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© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
in the clinic
Psoriasis
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What are the most common symptoms?




Erythematous lesions with loose, silvery-white scales
Removing scale can induce punctate bleeding: Auspitz sign
Papules can coalesce in pruritic patches / plaques
Nails and joints may be affected
A. Extensive, well-demarcated
erythematous plaques of
abdomen
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
B. Erythematous plaque of elbow
C. Erythematous, scaling plaques
of abdomen
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the differential diagnosis?
 Plaque
 Eczema; dermatophyte infection; superficial squamous /
basal cell CA; subacute cutaneous lupus
 Guttate
 Secondary syphilis; pityriasis rosea
 Erythrodermic
 Pityriasis rubra pilaris; drug eruptions
 Pustular
 Candidiasis; acute generalized exanthematic pustulosis
 Inverse
 Intertrigo; cutaneous T-cell lymphoma
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Which areas of the skin are most
commonly affected?
 In chronic plaque psoriasis
 Extensor surfaces (elbows and knees)
 Lumbosacral area
 Intergluteal cleft
 Scalp
 In inverse psoriasis
 Intertriginous areas
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
How often are the nails involved?
 Up to 55% with psoriasis have nail involvement
 Occurs in any subtype
 <5% of nail disease occurs in those lacking other
cutaneous findings of psoriasis
 ≤90% with psoriatic arthritis have nail involvement
 Fingernail involvement in 50% of cases
 Toenail involvement in 30% of cases
 Requires aggressive treatment: intralesional steroid
injections
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
How often are joints affected by
psoriasis? Which ones?
 Psoriatic arthritis occurs in up to 30%
 Inflammatory, seronegative spondyloarthropathy
 Stiffness, pain, swelling of joints, ligaments, tendons
 Hands more likely involved than feet
 Polyarticular peripheral joint involvement common
 About 5% have only axial involvement
 Up to 50% have both spine & peripheral joint involvement
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
 Enthesitis: inflammation where
tendon, ligament, or joint
capsule fibers insert into bone
 Dactylitis: enthesitis of tendons
and ligaments + synovitis of an
entire digit
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When should joints be tapped to
diagnose PsA?
 Arthrocentesis is not recommended
 Use clinical observations
 Symmetrical joint stiffness (hands, feet, large joints) for
≥30 minutes in morning or after long periods of inactivity
 Use radiologic observations
 Joint erosions, joint-space narrowing
 Bony proliferation, spur formation
 Osteolysis with “pencil-in-cup” deformities
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Aside from skin and joints, what else
should be examined when considering a
diagnosis of psoriasis?
 Psoriasis: systemic inflammatory disorder
 Inflammation cascade promotes endothelial dysfunction and
oxidative stress
 Increases risk for:
 Atherosclerosis-based CV disease
 Hypertension
 Obesity and the metabolic syndrome
 Diabetes
 Smoking
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What triggers or unmasks psoriasis?
 Bacterial and viral infections
 URI associated with guttate psoriasis
 Especially Streptococcus pyogenes
 Stress
 Often first outbreak traced to stressful event
 Lesions can be induced locally in areas of physical trauma,
i.e., vaccination, tattoos, sunburn, excoriation
 Certain medications
 Lithium, interferon, antimalarials, β-blockers, ACE
inhibitors, NSAIDs, withdrawal of oral corticosteroids
 Cold weather with low humidity
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Are there any specific diagnostic tests
for psoriasis?
 No
 Diagnosis is clinical
For initial work-up:
 Total body skin evaluation, including nails and scalp
 ? Joint symptoms (stiffness, swelling, pain, decreased ROM)
 ? Personal or family history of autoimmune diseases
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Which blood tests are abnormal in psoriasis,
and how specific are they to the diagnosis?
 Rarely needed for diagnosis
 Rapid plasma reagin: to distinguish from syphilis
 Antinuclear antibody, anti-Ro, and anti-La: confirms Dx
if subacute cutaneous lupus suspected
 CRP levels: occasionally elevated in PsA
 Uric acid levels: may be elevated, especially in
erythrodermic psoriasis
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the role of skin biopsy in
making the diagnosis?
 Histologic confirmation
 Classic findings of psoriasis
 Epidermal hyperplasia
 Parakeratosis
 Thinning of granular layer
 Neutrophil + lymphocyte infiltration in epidermis and dermis
 Increased prominence of dermal papillary vasculature
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Diagnosis
and Evaluation…
 Diagnosis most often made clinically
 Psoriasis papules, patches, or plaques: sharply demarcated,
erythematous, scaly, pruritic
 Concomitant joint and nail involvement
 Histologic and lab abnormalities not required
 Triggers: infection, trauma, stress, and certain drugs
 Psoriasis increases risk for CV disease and events
 If diagnosis uncertain, consult dermatologist
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What drug therapies are used in treatment?
Topical therapies
Systemic therapies
 Corticosteroids
 Methotrexate
 Vitamin D analogues
 Cyclosporine A
 Topical retinoids
 Oral vitamin A derivatives
 Calcineurin inhibitors
 Salicylic acid
Biological therapies
 Anthralin
 Adalimumab
 Coal tar
 Alefacept
 Phototherapy
 Etanercept
 Golimumab
 Infliximab
 Ustekinumab
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
How should a clinician choose between
topical and systemic drug therapy?
 Determine disease severity
 Measure affected body surface area
 ≤3%: mild
 3%-10%: moderate
 ≥10% or serious adverse affect on QOL: severe
 Determine the location of lesions
 Consider affect on QOL
 Mild disease: topical therapies
 Moderate-to-severe disease: systemic and topical
therapies; biologics if systemics fail / can’t be used
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the role of phototherapy?
 For widespread disease or when disease substantially
affects QOL
 Efficacious and cost-effective
 Not immunosuppressive like systemic drugs
 Affects Langerhans cells directly, cytokines indirectly
 Don’t use with photosensitive disorders
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Is there a role for combination drug
therapy and phototherapy?
 Improves efficacy and decreases toxicity of a potentially
hazardous combination agent
Phototherapy can be combined with:
 Anthralin or coal tar
 MTX
 Retinoids
 Biological therapies
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What alternative therapies are shown to
improve quality of life and outcomes?
 Salicylic acid
 Combine with other topical therapies
 Dead Sea
 Unique UVA-UVB ratio + high water salinity improves
psoriasis
 May increase risk for nonmelanoma skin cancer
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
How should psoriasis be treated in
pregnant patients?
 Consider therapy benefits vs. potential fetal risk
 First-line treatment: topical agent or phototherapy
 Alternative to phototherapy: TNF-α blocker (Category B)
 Severe psoriasis: cyclosporine A (Category C)
 Contraindicated: retinoids, MTX, oral vitamin A derivatives
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When is it necessary to hospitalize
patients with psoriasis?
 Erythrodermic psoriasis
 Inflammation of ≥75% BSA +/- presence of exfoliation
 Triggers: steroid withdrawal, sun exposure, drug reactions,
emotional stress
 First-line: adjuvant topical treatment + CSA or infliximab
 Hospitalize for hypothermia or hyperthermia, protein loss,
dehydration, infection, renal failure, hi-output cardiac failure
 Acute episodes of generalized pustular psoriasis
 Pinhead-sized pustules on erythematous background
 Pustules may dry out, exfoliate, and redevelop
 Triggers: corticosteroid withdrawal for plaque psoriasis
 Retinoids uniquely effective treatment
 Hospitalize for systemic symptoms
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When should patients be referred to a
dermatologist?
 Recalcitrant disease
 Moderate-to-severe disease
 Disease that significantly impairs quality of life
Dermatologist can initiate
 Phototherapy
 Systemic therapy
 Combination therapy
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When should patients be referred to a
rheumatologist?
 When PsA is diagnosed
 Majority have psoriasis years before joint symptoms
develop
 Rheumatologist guides treatment to
 Alleviate pain and swelling
 Inhibit structural damage
 Improve quality of life
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
When should patients be referred to a
psychiatrist?
Order a consultation if psychiatric disorder suspected
 Screen for psychosocial aspects
 Psychosocial morbidity + decreased occupational
function
 Clinical severity may not reflect extent of emotional
impact
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What is the role of the PCP in treating
psoriasis?

Identify conditions associated with psoriasis

Help prevent comorbid conditions

Provide counsel regarding lifestyle modifications

Consult specialists (dermatology, rheumatology)
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
How often should patients be followed
by a dermatologist?
 Regularly to assess:
 Disease severity
 Compliance and medication toxicity
 Quality-of-life issues
 Topical steroids: every 6-12 months
 More frequently if using more potent topical steroids
 Systemics: Follow more frequently
 MTX/CsA: Examine for response and skin cancer
 Phototherapy: annually
 Check for photoaging, pigmentation, skin cancer
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
Should patients be routinely followed by
other specialists?
 Mild PsA: PCP
 Treat with NSAIDs or intra-articular steroid injections
 Moderate-to-severe PsA: rheumatologist / dermatologist
 Risk for structural damage
 More aggressive therapy required
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Treatment
and management…
 Mild-to-moderate psoriasis
 Topical therapy: steroid, vitamin D analogue, retinoid,
calcineurin inhibitor
 Moderate-to-severe psoriasis
 Traditional systemic medications, biological agents, or
phototherapy + topical therapy
 For PsA, start treatment early to avoid structural damage
 Mild disease: NSAIDs
 More severe systemic disease: biological agent, MTX, or a
combination of the two
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
How should patients be educated about
psoriasis pathophysiology and genetics?
 Normal skin cells: mature + fall off body in 28 days
 Psoriasis skin cells: mature in just 3 to 4 days + pile up
into lesions instead of shedding
 Requires both inheritance + environmental trigger
 ≥10% of general population inherits ≥1 predisposing gene
 But only 3% of population develops psoriasis
 If both parents have psoriasis, offspring incidence up to 50%
 If 1 parent affected, offspring incidence 16%
 If only a sibling affected, incidence 8%
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What should patients be told about
preventing exacerbations?
 Avoid common triggers
 Adhere to prescribed treatments
 Use occlusive agents, emollients, and humectants
 Provide and retain moisture in the skin
 Enhance efficacy of topical corticosteroids and exert a
steroid-sparing effect
 Prevent disease exacerbation
 Inhibit the Koebner response
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What should patients be told about the
risks of topical or systemic steroids?
 Don’t use systemic steroids for psoriasis
 Topical steroid side effects
 Atrophy, telangiectasia, striae, acne
 May exacerbate pre- / co-existing dermatoses
 Can cause contact dermatitis
 May lead to rebound
 Limit superpotent topicals (≤2x/d for ≤4wks, ≤50 g/wk)
 Replace or combine with vitamin D analogues, retinoids,
and calcineurin inhibitors
 Increases efficacy with less steroid exposure
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
What behavior modifications can
ameliorate the effects of psoriasis?
 Stopping tobacco use
 Reducing alcohol use
 Maintaining ideal body weight
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.
CLINICAL BOTTOM LINE: Patient
Education…
 Essential to optimizing treatment
 Genetic + environmental factors contribute to psoriasis
 Smoking, alcohol, obesity = more severe symptoms
 Counsel patients on lifestyle modification
 Individualized treatment regimen promotes adherence,
improves treatment outcomes, and avoids toxicity
© Copyright Annals of Internal Medicine, 2011
Ann Int Med. 155 (3): ITC2-1.