requena, MD.

Nail Psoriasis

Dermatology, Fig. 8.14Courtesy, Marcel C Pasch, MD

-Pitting-Oil Spots

-Distal onycholysis-Subungual and

proximalhyperkeratosis

Nail Psoriasis

Andrews’ Fig 10.35Andrews’ Fig 10.31

Psoriatic Arthritis

• 5-30% of psoriasis patients

• asymmetric oligoarthritis

• Those with nail findings more likely to develop

• May develop 10 years after skin findings.

Fig. 8.15Sites of psoriatic arthritis and reactive arthritis (formerly Reiter disease).Adapted from Cush JJ: Evaluation of musculoskeletal complaints, in Rheumatology: Diagnosis and Therapeutics, 2nd ed. Lippincott, 2003.

Andrews’ Fig. 10.5

Andrews’ Fig 10.6Arthritis mutilans

Dermatology Fig. 8.16Asymmetric arthritis

Sausage digits

• Comparative performance of psoriatic arthritis screening tools in patients with psoriasis in European/North American dermatology clinics.

Mease, JM; Gladman, DD; Alvarez, D et al. JAAD 2014.05.010.

• Screening Tools for non-rheumatologists

• PEST, PASQ, ToPAS

• 25% false positive rate, but identified many with new diagnosis of PsA.

• early dx important prior to permanent joint damage.

Treatment• Disease severity

• Mild <5% BSA

• Moderate 5-10% BSA

• Severe >10% BSA

• Location and QOL

• Drug Trials use PASI and PGA

Class 1Superpotent

Class 2Potent

Class 3Upper Mid

Class 4Mid

Clobetasol 0.05%

crm/spray/oint/foam/shampoo

Fluocinonide 0.05%

crm/gel/oint

Fluticasone propinate0.005%

oint

mometasone furoate0.1%

Betamethasone Diproprionate

0.05%oint

Desoximetasone0.25%

crm/oint

fluocinonide-e 0.05%cream

hydrocortisone validate

0.2%oint

Halobetasol propinate 0.05%

cream/oint/lot

Desoximetasone0.05%

gel

betamethasone valerate 0.12%foam

triamcinolone acetone

0.1% cream/spray

https://www.psoriasis.org/about-psoriasis/treatments/topicals/steroids/potency-chart

Class 5Lower-Mid

Class 6Mild

Class 7Least Potent

hydrocortisone valerate 0.2%

cream

desonide 0.05%gel

hydrocortisone0.5/1/2/2.5%

crm/lot/oint/spray

desonide 0.05%lotion

fluocinolone acetonide

0.01% oil/crm/sol

hydrocortisone0.1%

crm/lot/oint/sol

alclometasone 0.05%

crm/oint

Topical Steroids• What strength do I use?

• scalp/face/axillae/groin/hands/feet

• occluded or not

• What vehicle do I use?

• body location, absorption, patient preference

• How much do I order?

• FTU = 0.5gm/2% BSA

• 5% BSA x 2 weeks=35gm

Fig 49-2DermatologySecrets Plus

Area to be treated No. of fingertip Units Approximate BSA(%)

Scalp 3 6

Face and Neck 2.5 5

One Hand/fingers 1 2

Trunk anterior 8 16

One Leg 8 16

https://www.aad.org/practicecenter/quality/clinical-guidelines/psoriasis/topical-therapy

Topical Steroidside effects

• Atrophy

• topical and intralesional

• Telangiectasia

• Striae

• Tachyphylaxis

• Irritant contact dermatitis

• propylene glycol, alcohol, acetone

• Allergic contact dermatitis

• propylene glycol, Fig. 49-3 and 49-4

Dermatology Secrets Plus49-3 Courtesy Fitzsimons AMC

Topicals cont.• Vitamin D analogues

• calcipotriene

• combination with TCS

• Topical retinoids

• tazorotene

• Salicylic acid

• 6% shampoo

• Tar

• Calcineurin inhibitors

• facial/flexural

Light Therapy• NB-UVB

• BB-UVB

• PUVA

• Eximer laser

• scalp/hands/feet or focal plaque psoriasis

• sub-blistering dosing

Oral agents

• Methotrexate

• Acitretin

• mono therapy or combined with light therapy (RE-PUVA, or RE-NBUVB)

• Cyclosporine

• Apremilast

Biologics• TNF alpha inhibitors

• etanercept, adalimumab, infliximab

• p40 subunit of IL 12/23

• Ustekinumab

• IL-17

• secukinumab, ixekizumab, brodalumab

• Il-23

• guselkumab

Diet and Nutrition• Weight loss

• Obesity and increasing BMI linked to risk of psoriasis and more severe psoriasis

• JAAD

• Heart Healthy Diet

• Anti-Inflammatory Diet

• ? Gluten Free Diet

• Vitamins

• Omega-3 fatty acids

• n-3 and n-6 PUFA affect IL-1, IL-6, TNF

• Vit D

• glucosamine and chondroitin

• MSM (Methylsulfonylmethane)

Psoriasis Comorbidities• Cardiovascular disease

• Independent risk factor for MI

• risk increases with the severity of psoriasis

• risk similar to that of diabetes for MACE

• 3-fold increased risk for MI, 3.5-4.4y reduction in life expectancy

• increased risk of metabolic syndrome OR 2.26

• TNF alpha and IL-6 can target adipocytes and induce dyslipidemia

• 18FDG PET/CT shows aortic inflammation in psoriasis patients

Psoriasis ComorbiditiesCardiovascular

• Obesity

• Risk for psoriasis increases with increasing BMI

• psoriasis severity increases with increasing BMI as well

Psoriasis ComorbiditiesCardiovascular

• Hypertension

• Increased OR 1.58 psoriasis vs no psoriasis

• Poorly controlled HTN, worsens with disease

• Dyslipidemia

• More prevalent in Psoriasis patients

Psoriasis ComorbiditiesCardiovascular

• Diabetes

• More likely to require pharmacologic management

• increased likelihood of micro and macrovascular complications.

Psoriasis ComorbiditiesGastrointestinal

• May be associated with increased risk for inflammatory bowel disease, Crohn’s in particular.

• Associated with NAFLD, in one study, 59% patients with psoriasis

• Increased risk of methotrexate induced hepatotoxicity in comparison to other diseases.

• liver biopsy 1.5gm recommended

Chronic kidney disease

• Moderate to severe psoriasis may be independent risk factor for chronic kidney disease and increases with severity of psoriasis

• “psoriatic nephropathy” 4 fold increased risk of disease from nephritic disease or non-hypertensive kidney disease

Malignancy

• Psoriasis may be associated with increased risk of cancer.

• Lymphoma, and in particular, CTCL associated with highest risk.

• Lymphoma 1.2 to 2 fold increased risk

• AR remains quite low

Mood Disorders

• Mood disorders are common in patients with psoriasis

• Associated with increased risk of depression, anxiety, and suicidal ideation

• Depression up to 62% prevalence in psoriasis

• Higher in those receiving meds for severe psoriasis