1. Psoriasis Georgia Skin and Cancer Clinic Chris Anderson ANP

2. What is Psoriasis? Psoriasis is a chronic skin condition of unknown cause Psoriasis is a chronic skin condition of unknown cause Causes red/scaly patches Causes red/scaly patches Usually lifelong/relapsing Usually lifelong/relapsing Wide range of distribution Wide range of distribution History: History: Ancient condition; widely confused Ancient condition; widely confused Grouped with Leprosy at one time Grouped with Leprosy at one time Differentiated in 18th century by Dr. Ferdinand Von Hebra as psoriasis Differentiated in 18th century by Dr. Ferdinand Von Hebra as psoriasis

3. The Many Faces of Psoriasis

18. Who has Psoriasis? Often first seen ages 15-25 Often first seen ages 15-25 1/3 have a family history 1/3 have a family history 1-2 % of the world affected. 1-2 % of the world affected. More common in Caucasians More common in Caucasians Found equally in men and women. Found equally in men and women. Famous people with psoriasis: Famous people with psoriasis: Benjamin Franklin, Jerry Mathers, Art Garfunkel, John Updike Benjamin Franklin, Jerry Mathers, Art Garfunkel, John Updike

19. Pathophysiology Epidermis has rapid accumulation of cells (accounts for the classic psoriatic lesion) 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. 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. Most current therapies are directed at suppression of responsible T cells. www.psoriasis.or.id

20. Pathophysiology www.gene.com

21. Clinical Manifestations Integument: Integument: Silvery scale on an erythematous base Silvery scale on an erythematous base Auspitz’s sign Auspitz’s sign ***Koebner’s phenomenon ***Koebner’s phenomenon Arthritis: Arthritis: 10-30% of patients 10-30% of patients Pruritus: Pruritus: Varies from asymptomatic to quite pruritic Varies from asymptomatic to quite pruritic Psychosocial problems: Psychosocial problems: Poor self-esteem Poor self-esteem Exacerbating factors: Exacerbating factors: Stress, winter months (UV exposure) Stress, winter months (UV exposure) Illness: Strep pharyngitis, HIV Illness: Strep pharyngitis, HIV Meds: anti-malarials, beta-blockers, lithium, interferon Meds: anti-malarials, beta-blockers, lithium, interferon Excessive alcohol consumption Excessive alcohol consumption

22. Clinical Manifestations KÖEBNER PHENOMENON KÖEBNER PHENOMENON Lesions can appear in traumatized/damaged areas of skin Lesions can appear in traumatized/damaged areas of skin Trauma Sun lamp burn Radiation

23. Distribution of Lesions Wide range of distribution Wide range of distribution Can range from one small localized plaque to generalized exfoliative erythroderma Can range from one small localized plaque to generalized exfoliative erythroderma Usually symmetrical Usually symmetrical Usually spares the face Usually spares the face www.aafp.org

24. Variations of Psoriasis

25. Localized psoriasis Localized psoriasis Scalp Psoriasis Scalp Psoriasis Generalized psoriasis Generalized psoriasis Guttate psoriasis Guttate psoriasis Psoriasis in children Psoriasis in children Palmoplantar psoriasis Psoriatic Nails Psoriatic Arthritis Inverse psoriasis Erythrodermic psoriasis (exfoliative dermatitis)

26. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp Psoriasis Scalp Psoriasis Generalized psoriasis Generalized psoriasis Guttate psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Inverse psoriasis Psoriasis in children

27. Variations of Psoriasis Localized psoriasis

28. Localized Plaque Psoriasis Basics Basics Mildest manifestation Mildest manifestation Often an incidental finding Often an incidental finding May consist of nail pitting or mild patches on elbows or knees. May consist of nail pitting or mild patches on elbows or knees. Patient often unaware or not troubled Patient often unaware or not troubled

29. Localized Plaque Psoriasis Diagnosis Diagnosis Usually based on exam Usually based on exam Family history, aggravating factors and nail findings often helpful Family history, aggravating factors and nail findings often helpful Skin biopsy and fungal examinations can be performed Skin biopsy and fungal examinations can be performed

30. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp Psoriasis

31. Basics Basics May involve the scalp alone or included other areas. May involve the scalp alone or included other areas. Plaques frequently hidden in the scalp or behind the ears. Plaques frequently hidden in the scalp or behind the ears. Plaques often thick and well demarcated with a white scale. Plaques often thick and well demarcated with a white scale. Pruritus and scratching may exacerbate (Koebner’s) Pruritus and scratching may exacerbate (Koebner’s) Psoriasis around hairline

32. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp Psoriasis Generalized psoriasis

33. Generalized Plaque Psoriasis Basics Basics Can flare very quickly Can flare very quickly May cover 20% to 80% of the body May cover 20% to 80% of the body Topical therapy alone becomes less effective Topical therapy alone becomes less effective UV light treatment, systemic medications and/or biologics may be necessary UV light treatment, systemic medications and/or biologics may be necessary

34. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp Psoriasis Scalp Psoriasis Generalized psoriasis Generalized psoriasis Guttate Psoriasis

35. Basics 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. DDx Pityriasis Rosea, drug rash, secondary syphilis Treatment Abx therapy if positive ASO. Consider traditional treatment for poor responders. www.psoriasis.org

36. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp Psoriasis Scalp Psoriasis Generalized psoriasis Generalized psoriasis Guttate psoriasis Guttate psoriasis Palmoplantar psoriasis

37. Psoriasis of the Palms and Soles Basics Basics Hyperkeratotic type: Hyperkeratotic type: Well-demarcated plaques. Well-demarcated plaques. Koebner’s phenomenon? Koebner’s phenomenon? Often cause pain, impairment of function, and embarrassment. Often cause pain, impairment of function, and embarrassment. Pustular type: Pustular type: Usually seen in adults Usually seen in adults Yellow pustules (sterile) Yellow pustules (sterile) DDx: DDx: Contact dermatitis Contact dermatitis Dishydrosis Dishydrosis Tinea Tinea

38. Psoriasis of the Palms and Soles Treatment Treatment Topicals are the first line Topicals are the first line Class I TCS needed to penetrate thicker stratum corneum, often under occlusion. Class I TCS needed to penetrate thicker stratum corneum, often under occlusion. Systemics or Biologics for poor responders Systemics or Biologics for poor responders

39. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp Psoriasis Scalp Psoriasis Generalized psoriasis Generalized psoriasis Guttate psoriasis Guttate psoriasis Palmoplantar psoriasis Palmoplantar psoriasis Psoriatic Nails

40. Basics Basics Nail involvement common. Nail involvement common. Usually cosmetic condition only. Usually cosmetic condition only. More common in patients with generalized psoriasis and psoriatic arthritis. More common in patients with generalized psoriasis and psoriatic arthritis. DDx: DDx: Onychomycosis Onychomycosis Paronychia Paronychia Contact dermatitis Contact dermatitis www.dartmouth.edu www.psoriasis.org

41. Psoriatic Nails Typical Nail Changes: Typical Nail Changes: Pitting Pitting Classic nail finding in psoriasis. 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. Produced by tiny punctate lesions that arise from the nail matrix and appear on the nail plate as it grows. Onycholysis Onycholysis Represents a separation of the nail plate from underlying pink nail bed. Represents a separation of the nail plate from underlying pink nail bed. “Oil Spots” “Oil Spots” Orange-brown areas appearing under the nail plate. Presumably the result of psoriasis of the nail bed. Orange-brown areas appearing under the nail plate. Presumably the result of psoriasis of the nail bed. Subungual hyperkeratosis: Subungual hyperkeratosis: Buildup of scale beneath the nail plate. Buildup of scale beneath the nail plate. Onycholysis Pitting

42. Psoriatic Nails Treatment is generally unrewarding, but some measures can be helpful: Treatment is generally unrewarding, but some measures can be helpful: Careful trimming and paring of the nails are recommended. Careful trimming and paring of the nails are recommended. Topical steroids need to be directed toward the proximal fold (closer to matrix) Topical steroids need to be directed toward the proximal fold (closer to matrix) Intralesional steroids can be injected into the nail matrix Intralesional steroids can be injected into the nail matrix Consider systemic/biologic therapy based on the situation Consider systemic/biologic therapy based on the situation

43. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp Psoriasis Scalp Psoriasis Generalized psoriasis Generalized psoriasis Guttate psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic Nails Inverse psoriasis

44. Inverse Psoriasis Variation that occurs in flexural areas Variation that occurs in flexural areas Under breasts, axillary, gluteal cleft, anogenital Under breasts, axillary, gluteal cleft, anogenital Koebner’s may play part Koebner’s may play part Often mistaken for candidal infection. Often mistaken for candidal infection. Psoriasis. org Emedicinehealth.com

45. Variations of Psoriasis Localized psoriasis Localized psoriasis Scalp psoriasis Scalp psoriasis Generalized psoriasis Generalized psoriasis Guttate psoriasis Guttate psoriasis Palmoplantar psoriasis Psoriatic nails Inverse psoriasis Psoriasis in Children

46. Basics Basics Begins before age 10 in 10% of those with psoriasis. Begins before age 10 in 10% of those with psoriasis. Early onset may predict more severe disease. Early onset may predict more severe disease. Often an associated family history. Often an associated family history. May be difficult to distinguish from irritant/atopic dermatitis or cutaneous candidiasis. May be difficult to distinguish from irritant/atopic dermatitis or cutaneous candidiasis. May also present with typical plaques. May also present with typical plaques. Requires intensive educational of the patient and family. Requires intensive educational of the patient and family.

47. Infantile Psoriasis

49. Psoriasis in Children Treatments: 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. 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 Low to medium potency topical steroids Calcipotriene (Dovonex) Calcipotriene (Dovonex) Keratolytics Keratolytics Natural sunlight if available. Natural sunlight if available. Some success with biologic therapy (off label??) Some success with biologic therapy (off label??)

50. Management of Psoriasis

51. Aimed at: Aimed at: Decreasing size/thickness of plaques Decreasing size/thickness of plaques Relieving pruritus and/or arthritis Relieving pruritus and/or arthritis Improving self-image Improving self-image Education: Education: Disease process Disease process Treatment options Treatment options Support Groups: Support Groups: National Psoriasis Foundation (www.psoriasis.org) National Psoriasis Foundation (www.psoriasis.org) Psoriasis Connections (www.psoriasisconnect.com) Psoriasis Connections (www.psoriasisconnect.com)

52. Management of Psoriasis: Where Do I Start??? Treatment based on severity: Treatment based on severity: Proportion of body surface affected Proportion of body surface affected Disease activity Disease activity Response to previous treatments Response to previous treatments **Impact on each individual **Impact on each individual Assessment Tools: Assessment Tools: PASI PASI Physician’s Global Assessment Physician’s Global Assessment NPF-Psoriasis Score NPF-Psoriasis Score Dermatology Life Quality Index Dermatology Life Quality Index

53. Management of Psoriasis “Old” paradigm “Old” paradigm Follows a sequential stepwise progression Follows a sequential stepwise progression Patients must fail the previous “step” Patients must fail the previous “step” En.Wikipedia.org

54. Management of Psoriasis: New/Emerging Treatment Paradigm FAILURE OF TOPICALS? Oral Systemics MTX Soriatane CSA Phototherapy PUVA UVB Biologics Amevive Enbrel Humira Raptiva Remicade

55. Management of Psoriasis: Topical Treatments Topical Corticosteroids Topical Corticosteroids Popular method for treating psoriasis Popular method for treating psoriasis Advantages Advantages Rapid onset Rapid onset Variety of vehicles Variety of vehicles Variety of prices Variety of prices Disadvantages Disadvantages Steroid rosacea, local atrophy, hypothalamic-pituitary-adrenal suppression possible. Steroid rosacea, local atrophy, hypothalamic-pituitary-adrenal suppression possible.

56. Management of Psoriasis: Topical Treatments Calcipotriene 0.005% Calcipotriene 0.005% Topical vitamin D3 Topical vitamin D3 Cream, ointment, solution Cream, ointment, solution Advantages Advantages Good maintenance therapy Good maintenance therapy Effective in reducing scale Effective in reducing scale No tachyphylaxis reported No tachyphylaxis reported Disadvantages Disadvantages Expensive, slow onset Expensive, slow onset Additional Suggestions Additional Suggestions Use in rotational therapy with TCS. Use in rotational therapy with TCS.

57. Management of Psoriasis: Topical Treatments Tazarotene Tazarotene Topical retinoid derivative Topical retinoid derivative Advantages Advantages Remissions are possibly longer Remissions are possibly longer No tachyphylaxis reported No tachyphylaxis reported Disadvantages Disadvantages Expensive, often irritating, slow onset Expensive, often irritating, slow onset Category X Category X Additional Suggestions Additional Suggestions Use in conjunction with topical steroids to minimize irritation. Use in conjunction with topical steroids to minimize irritation.

58. 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

59. Management of Psoriasis: Topical Treatments Techniques: Techniques: Occlusion of Topical Steroids 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. 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 Wraps”

60. Wet Wrap Therapy Cotton clothing Cotton tube socks Triamcinolone/Vanicream

61. Management of Psoriasis: Systemic Treatments Phototherapy Phototherapy Systemic Therapy Systemic Therapy Methotrexate Methotrexate DMARD DMARD Inexpensive Inexpensive Possible hepatic fibrosis, bone marrow suppression. Possible hepatic fibrosis, bone marrow suppression. Liver Biopsy at 1500mg, Cat X Liver Biopsy at 1500mg, Cat X Soriatane Soriatane Oral retinoid family Oral retinoid family Category X, higher cost Category X, higher cost Lipid elevation, myalgias, hair loss Lipid elevation, myalgias, hair loss Cyclosporine Cyclosporine Immunosuppressant (T-cells) Immunosuppressant (T-cells) Frequent BW Frequent BW Risks to kidney function Risks to kidney function

62. Management of Psoriasis: Systemic Treatments Biologic Therapy Biologic Therapy adalimumab (Humira) adalimumab (Humira) alafecept (Amevive) alafecept (Amevive) efalizumab (Raptiva) efalizumab (Raptiva) etanercept (Enbrel) etanercept (Enbrel) infliximab (Remicade) infliximab (Remicade)

63. Management of Psoriasis: Biologics Summary: Summary: Manufactured proteins Manufactured proteins Some have been around many years for other auto-immune conditions Some have been around many years for other auto-immune conditions All given via injection (SC, IM or IV) All given via injection (SC, IM or IV) Advantages: Advantages: Focus on T-cell or cytokine actions instead of total immune system Focus on T-cell or cytokine actions instead of total immune system Effective/fairly quick onset Effective/fairly quick onset Relatively low risk profile Relatively low risk profile Disadvantages: Disadvantages: Cost Cost Long term side effects unknown Long term side effects unknown

64. Pathophysiology www.gene.com

65. Cautions: What else causes scaling plaques or patches? What else causes scaling plaques or patches? Lichen simplex chronicus Lichen simplex chronicus Nummular eczema Nummular eczema Fungal infections: Tinea corporis/cruris, Candidiasis Fungal infections: Tinea corporis/cruris, Candidiasis Extramammary Paget’s Extramammary Paget’s Pityriasis Rubra Pilaris Pityriasis Rubra Pilaris Bowen’s disease (SCCA in situ) Bowen’s disease (SCCA in situ) CTCL (cutaneous T-cell lymphoma) CTCL (cutaneous T-cell lymphoma)

66. Medication Cautions Don’t forget to look at medications: Don’t forget to look at medications: Beta-blockers Beta-blockers ACE Inhibitors ACE Inhibitors Lithium Lithium Interferon (all psoriasis patients get worse with this) Interferon (all psoriasis patients get worse with this) Anti-malarials (can worsen) Anti-malarials (can worsen)

67. Differential Diagnosis: Bowen’s Disease Bowen’s Disease (Squamous Cell Carcinoma In Situ) Bowen’s Disease (Squamous Cell Carcinoma In Situ) Patients have a solitary lesion. Patients have a solitary lesion. The lesion may resemble a typical psoriatic plaque. The lesion may resemble a typical psoriatic plaque. It is unresponsive to topical steroids. It is unresponsive to topical steroids. Bowens Disease

68. Differential Diagnosis: Pityriasis Rubra Pilaris Usually progresses in cephalocaudal fashion. Usually progresses in cephalocaudal fashion. Usually older adults Usually older adults Reddish-orange scale/plaques Reddish-orange scale/plaques “Islands of sparing” “Islands of sparing” Waxy palms/soles Waxy palms/soles Tx: Oral retinoids, MTX Tx: Oral retinoids, MTX

69. Differential Diagnosis: Cutaneous T-Cell Lymphoma T cell lymphoma’s 1st manifestation in the skin T cell lymphoma’s 1st manifestation in the skin Randomly distributed Randomly distributed Early stages: Early stages: Often misdiag. as eczema, tinea or psoriasis Often misdiag. as eczema, tinea or psoriasis Annular, oval or arciform scaling patches Annular, oval or arciform scaling patches “Cigarette-paper” appearance “Cigarette-paper” appearance

70. Outlook/What’s Ahead for Psoriasis? IL-12/IL-23 inhibitors: IL-12/IL-23 inhibitors: CNTO 1275 (Centocor) CNTO 1275 (Centocor) ABT 874 (Abbott) ABT 874 (Abbott) Oral anti-TNF’s: Oral anti-TNF’s: CC-10004 (Celgene) CC-10004 (Celgene)

71. QUESTIONS????