Transcript acne Pictures - UNC School of Medicine

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
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. Keensighted, though we hate to
look upon ourselves. The
name of the disease,
spiritually speaking,
is….
Humiliation
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:
Definition
• 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 days
– Psoriatic skin cell matures in 3-6 days
Psoriasis: Types
• Plaque-type
Localized or
Generalized
• Pustular
Localized 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,
medications
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
• Neurodermatitis/
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% BSA
Topical Therapies
1. Emollients
2. Keratolytic agents
3. Topical steroids
4. Calcipotriene
5. Tazarotene gel
6. Topical calcineurin
inhibitors
7. Anthralin
8. 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 treatments
 Use for short periods of time and minimum amount
 Avoid 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
Algorithm for Treatment of Localized Psoriasis
(From
Pardasan AG,
et al. Am Fam
Physician
2000)
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 510 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
Methotrexate
Indications:
•
•
•
•
•
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
• Efalizumab
• Etanercept
• Infliximab
•
•
•
•
Amevive
Raptiva
Enbrel
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
• Treatment plan:
Case
• Use moisturizer cream & sunlight daily
SCALP
• Medicated shampoo
• BMV foam (Luxiq) BID for 7 days
• Calcipotriene solution qhs
BODY- 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 brochure
http://www.aafp.org/afp/20000201/20000201d.html
• Comprehensive WEB listing
http://www.edae.gr/psoriasis.html
Bibliography
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treatments for psoriasis. Dermatol Online J 2003; 9(1): 2.
Lebwohl MG, Tan MH, Meador SL, Singer G. Limited application of fluticasone
proprionate ointment, 0.005% in patients with psoriasis of the face and
intertriginous area. J Am Acad Dermatol 2001; 44: 77-82.
Koo JY, Lowe NJ, Lew-Kaya DA, et al. Tazarotene plus UVB phototherapy in
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Gaston L, Crombez JC, Lassonde M, Bernier-Buzzanga J, Hodgins S. Psychological
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