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Psoriasis Georgia Skin and Cancer Clinic Chris Anderson ANP What is Psoriasis? Psoriasis is a chronic skin condition of unknown cause Causes red/scaly patches Usually lifelong/relapsing Wide range of distribution History: 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? 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 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 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 KÖEBNER PHENOMENON Lesions can appear in traumatized/damaged areas of skin Trauma Sun lamp burn Radiation Distribution of Lesions 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 Palmoplantar psoriasis Psoriatic Nails Psoriatic Arthritis Inverse psoriasis Erythrodermic psoriasis (exfoliative dermatitis) Variations of Psoriasis Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Inverse psoriasis Psoriasis in children Variations of Psoriasis Localized psoriasis Localized Plaque Psoriasis Basics 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 Diagnosis Usually based on exam Family history, aggravating factors and nail findings often helpful Skin biopsy and fungal examinations can be performed Variations of Psoriasis Localized psoriasis Scalp Psoriasis Scalp Psoriasis 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 Localized psoriasis Scalp Psoriasis Generalized psoriasis Generalized Plaque Psoriasis Basics 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 Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate Psoriasis Guttate Psoriasis Basics DDx Pityriasis Rosea, drug rash, secondary syphilis Treatment 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 Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriasis of the Palms and Soles Basics Hyperkeratotic type: Pustular type: 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 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 Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Psoriatic Nails 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 Typical Nail Changes: 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 Treatment is generally unrewarding, but some measures can be helpful: 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 Localized psoriasis Scalp Psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Inverse psoriasis Inverse Psoriasis 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 Localized psoriasis Scalp psoriasis Generalized psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic nails Inverse psoriasis Psoriasis in Children Psoriasis in Children Basics 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 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 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??? Treatment based on severity: Proportion of body surface affected Disease activity Response to previous treatments **Impact on each individual Assessment Tools: PASI Physician’s Global Assessment NPF-Psoriasis Score Dermatology Life Quality Index Management of Psoriasis “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 Topical Corticosteroids 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 Calcipotriene 0.005% 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 Tazarotene 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 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 Techniques: Occlusion of Topical Steroids 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 Phototherapy Systemic Therapy 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 Biologic Therapy adalimumab (Humira) alafecept (Amevive) efalizumab (Raptiva) etanercept (Enbrel) infliximab (Remicade) Management of Psoriasis: Biologics Summary: Advantages: 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: Cost Long term side effects unknown Pathophysiology www.gene.com Cautions: 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) Medication Cautions Don’t forget to look at medications: Beta-blockers ACE Inhibitors Lithium Interferon (all psoriasis patients get worse with this) Anti-malarials (can worsen) Differential Diagnosis: Bowen’s Disease Bowen’s Disease (Squamous Cell Carcinoma In Situ) 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 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 T cell lymphoma’s 1st manifestation in the skin Randomly distributed Early stages: Often misdiag. as eczema, tinea or psoriasis Annular, oval or arciform scaling patches “Cigarette-paper” appearance Outlook/What’s Ahead for Psoriasis? IL-12/IL-23 inhibitors: CNTO 1275 (Centocor) ABT 874 (Abbott) Oral anti-TNF’s: CC-10004 (Celgene) QUESTIONS????