Transcript Psoriasis - Georgia Skin and Cancer Clinic

Psoriasis
Georgia Skin and Cancer Clinic
Chris Anderson ANP
What is Psoriasis?
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Psoriasis is a chronic skin
condition of unknown cause
Causes red/scaly patches
Usually lifelong/relapsing
Wide range of distribution
History:
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Ancient condition; widely
confused
Grouped with Leprosy at one
time
Differentiated in 18th century by
Dr. Ferdinand Von Hebra as
psoriasis
The Many Faces of Psoriasis
Who has Psoriasis?
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Often first seen ages 15-25
1/3 have a family history
1-2 % of the world affected.
More common in Caucasians
Found equally in men and
women.
Famous people with
psoriasis:
 Benjamin Franklin, Jerry
Mathers, Art Garfunkel,
John Updike
Pathophysiology
www.psoriasis.or.id
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Epidermis has rapid accumulation of cells (accounts for the
classic psoriatic lesion)
Lesions result from an increase in epidermal cell turnover.
Transit time decreases from the normal 28 days to 2-3 days.
Most current therapies are directed at suppression of responsible
T cells.
Pathophysiology
www.gene.com
Clinical Manifestations
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Integument:
 Silvery scale on an erythematous base
 Auspitz’s sign
 ***Koebner’s phenomenon
Arthritis:
 10-30% of patients
Pruritus:
 Varies from asymptomatic to quite
pruritic
Psychosocial problems:
 Poor self-esteem
Exacerbating factors:
 Stress, winter months (UV exposure)
 Illness: Strep pharyngitis, HIV
 Meds: anti-malarials, beta-blockers,
lithium, interferon
 Excessive alcohol consumption
Clinical Manifestations
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KÖEBNER PHENOMENON
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Lesions can appear in traumatized/damaged areas of skin
Trauma
Sun lamp
burn
Radiation
Distribution of Lesions
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Wide range of distribution
Can range from one small
localized plaque to
generalized exfoliative
erythroderma
Usually symmetrical
Usually spares the face
www.aafp.org
Variations of
Psoriasis
Variations of Psoriasis
Localized psoriasis
 Scalp Psoriasis
 Generalized
psoriasis
 Guttate psoriasis
 Psoriasis in children
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Palmoplantar
psoriasis
 Psoriatic Nails
 Psoriatic Arthritis
 Inverse psoriasis
 Erythrodermic
psoriasis (exfoliative
dermatitis)
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Variations of Psoriasis
Localized psoriasis
 Scalp Psoriasis
 Generalized
psoriasis
 Guttate psoriasis
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Palmoplantar
psoriasis
 Psoriatic Nails
 Inverse psoriasis
 Psoriasis in children
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Variations of Psoriasis
Localized psoriasis
Localized Plaque Psoriasis
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Basics
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Mildest manifestation
Often an incidental finding
May consist of nail pitting or
mild patches on elbows or
knees.
Patient often unaware or not
troubled
Localized Plaque Psoriasis
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Diagnosis
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Usually based on exam
Family history, aggravating
factors and nail findings often
helpful
Skin biopsy and fungal
examinations can be performed
Variations of Psoriasis
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Localized psoriasis
Scalp Psoriasis
Scalp Psoriasis
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Basics
 May involve the scalp alone or
included other areas.
 Plaques frequently hidden in the
scalp or behind the ears.
 Plaques often thick and well
demarcated with a white scale.
 Pruritus and scratching may
exacerbate (Koebner’s)
Psoriasis around hairline
Variations of Psoriasis
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Localized psoriasis
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Scalp Psoriasis
Generalized psoriasis
Generalized Plaque Psoriasis
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Basics
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Can flare very quickly
May cover 20% to 80% of the body
Topical therapy alone becomes less effective
UV light treatment, systemic medications and/or biologics may be necessary
Variations of Psoriasis
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Localized psoriasis
Scalp Psoriasis
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Generalized psoriasis
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Guttate Psoriasis
Guttate Psoriasis
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Basics
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DDx
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Pityriasis Rosea, drug rash, secondary
syphilis
Treatment
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www.psoriasis.org
Sudden onset of multiple raindrop
shaped lesions.
Usually on trunk
Often the initial presentation in
children/young adults.
Can follow group A beta-hemolytic
strep pharyngitis.
Abx therapy if positive ASO.
Consider traditional treatment for poor
responders.
Variations of Psoriasis
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Localized psoriasis
Scalp Psoriasis
Generalized psoriasis
Guttate psoriasis
Palmoplantar psoriasis
Psoriasis of the Palms and Soles
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Basics
 Hyperkeratotic type:
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Pustular type:
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Well-demarcated plaques.
Koebner’s phenomenon?
Often cause pain,
impairment of function,
and embarrassment.
Usually seen in adults
Yellow pustules (sterile)
DDx:
 Contact dermatitis
 Dishydrosis
 Tinea
Psoriasis of the Palms and Soles
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Treatment
 Topicals are the first line
 Class I TCS needed to penetrate
thicker stratum corneum, often
under occlusion.
 Systemics or Biologics for poor
responders
Variations of Psoriasis
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Localized psoriasis
Scalp Psoriasis
Generalized psoriasis
Guttate psoriasis
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Palmoplantar psoriasis
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Psoriatic Nails
Psoriatic Nails
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Basics
 Nail involvement common.
 Usually cosmetic condition
only.
 More common in patients
with generalized psoriasis
and psoriatic arthritis.
DDx:
 Onychomycosis
 Paronychia
 Contact dermatitis
www.psoriasis.org
www.dartmouth.edu
Psoriatic Nails
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Typical Nail Changes:
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Pitting
 Classic nail finding in psoriasis.
 Produced by tiny punctate lesions that
arise from the nail matrix and appear
on the nail plate as it grows.
Onycholysis
 Represents a separation of the nail
plate from underlying pink nail bed.
“Oil Spots”
 Orange-brown areas appearing under
the nail plate. Presumably the result
of psoriasis of the nail bed.
Subungual hyperkeratosis:
 Buildup of scale beneath the nail
plate.
Onycholysis
Pitting
Psoriatic Nails
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Treatment is generally unrewarding, but some measures
can be helpful:
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Careful trimming and paring of the nails are recommended.
Topical steroids need to be directed toward the proximal fold
(closer to matrix)
Intralesional steroids can be injected into the nail matrix
Consider systemic/biologic therapy based on the situation
Variations of Psoriasis
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Localized psoriasis
Scalp Psoriasis
Generalized psoriasis
Guttate psoriasis
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Palmoplantar psoriasis
Psoriatic Nails
Inverse psoriasis
Inverse Psoriasis
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Variation that occurs in
flexural areas
Under breasts, axillary,
gluteal cleft, anogenital
Koebner’s may play part
Often mistaken for
candidal infection.
.
Psoriasis org
Emedicinehealth.com
Variations of Psoriasis
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Localized psoriasis
Scalp psoriasis
Generalized psoriasis
Guttate psoriasis
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Palmoplantar psoriasis
Psoriatic nails
Inverse psoriasis
Psoriasis in
Children
Psoriasis in Children
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Basics
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Begins before age 10 in 10% of those with psoriasis.
Early onset may predict more severe disease.
Often an associated family history.
May be difficult to distinguish from irritant/atopic dermatitis
or cutaneous candidiasis.
May also present with typical plaques.
Requires intensive educational of the patient and family.
Infantile Psoriasis
Psoriasis in Children
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Treatments:
 Many of the treatments that are used in adults, such as Class I
topical steroids, phototherapy, methotrexate, and retinoids,
are generally avoided in children.
 Low to medium potency topical steroids
 Calcipotriene (Dovonex)
 Keratolytics
 Natural sunlight if available.
 Some success with biologic therapy (off label??)
Management of
Psoriasis
Management of Psoriasis
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Aimed at:
 Decreasing size/thickness of
plaques
 Relieving pruritus and/or arthritis
 Improving self-image
Education:
 Disease process
 Treatment options
Support Groups:
 National Psoriasis Foundation
(www.psoriasis.org)
 Psoriasis Connections
(www.psoriasisconnect.com)
Management of Psoriasis:
Where Do I Start???
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Treatment based on severity:
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Proportion of body surface affected
Disease activity
Response to previous treatments
**Impact on each individual
Assessment Tools:
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PASI
Physician’s Global Assessment
NPF-Psoriasis Score
Dermatology Life Quality Index
Management of Psoriasis
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“Old”
paradigm
Follows a
sequential
stepwise
progression
Patients must
fail the
previous
“step”
En.Wikipedia.org
Management of Psoriasis:
New/Emerging Treatment Paradigm
FAILURE OF
TOPICALS?
Oral Systemics
MTX
Soriatane
CSA
Biologics
Amevive
Enbrel
Humira
Raptiva
Remicade
Phototherapy
PUVA
UVB
Management of Psoriasis:
Topical Treatments
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Topical Corticosteroids
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Popular method for treating psoriasis
Advantages
 Rapid onset
 Variety of vehicles
 Variety of prices
Disadvantages
 Steroid rosacea, local atrophy,
hypothalamic-pituitary-adrenal
suppression possible.
Management of Psoriasis:
Topical Treatments
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Calcipotriene 0.005%
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Topical vitamin D3
Cream, ointment, solution
Advantages
 Good maintenance therapy
 Effective in reducing scale
 No tachyphylaxis reported
Disadvantages
 Expensive, slow onset
Additional Suggestions
 Use in rotational therapy
with TCS.
Management of Psoriasis:
Topical Treatments
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Tazarotene
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Topical retinoid derivative
Advantages
 Remissions are possibly longer
 No tachyphylaxis reported
Disadvantages
 Expensive, often irritating, slow
onset
 Category X
Additional Suggestions
 Use in conjunction with topical
steroids to minimize irritation.
Management of Scalp Psoriasis
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Difficult to treat because hair
blocks UV light and topical
applications of medications.
Mild Cases
 Topical corticosteroids (foams,
liquids, gels)
 Topical Dovonex (liquid)
 Anti-dandruff shampoos with
sal.acid or tar component)
Moderate-Severe Cases:
 Consider systemic agents:
 MTX
 Retinoids
 Biologics
Management of Psoriasis:
Topical Treatments
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Techniques:
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Occlusion of Topical Steroids
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Generally a medium-potency agent is applied
and is then covered with a polyethylene wrap
such as Saran Wrap for several hours or
overnight, if tolerated. Cordran tape is
similarly effective.
“Wet Wraps”
Wet Wrap Therapy
Cotton clothing
Cotton tube socks
Triamcinolone/Vanicream
Management of Psoriasis:
Systemic Treatments
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Phototherapy
Systemic Therapy
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Methotrexate
 DMARD
 Inexpensive
 Possible hepatic fibrosis, bone marrow
suppression.
 Liver Biopsy at 1500mg, Cat X
Soriatane
 Oral retinoid family
 Category X, higher cost
 Lipid elevation, myalgias, hair loss
Cyclosporine
 Immunosuppressant (T-cells)
 Frequent BW
 Risks to kidney function
Management of Psoriasis:
Systemic Treatments
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Biologic Therapy
adalimumab (Humira)
 alafecept (Amevive)
 efalizumab (Raptiva)
 etanercept (Enbrel)
 infliximab (Remicade)
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Management of Psoriasis:
Biologics
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Summary:
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Advantages:
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Manufactured proteins
Some have been around many years for other auto-immune conditions
All given via injection (SC, IM or IV)
Focus on T-cell or cytokine actions instead of total immune system
Effective/fairly quick onset
Relatively low risk profile
Disadvantages:
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Cost
Long term side effects unknown
Pathophysiology
www.gene.com
Cautions:
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What else causes scaling plaques or patches?
Lichen simplex chronicus
 Nummular eczema
 Fungal infections: Tinea corporis/cruris, Candidiasis
 Extramammary Paget’s
 Pityriasis Rubra Pilaris
 Bowen’s disease (SCCA in situ)
 CTCL (cutaneous T-cell lymphoma)
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Medication Cautions
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Don’t forget to look at medications:
Beta-blockers
 ACE Inhibitors
 Lithium
 Interferon (all psoriasis patients get worse with this)
 Anti-malarials (can worsen)
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Differential Diagnosis:
Bowen’s Disease
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Bowen’s Disease
(Squamous Cell
Carcinoma In Situ)
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Patients have a solitary
lesion.
The lesion may resemble
a typical psoriatic plaque.
It is unresponsive to
topical steroids.
Bowens Disease
Differential Diagnosis:
Pityriasis Rubra Pilaris
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Usually progresses in cephalocaudal
fashion.
Usually older adults
Reddish-orange scale/plaques
“Islands of sparing”
Waxy palms/soles
Tx: Oral retinoids, MTX
Differential Diagnosis:
Cutaneous T-Cell Lymphoma
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T cell lymphoma’s 1st
manifestation in the skin
Randomly distributed
Early stages:
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Often misdiag. as eczema,
tinea or psoriasis
Annular, oval or arciform
scaling patches
“Cigarette-paper”
appearance
Outlook/What’s Ahead for
Psoriasis?
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IL-12/IL-23 inhibitors:
CNTO 1275 (Centocor)
 ABT 874 (Abbott)
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Oral anti-TNF’s:
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CC-10004 (Celgene)
QUESTIONS????