Public Forum on Psoriasis National Series

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1 Public Forum on Psoriasis 2011 National Series

2 Jerry Tan MD FRCPC Schulich School of Medicine and Dentistry, University of Western Ontario Windsor, Ontario, Canada Presented at Caboto Club, Windsor, April 13, 2011

3 Conflict declaration Advisory board member, clinical investigator, speaker, and/or received honoraria from: Abbott, Allergan, Amgen-Wyeth, Astellas, Biogen, Centocor, Fujisawa, Galderma, Isotechnika, Janssen- Cilag, Johnson and Johnson, Leo, Novartis, OrthoBiotech, Pfizer, Schering, Serono

4 Acknowledgements Canadian Dermatology Association and Association des Dermatologistes du Quebec Canadian Dermatology Foundation for grant support Barat Wolfe, PhD candidate, Dept of Psychology, University of Windsor CANADIAN DERMATOLOGY FOUNDATION FONDATION CANADIENNE DE DERMATOLOGIE copyright Jerry Tan

5 Overview Affects 2% ~ 1 million Canadians Severity distribution 75% mild / ~25% moderate-to-severe Physical, emotional, social effects

6 Patient experiences Many give up after trying 2-3 treatments ~80% frustrated with treatment A large percentage are not treated at all

7 Program: Psoriasis What is it? How did I get it? How do I control it? Is there hope?

8 Hope Week 0 Week 12

9 What is psoriasis?

10 What is it? Disease of the skin Diagnosis is visual: Sharply defined bright red spots Silver-white scale

11 Psoriasis Skin Involvement Often equally on both sides of body Common areas of involvement: Scalp Elbows/knees Palms/soles Nails Genitals

12

13 Widespread plaque psoriasis

14

15 Different psoriasis types plaque guttate pustular erythrodermic inverse

16 Guttate (raindrop) psoriasis

17 Pustular psoriasis

18 Erythrodermic psoriasis

19 Inverse psoriasis

20 How did I get it? Biology of psoriasis Genetics Environment Inflammation

21 An old concept of psoriasis Adapted from: Nickoloff BJ, Nestle FO. J Clin Invest. 2004; 113: Trigger/ Initiation? Psoriasis spots

22 Current concept of psoriasis Adapted from: Nickoloff BJ, Nestle FO. J Clin Invest. 2004; 113: Trigger/ Initiation? Psoriasis spots form Keratinocyte activation and proliferation Inflammatory chemokines and cytokines Dendritic cell Naïve T cell AutoreactiveT cells T cell activation, cytokine release Leucocyte recruitment, angiogenesis T cell

23 What else should I know? Chronic Symptoms Incurable Other medical problems Quality of Life Impact

24 What else should I know? Other medical problems Heart disease Inflammatory bowel disease Diabetes, high cholesterol, obesity Some cancers Arthritis Depression

25 Psoriatic arthritis Inflammation of joints Affects ~40% of skin psoriasis patients

26 Cardiovascular/Metabolic comorbidities Coronary artery disease (5X) Myocardial infarction (1-3X) Hypertension (3X) High lipids/cholesterol (2X) Obesity (2X) Metabolic syndrome (5X) Diabetes (2X)

27 Discussion Question How do you think psoriasis compares with other diseases in terms of impact on physical health? Mental health? Congestive heart failure Psoriasis Type 2 diabetes Chronic lung disease MI Arthritis Hypertension Depression Cancer Dermatitis Healthy adults SF-36 physical or mental component summary score

28 Psoriasis: Impact on Physical Health Compared with other conditions, psoriasis imparts a negative impact on health-related quality of life (HRQL) Congestive heart failure 35 Psoriasis 41 Type 2 diabetes 42 Chronic lung disease 42 MI Arthritis 43 Hypertension 44 Depression 45 Cancer 45 Dermatitis 47 Healthy adults SF-36 physical component summary score Lower rank (score) indicates poorer function Rapp SR, et al. J Am Acad Dermatol 1999;41:401

29 Psoriasis: Impact on Mental Health Compared with other conditions, psoriasis imparts a negative impact on health-related quality of life (HRQL) Depression 35 Chronic lung disease 44 Psoriasis 46 Dermatitis 46 Arthritis 49 Cancer 49 Congestive heart failure 50 Type 2 diabetes 52 Hypertension 52 MI 52 Healthy adults SF-36 mental component summary score Lower rank (score) indicates poorer function 60 Rapp SR, et al. J Am Acad Dermatol 1999;41:401

30 Assessing psoriasis severity 1. Extent of involvement Size of patients palm = 1% body surface area Rule of 9 s (head/neck, each arm, double for each side of torso and each leg) 2. Sites of involvement Face, palms/soles, genitals considered more severe 3. Affect on patients quality of life

31 Determining severity Mild <5% BSA, minimal QoL impact Moderate 5-9% BSA, moderate QoL impact Severe > 10% BSA, severe QoL impact

32 Mild Psoriasis <5% of body area involved Minimal effect on quality of life (QoL) Select treatments with no known serious risk

33 Moderate Psoriasis 5-10% body area affected Some effect on quality of life May require more intensive treatments

34 Severe Psoriasis >10% BSA Adverse impact on quality of life Requires more intensive therapy

35 Severity determines treatment Mild <5% BSA, minimal QoL impact Moderate 5-9% BSA, moderate QoL impact Severe > 10% BSA, severe QoL impact TOPICALS + PHOTOTHERAPY + SYSTEMICS

36 How do you choose?

37 Treatment strategy Milder Psoriasis Severe Psoriasis Topicals Phototherapy Pills Injections - Any treatment applied directly onto your skin - Creams, gels, lotions, sprays, ointments, solutions - Can be time consuming and messy to apply - Can be combined with other treatments - Treatments using natural or artificial light (natural sunlight, UVB or UVA) - Can require extra time and space - Can be done in some clinics or at home - Can be combined with pills - Treatments taken by mouth (orally) - May require you to stop and start from time to time or change treatment to reduce risk of serious side effects - Treatments which are injected (into skin, muscle or veins) -Generally called biologics - Can be done in doctor s office, special clinic, or at home

38 Do you have psoriatic arthritis? PsA NSAID MTX TNF Blockers Clinical trials

39 Topical options Corticosteroids Vitamin D analogues Calcineurin inhibitor Other Low potency Calcipotriol (Dovonex) Tacrolimus Retinoids Mid Calcitriol (Silkis) Coal tar High Corticosteroid + Vit D (Dovobet) Pimecrolimus Anthralin

40 Topical treatment - mechanisms antiinflammatories antiproliferatives Corticosteroids Coal tar Vit D analogues Vit A analogues

41 Treatment Options: Mild-Moderate Psoriasis Topicals Corticosteroids (C) Vitamin D Analogues (D) Combination C+D Topical Retinoids Average Improvement (12-16 weeks) 41-92% 69% 66-74% 50% When you can expect some improvement Cost C$ to treat 1% BSA per year In 1-2 weeks In 2-4 weeks In 1-2 weeks In 1-2 weeks

42 Treatment Options: Mild-Moderate Psoriasis Topicals Corticosteroids (C) Vitamin D Analogues (D) Combination C+D Topical Retinoids Other Benefits Serious Side Effects - Very rare - Rates similar to people taking no treatment (placebo) - Can be used as long-term therapy - No blood testing or other testing usually required - Very rare - Rates similar to people taking no treatment (placebo) - Very rare - Not reported Application Other Concerns - Applied directly to affected areas, once or more than once daily -Prolonged use can lead to skin thinning, stretch marks, prominent blood vessels, easy bruising - Caution if you have abnormal calcium metabolism, renal/liver disease, skin irritation - similar to corticosteroids and vit D analogues - May be irritating

43 Ultraviolet Light Therapy (Phototherapy) Natural sunlight Broadband UVB light therapy Narrowband UVB light therapy Psoralen Ultraviolet-A (PUVA) Light Therapy Phototherapy booth

44 Ultraviolet Light Therapy + Effective for many patients + Can be done in backyard! - Few facilities available - Side effects are nausea (PUVA), itching, redness of skin, sunburns; higher risk of skin cancer (PUVA). May be used alone or with steroids, UVB or some systemics

45 Treatment Options: Mild-Moderate-Severe Phototherapy Number of people who achieve clearance PUVA UVB Narrowband UVB Broadband 89/100 Works quickly - 1 month (24 treatments to clearance) 88/ treatments (15-20 treatments to clearance) 59/100-1 month (20-25 treatments to clearance)

46 Systemic options Conventionals Methotrexate Cyclosporine Acitretin Psoralen + UVA Biologics Alefacept Etanercept Infliximab Adalimumab Ustekinumab

47 Pill options Methotrexate Cyclosporine Acitretin

48 Treatment Options: Moderate-Severe Psoriasis Pills Number of people who achieve excellent control When to expect improvement Other Benefits Serious Side Effects Acitretin Cyclosporine Methotrexate 23/ /100 60/100-4 to 8 weeks - 4 weeks - 4 to 8 weeks -N/A - Rates not reported though rare - Examples: skeletal abnormalities - Long term OR intermittent use 2.3/100 Long term, continuous use (up to decades) - Rates not reported though very rare - Examples: renal toxicity, pancytopenia, pulmonary toxicity, lymphoma, acute myelosuppression

49 Biologic Agents TNFα inhibitors: Adalimumab (Humira TM ) Etanercept (Enbrel TM ) Infliximab (Remicade TM ) T lymphocyte inhibitor Alefacept (Amevive TM ) IL-12/23 inhibitor Ustekinumab (Stelara TM )

50 Treatment Options: Moderate-Severe Psoriasis Biologics Number of people who achieve excellent control When you can expect some improvement Adalimumab Humira Etanercept Enbrel Infliximab Remicade Alefacept Amevive Ustekinumab Stelara 80/100 49/100 80/100 25/100 76/100 In 1 week In 4 to 8 weeks In 1 to 2 weeks In weeks In 2 weeks Other Benefit - Long term, continuous use - Long term, continuous use - Long term, continuous use -Intermittent use in 12 week cycles - Long term, continuous use Serious Side Effects Examples: Cancer, Serious infections, Autoimmune conditions, Liver damage, Infusion reactions, Heart damage Less than 1/100 Less than 1/100 1/100 Less than 1/100 About 1/100

51 Do you have any of the following? Arthritis (joint pain or stiffness?) Heart disease? High blood pressure? High cholesterol? Liver disease? Kidney disease? Pregnancy, breast-feeding or planning this in the near future? Blood disease? Nerve disease (eg. MS, seizures)? Chronic infections? (eg. TB, HIV/AIDS, Hepatitis) Sensitivity to sunlight? Cancer or history of cancer?

52 Medical conditions & contraindicated systemic medications Heart failure? Nerve disease? Kidney disease? Hypertension? Liver disease? Blood disorders? Photosensitive disease? Pregnancy? Breast feeding? Cancer? (excl. BCC) Chronic infections? TNF blockers Cyclosporine (MTX if decreased GFR) MTX Phototx All (except phototx) All (except Soriatane and phototx)

53 What is important to you? Effectiveness? Side effects? Speed of response? Cost? Ease of use?

54 What treatments would you consider? Treatment Type Preference (1 4) Why? Did you have enough information to make a treatment decision? If not, what else do you need?

55 Take Action empower yourself! Information (is power) Ask and engage Get involved in advocacy, support groups, research

56 Psoriasis if you have it... now you know What is it? How did I get it? How do I control it? Is there hope?

57 Help and hope is available 3 dermatologists in Essex-Kent county New research treatments Support groups and patient organizations

58 Canadian Skin Patient Alliance National Psoriasis Foundation.org Alliance Québécoise du Psoriasis

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