Psoriasis: Basic Facts

Transcription

1 Psoriasis Module

2 Module Instructions The following module contains hyperlinked information which serves to offer more information on topics you may or may not be familiar with. We encourage that you read all the hyperlinked information.

3 Psoriasis: Basic Facts Psoriasis is a inflammatory disease of the skin It affects approximately 2% of the U.S. population Age of onset occurs in two peaks: ages and ages ,, but can be seen at any age There is a strong genetic component 1 out of 3 patients with psoriasis has a family member with psoriasis

4 Psoriasis: Basic Facts There are many forms of psoriasis, however this module will focus on PLAQUE PSORIASIS as it is by far the most common form accounting for >90% of cases It is characterized by erythematous, well demarcated plaques with an adherent, silvery scale ( micaceous( scale ) Micaceous refers to the fact that psoriasis scale peels in layers

5 Psoriasis: Pathogenesis The pathogenesis of psoriasis involves the activation of T cells by components of the innate immune system, and release of inflammatory cytokines In contrast to atopic dermatitis which favors a Th2 response, psoriasis favors a Th1/Th17 immune response

6 Typical Psoriatic Plaque On exam, there are three well-demarcated plaques with overlying silvery scale and underlying erythema

7 Case 1

8 Case 1: History HPI: A 24 year-old male walks into your office and shows you a red spot around his belly button that has been present for a month and itches at times. Having been doing reading on the internet he asks: Do I have psoriasis?

9 Case 1: Question 1 What elements in the history are important to ask in this case to arrive at a diagnosis of psoriasis? a. Recent illnesses / Past medical history b. Medications c. Family history d. Social history e. All of the above

10 Case 1: Question 1 Answer: e What elements in the history are important to ask in this case to arrive at a diagnosis? a. Recent illnesses / Past medical history b. Medications c. Family history d. Social history e. All of the above

11 Why ask Recent Illnesses and PMH? Psoriasis can be triggered by infections, especially streptococcal pharyngitis Psoriasis is more severe in patients with HIV Psoriasis is more common in patients with Crohn s disease Psoriasis co-morbidities include depression and the metabolic syndrome It is important to explore how the patient is coping with the illness given the increased risk of depression There is a positive correlation between stress and disease severity Up to 20% of psoriasis patients have psoriatic arthritis, which can lead to joint deformities

12 Why ask about Medications? Psoriasis can be triggered or exacerbated by a number of medications including: Systemic corticosteroid withdrawal Interferons Lithium Beta blockers Antimalarials Gemfibrozil

13 Why ask Family History? There is a strong genetic predisposition to developing psoriasis If a patient has family members with psoriasis, it makes the diagnosis much more likely in that patient 1/3 of psoriasis patients have a positive family history HOWEVER, this means up to 2/3 of patients with psoriasis do not have a family history of psoriasis, so a negative FH does not rule it out!

14 Why ask Social History? Psoriasis can be worsened by alcohol use and smoking Psoriasis can appear in areas of trauma to skin, a phenomenon known as koebnerization Inquire about occupation and recreational hobbies

15 Back to Case 1

16 Case 1: History PMH: none FH: patient is adopted and does not know his family history SH: patient lives with his wife in the city. He denies any history of smoking or drug use. He reports that he does drink beers on weekends. ROS: +pruritus+

17 Case 1: Question 2 You are now ready to examine the patient. In addition to checking the spot lesions the patient mentions, which of the following other place(s) is(are) ) most important to check in evaluating for psoriasis? a. flexor surfaces b. mucous membranes c. gluteal fold d. face e. only the spot lesions the patient mentions

18 Case 1: Question 2 Answer: c You are now ready to examine the patient. In addition to checking the spot lesions the patient mentions, which of the following other place(s) is(are) ) important to check in evaluating this patient for psoriasis? a. flexor surfaces (would be more characteristic of atopic dermatitis) b. mucous membranes (not associated with psoriasis) c. gluteal fold d. face e. only the spot lesions the patient mentions

19 Location is Critical! Although you should perform a full body skin exam, plaque psoriasis tends to appear in CHARACTERISTIC locations which you should ALWAYS check Key Areas: scalp, ears, elbows and knees (extensor surfaces), umbilicus, gluteal cleft, nails, and sites of recent trauma Observation of psoriatic lesions in these locations helps distinguish psoriasis from other papulosquamous disorders

20 Case 1: Exam On exam, Gen: well appearing in NAD Skin: a erythematous plaque with small amounts of fine overlying scale is present around the umbilicus

21 Case 1: Exam After performing a full body skin exam you find an additional lesion Skin: a erythematous plaque with overlying silvery scale is present in the gluteal cleft NOTE: FULL BODY SKIN CHECK in a patient with psoriasis can yield findings that the patient is unaware of. Remember, many patients do not regularly see their buttocks and thus would not know to tell you about it!

22 Case 1: Question 3 What study would most assist you in arriving at a diagnosis? a. KOH prep b. blood test to evaluate for psoriasis antibodies c. Wood s s light examination d. all of the above

23 Case 1: Question 3 Answer: a What study would most assist you in arriving at a diagnosis? a. KOH prep (rule out fungal infection) b. blood test to evaluate for psoriasis antibodies (does not exist) c. Wood s s light examination d. all of the above

24 Case 1: Labs KOH prep does not show the presence of any hyphae and the patient is diagnosed with plaque psoriasis given the presence of psoriatic plaques in typical anatomic areas

25 Psoriasis: Differential Diagnosis Despite psoriasis having a long differential diagnosis, it is typically diagnosed on clinical exam due to its characteristic location and appearance. Listed are other diagnoses that are on the differential: ial: Tinea corporis: : Scaly pink plaque with elevated rim and central clearing; KOH+ Pityriasis rosea: : Herald patch, Christmas tree pattern on trunk Nummular eczema: : Minimal scale, more pruritic Seborrheic dermatitis: : Ill-defined erythema with greasy yellow- brown scale Cutaneous T cell lymphoma: Ill-defined pink patches around buttocks Pityriasis Rubra Pilaris: : Salmon-colored erythema with islands of sparing; waxy palms and soles Others: Secondary syphilis, drug eruption,, sub-acute cutaneous lupus

26 Case 2

27 Case 2: History HPI: 68 yo man with severe psoriasis presents with increased joint pain and deformity. He is currently treating his psoriasis with topical clobetasol. PMH: psoriasis x 40yrs All: none Meds: topical clobetasol FH: mother and father both had psoriasis SH: lives with his wife in the city ROS: negative

28 Case 2: Exam On exam, Gen: well appearing in NAD Skin: Scalp: on the anterior scalp there is a large erythematous plaque with overlying silvery scale Ear: erythematous plaque with overlying silvery scale behind the ear and at the entrance of the canal

29 Case 2: Exam On exam, Extremities: the extensor surface of the left arm has erythematous plaques with overlying silvery scale. Note that the patient also has vitiligo with macular depigmentation in the same region Nails: there is extensive nail pitting and nail dystrophy Nail pitting Nail dystrophy

30 Case 2: Exam On exam, There is notable swelling of the interphalangeal joints

31 Case 2: Question 1 Which of the following is the most likely cause of this patient s interphalangeal joint swelling? a. rheumatoid arthritis b. psoriatic arthritis c. lupus d. gout

32 Case 2: Question 1 Answer: b Which of the following is the most likely cause of this patient s interphalangeal joint swelling? a. rheumatoid arthritis b. psoriatic arthritis c. lupus d. gout

33 Psoriatic Arthritis Psoriatic arthritis is arthritis in the presence of psoriasis Up to 20% of psoriasis patients will develop psoriatic arthritis It is NOT related to the severity of psoriasis 80-90% of psoriatic arthritis cases are accompanied by nail findings of psoriasis

34 Another Example of Psoriatic Arthritis On exam, Patient has erythematous feet bilaterally with desquamation of the overlying skin as well as joint swelling and deformity (arthritis mutilans)

35 Case 3

36 Case 3: History HPI: An 18 year old healthy female with a new diagnosis of psoriasis reports lesions localized to her knees with no other affected areas. She has not tried any therapy. PMH: none All: none Meds: none FH: non-remarkable SH: lives in the city with her parents and attends high school ROS: slight pruritus

37 Case 2: Exam On exam, Gen: well appearing in NAD Skin: erythematous plaques with overlying silvery scale on the extensor surface of the knee.

38 Case 3: Question 1 What is your initial treatment recommendation? a. systemic steroids b. immunomodulators c. high potency topical steroid d. low potency topical steroid e. all of the above

39 Case 3: Question 1 Answer: c What is your initial treatment recommendation? a. systemic steroids b. immunomodulators c. high potency topical steroid d. low potency topical steroid e. all of the above

40 Psoriasis: Treatment Since the psoriasis is localized (less than 3% body surface area), topical treatment is appropriate First line agents: High potency topical steroid in combination with calcipotriene (vitamin D analog Dovonex) Other topical options: tazarotene,, salicylic or lactic acid, tar, calcineurin inhibitors

41 Psoriasis: Topical Treatment Medication Corticosteroids Calcipotriene (Dovonex) Tazarotene (Tazorac) Salicylic acid or Lactic acid Tar Calcineurin inhibitors (Elidel or Protopic) Pros Excellent efficacy No skin atrophy Good second line agent Reduces hyperkeratosis Highly effective Excellent for thin- skinned areas such as eyelids and face Cons Possible skin atrophy Weak when used alone; irritation May burn, sting; Pregnancy category X May burn, sting Messy to use Minimally effective on trunk and extremities

42 Clinical Pearl Topical medications for psoriasis are more effective when used with occlusion which allows for better penetration A bandage, saran-wrap, gloves, or socks placed over the medication can serve this purpose

43 Case 3: Question 2 What would be an appropriate treatment if the patient had presented like this? a. systemic steroid b. topical steroid c. topical steroid and systemic steroid d. topical steroid and UV light therapy e. all of the above

44 Case 3: Question 2 Answer: d What would be an appropriate treatment if the patient had presented like this? a. systemic steroid b. topical steroid c. topical steroid and systemic steroid d. topical steroid and UV light therapy e. all of the above

45 Psoriasis: Treatment Since the psoriasis is generalized (multiple areas and more than 3% body surface area), systemic treatment is required and should be supplemented with topical treatment Many patients with generalized psoriasis are given only topical medications and never get better don don t t make this mistake! ORAL STEROIDS SHOULD NEVER BE USED IN PSORIASIS AS THEY CAN SEVERELY FLARE PSORIASIS UPON DISCONTINUATION!

46 Psoriasis: Systemic Treatment In addition to topical high potency corticosteroids, there are 3 choices for systemic treatment: 1. Phototherapy: narrow-band ultraviolet B light (nbuvb( nbuvb), broad-band band ultraviolet B light (bbuvb( bbuvb), or psoralen plus ultraviolet A light (PUVA) 2. Oral medications: methotrexate, acitretin (Soriatane( Soriatane), cyclosporine (Neoral( Neoral) 3. Biologic Agents: etanercept (Enbrel( Enbrel), adalumimab (Humira), infliximab (Remicade( Remicade), alefacept (Amevive), efaluzimab (Raptiva) The choice of systemic therapy depends on 3 factors: convenience, side effect risk profile, and presence or absence of psoriatic arthritis (PsA( PsA)

47 Psoriasis Systemic Therapy Treatment Pros Cons Helps PsA? Phototherapy Very Safe; OK in pregnancy (except PUVA) Time consuming (3x week) No Methotrexate Inexpensive; weekly dosing convenient Possible hematologic and liver toxicity; GI upset; Pregnancy X Yes Acitretin (Soriatane) Synergistic with phototherapy Possible elevation of lipids, LFTs; ; Pregnancy X No Cyclosporine (Neoral) Highly effective Renal toxicity, HTN, increased malignancy No TNF Biologics (Enbrel, Humira, Remicade) No organ toxicity and medication interactions Expensive; increased risk of infections and possibly malignancy Yes Other Biologics (Amevive, Raptiva) No organ toxicity and medication interactions Expensive; not as effective as TNF agents No

48 Other Types of Psoriasis Besides plaque psoriasis, there are several other psoriasis sub-types to be aware of: Guttate Inverse Pustular Hand and Foot (Palmoplantar) Erythrodermic

49 Guttate Psoriasis Acute onset of raindrop-sized lesions on trunk and extremities in young adults, often preceded by streptococcal pharyngitis

50 Inverse Psoriasis Erythematous plaques in the axilla,, groin, inframammary region, and other flexural areas. May lack scale due to moistness of area.

51 Pustular Psoriasis Characterized by psoriatic lesions with sterile pus. May result from corticosteroid withdrawal. When generalized, pustular psoriasis can be a life- threatening emergency due to the risk of sepsis. These patients should be hospitalized and a dermatologist consulted.

52 Hand and Foot Psoriasis May occur as either plaque type or pustular type. Often very functionally disabling for the patient. Treatment is often with topicals plus occlusion, or PUVA. Plaque type palmoplantar psoriasis Pustular type palmoplantar psoriasis

53 Erythrodermic Psoriasis Involves almost the entire skin surface; skin is bright red. Associated with fever, chills, and malaise. Like pustular psoriasis, sis, hospitalization is sometimes required.

54 END OF MODULE