Hitchcock Clinic Manchester, NH. Psoriasis. Overview. Psoriasis 3/9/2009. From heartbreak to heart attack. Mark Quitadamo, MD

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1 Hitchcock Clinic Manchester, NH Psoriasis From heartbreak to heart attack Mark Quitadamo, MD Overview Psoriasis and psoriatic arthritis are common skin and joint disease Psoriasis Unfortunately it is a life-altering and often debilitating condition. Psoriatic arthritis Statistics Affects an estimated 2-3 percent of the world's population. 125 million people worldwide have psoriasis Between 5.8 and 7.5 million Americans have psoriasis. 10 percent to 30 percent of people with psoriasis also develop psoriatic arthritis. 1

2 Age of Onset Often appears between the ages of 15 and 25, but can develop at any age. Psoriatic arthritis usually develops between the ages of 30 and 50, but it too can develop at any time. Genetics About one out of three people with psoriasis report that a relative had psoriasis. If one parent has psoriasis, a child has about a 10 percent chance of having psoriasis. If both parents have psoriasis, a child has approximately a 50 percent chance of developing the disease. Severity Mild psoriasis is defined as affecting less than three percent of the body 3 percent to 10 percent is considered moderate More than ten percent is considered severe. Severity The palm of the hand equals 1 percent of the skin. Mild severity Moderate severity 2

3 Severe disease Severity The majority of people with psoriasis have mild disease. Nearly one-quarter of people with psoriasis have cases that are considered moderate to severe. Severity of psoriasis is also measured by how psoriasis affects quality of life. Psoriasis can have a serious impact even if it involves a small area, such as the palms of the hands or soles of the feet. Quality of Life In a 2001 survey by the National Psoriasis Foundation 60 percent reported their disease to be a large problem in their everyday life. Nearly 40 percent with psoriatic arthritis reported their disease to be a large problem Patients with psoriasis covering more of their body experienced a greater negative impact Psoriasis had a greater impact on quality of life in women and younger patients Quality of Life John Updike wrote in The New Yorker magazine July 19, 1976 The name of the disease, spiritually speaking, is Humiliation. Quality of Life Quality of life 3

4 Pathophysiology Pathophysiology Psoriatic Types Overview 5 Types of Psoriasis.. Psoriasis appears in a variety of forms. Each form has distinct characteristics. Often only one type of psoriasis appears at a time Occasionally two or more different types of psoriasis can occur at the same time May change from one form to another Trigger factors may "convert" some forms of psoriasis, such as plaque, to another form, such as pustular. Generally, one type of psoriasis will clear and then another form of psoriasis will appear later. Plaque Guttate Inverse Pustular Erythrodermic Plaque Psoriasis Plaque Psoriasis Plaque psoriasis is most prevalent form. About 80 percent of all those who have psoriasis have this form. It is characterized by raised, inflamed, red lesions covered by a silvery white scale. It is typically found on the elbows, knees, lower back and scalp. 4

5 Plaque Psoriasis Plaque Psoriasis Plaque Psoriasis Guttate Psoriasis Often starts in childhood or young adulthood. The word guttate is from the Latin word meaning "drop." This form of psoriasis resembles small, red, individual spots on the skin. Guttate lesions usually appear on the trunk and limbs. These spots are not usually as thick as plaque lesions. Guttate Psoriasis Guttate Psoriasis 5

6 Guttate Psoriasis Often comes on quite suddenly. A variety of conditions have been known to bring on an attack of guttate psoriasis, upper respiratory infections, streptoccocal infections, tonsillitis, stress, injury to the skin certain drugs (including antimalarials and betablockers). Guttate Psoriasis A streptococcal infection of the throat is the most common guttate psoriasis trigger. Strep throat can be present without symptoms and can still cause a flare of guttate psoriasis. Guttate psoriasis may persist despite clearance of the strep infection. Inverse Psoriasis Inverse Psoriasis Inverse psoriasis is found in the armpits, groin, under the breasts, Also in other skin folds such as the genitals and the buttocks. First shows up as lesions that are very red smooth and shiny. Lacks the scale associated with plaque psoriasis. Particularly subject to irritation from rubbing and sweating because of its location in skin folds It is more common and troublesome in overweight people and people with deep skin folds. Inverse Psoriasis Inverse Psoriasis 6

7 Pustular Psoriasis Pustular Psoriasis Primarily seen in adults Characterized by white pustules surrounded by red skin. The pus consists of white blood cells. It is not an infection, nor is it contagious. It may be localized to certain areas of the body (e.g.) the hands and feet. Can be generalized, covering most of the body. This is one of the true dermatologic emergencies It tends to go in a cyclereddening of the skin followed by formation of pustules and scaling. triggered by: internal medications (lithium, propranolol, iodides and indomethacin) irritating topical agents, overexposure to UV light, pregnancy, Systemic steroids, infections, emotional stress sudden withdrawal of systemic medications or potent topical steroids. Pustular Psoriasis Von Zumbusch 3 main types: Von Zumbusch generalized eruption Acropustulosis (acrodermatitis continua of Hallopeau) Palmo-plantar pustulosis(the most common form) The onset can be abrupt Widespread areas of reddened skin develop The skin becomes painful and tender. Within a few hours, the pustules appear. Pustules then dry and peel over the next 24 to 48 hours leaving the skin with a glazed, smooth appearance. A fresh crop of pustules may then appear. Eruptions often come in repeated waves that last days or weeks. Von Zumbusch Von Zumbusch Is associated with fever, chills, severe itching, dehydration, a rapid pulse rate, exhaustion, anemia, weight loss and muscle weakness. This puts excessive stress on the heart and kidneys, especially in older people. Because this form can be life-threatening, medical care must begin immediately. 7

8 Acropustulosis Characterized by skin lesions on the ends of the fingers and/or toes. The eruption occasionally starts after an injury or infection to the skin. Often the lesions are painful and disabling, producing deformity of the nails Occasionally bone changes occur in severe cases. This form has traditionally been hard to treat Acropustulosis Palmo-plantar Pustulosis Palmo-plantar Pustulosis Characterized by pustules on the palms of the hands and soles of the feet. Multiple pencil eraser-sized pustules in fleshy areas of the hands and feet, (e.g.) base of the thumb and the sides of the heels. The pustules appear in a studded pattern throughout They then turn brown, peel and become crusted. The course is usually cyclical, with new crops of pustules followed by periods of low activity. Consider smoking cessation, as these patients may have an abnormal response to nicotine Erythrodermic Erythrodermic Inflammatory form of psoriasis Affects most of the body surface. May occur in association with von Zumbusch pustular psoriasis. Characterized by periodic, widespread, fiery redness of the skin. The erythema (reddening) and exfoliation (shedding) are often accompanied by severe itching and pain. 8

9 Erythrodermic Erythrodermic Causes protein and fluid loss that can lead to severe illness. Edema especially around the ankles, may also develop along with infection. The body's temperature regulation is often disrupted, producing shivering episodes Infection, pneumonia and congestive heart failure brought on Thus erythrodermic psoriasis can be life threatening. Severe cases of this condition often require hospitalization. Specific Skin Sites Scalp psoriasis Genital psoriasis On the face On the hands and feet Involving the nails Scalp Psoriasis Very common. half of all people who have psoriasis have it on their scalp. Can be very mild, with slight, fine scaling. However, can also be very severe with thick, crusted plaques covering the entire scalp The severe form can cause hair loss. Psoriasis can extend beyond the hairline onto the forehead, the back of the neck and around the ears (a common area). Often people with scalp psoriasis have psoriasis on other parts of their body as well. For some, the scalp is the only affected area. Genital Psoriasis Occurs in the genital area often at the same time it occurs elsewhere It can appear in the genital area only. Affected areas range from small, red spots to large patches. The most common type of psoriasis in the genital region is inverse psoriasis. Genital Psoriasis 9

10 Facial Psoriasis Facial Psoriasis Often affects the eyebrows, the skin between the nose and upper lip, the upper forehead and the hairline. Can be confused with seborrheic dermatitis Often occurs with psoriasis affecting other areas of the body Rare to occur just on face alone Hand and Foot Psoriasis Hand and Foot Psoriasis Flares are accompanied by cracking, blisters and swelling. The most common form is the palmoplantar pustulosis Nail Psoriasis 50 percent of people with psoriasis and at least 80 percent of people with psoriatic arthritis have nail involvement. Changes of the nail include: Pittingshallow or deep holes in the nail Deformationalterations in the normal shape Thickening Onycholysisseparation of the nail from the nail bed Discolorationsuch as yellow-brown 10

11 Nail Psoriasis Psoriasis Therapy Therapy Therapy No known cure Many different therapies can reduce symptoms. No single treatment works for everyone Experimentation may be needed to find a treatment that works. Therapy Treatment falls into 3 main groups: Topical Phototherapy Systemic therapy Remember that unfortunately as the number of treatments for a disease increase the chance for a cure decreases 11

12 Therapy-home Topical Rx-OTC Salicyclic acid helps remove scales and is often combined with topical steroids, anthralin or tar to enhance effectiveness. Available in both OTC and prescription forms. Tar Coal tar is available in topical, shampoo and bath solution forms. Tar can help slow the rapid proliferation of skin cells and help reduce inflammation, itching and scaling. It can also be used in combination with phototherapy. Topical Rx-Prescription Anthralin Topical Very effective but it does not work as quickly or as thoroughly as superpotent topical steroids. Unlike steroids, it has no known long-term side effects other than it is messy and staining. Calcipotriene A form of synthetic vitamin D3 that slows down the rate of skin cell growth, flattens psoriasis lesions and removes scale. Useful for skin, scalp and nail disease. Moderately effective Topical Rx-Prescription Tazarotene Available as a prescription gel or cream tazarotene is a vitamin A derivative and is also known as a topical retinoid. It can be used on the face, scalp and nails. Marginally effective Betamethasone Dipropionate and Calcipotriene This prescription ointment combines calcipotriene and the potent steroid betamethasone dipropionate. The calcipotriene slows down the rate of skin cell growth, flattens psoriasis lesions and removes scale, while the steroid helps reduce inflammation and itch. VERY expensive Topical Rx-Prescription Topical steroids Corticosteroids, or simply "steroids" are routinely used to treat psoriasis. Topical steroid medications can be very effective in controlling mild to moderate psoriasis lesions. They are easy to use and work relatively quickly. Available in creams, ointments, lotions, solutions, sprays and foams. Consider intralesional use. Topical Rx-Prescription Helpful hints with steroids Use creams with severely inflamed lesions Use ointments with dry, scaly, fissured skin Use lotions, solutions or foams in hair bearing areas Use the correct strength steroids Use the right amount of steroid Consider combination therapy 12

13 Topical Rx-Prescription Topical Rx-Alternative Topical immune modulators Elidel (pimecrolimus) cream Protopic (tacrolimus) ointment Non FDA approved for psoriasis Has been helpful for inverse psoriasis and facial psoriasis for its steroid sparing effect Topical Rx-Alternative Topical Rx-Alternative Topical Rx-Alternative Aloe Apple cider vinegar Capsaicin Emu oil Evening primrose oil Oats Teatreeoil Phototherapy Consider pulsed dye laser therapy for local disease Consider outpatient tanning bed therapy Consider Dead Sea therapy 3 main forms of proven light therapy Ultraviolet B(UVB) Psoralen plus ultraviolet A(PUVA) Narrow band ultraviolet B (Nb-UVB) 13

14 Dead Sea Therapy Dead Sea Therapy Phototherapy Systemic therapy Methotrexate was discovered to be effective in clearing psoriasis in the 1950s and was eventually approved for this use by the FDA in the 1970s. Has anti inflammatory and immune suppressing properties. Dosing is just once per week. Monitoring of liver function and cbc vital. Long term toxicity on liver, and immune system Systemic therapy Cyclosporine In 1997, the FDA approved Neoral as a treatment for psoriasis. This is a powerful immune suppressing agent. Indeed first used for prevention of transplant rejection. Perhaps the fasting acting agent available. Required daily dosing starting at 5mg/kg/d. Monitoring of renal function is key as is following bp and host of other blood work. Systemic therapy Acitretin Oral retinoid, which is a synthetic form of vitamin A. Acitretin is the only oral retinoid approved by the FDA specifically for treating psoriasis. Requires daily dosing and close monitoring of blood work much like isotretinoin (another retinoid) does. Works best in combination therapy rather than monotherapy 14

15 Systemic therapy Biologics Biologic medications are developed from living sources, such as cells, rather than combinations of chemicals like traditional drugs. They work as immune suppressors alefacept inhibits T cell activation efalizumab inhibits T cell activation and trafficking etanercept, adalimumab, and infliximab are tumor necrosis factor inhibitors and are FDAapproved for the treatment of psoriasis and psoriatic arthritis. Systemic therapy Biologics are fairly new treatments for psoriasis. Their overall safety is still being evaluated; long-term side effects are not fully known. Most now need close monitoring including lft, cbc, annual check for TB and review for other infections and inflammatory conditions VERY expensive Systemic therapy Others to consider: isotretinoin, hydroxyurea, mycophenolate mofetil (cellcept), sulfasalazine, 6-Thioguanine Systemic Therapy-Alternative None scientifically proven Some to consider: Evening primrose oil Milk thistle Oregano Shark cartilage Tumeric Vitamins Therapy What next? Therapy What next? 15

16 Therapy What next? Dietary therapy Maintain healthy weight and cholesterol Watch for diabetes Data to suggest increased risk of cardiac disease with psoriasis Questionable association with gluten sensitive enteropathy. Some suggest gluten free diet for therapy The wrap up 16