1. 1 PsoriasisPsoriasis Dr. Majdy Naim

2. 2 PrevalencePrevalence Psoriasis occurs in 2% of the world’s population Psoriasis occurs in 2% of the world’s population Prevalence in the U.S may be as high as 4.6% Prevalence in the U.S may be as high as 4.6% Highest in Caucasians Highest in Caucasians In Africans, African Americans and Asians between 0.4% and 0.7% In Africans, African Americans and Asians between 0.4% and 0.7%

3. 3 Equal frequency in males and females Equal frequency in males and females May occur at any age from infancy to the 10 th decade of life May occur at any age from infancy to the 10 th decade of life

4. 4 PrevalencePrevalence Two Peaks of Occurrence Two Peaks of Occurrence –One at 20-30 years –One at 50-60 years Psoriasis in children Psoriasis in children –Low – between 0.5 and 1.1% in children 16 years old and younger –Mean age of onset - between 8 and 12.5 years

5. 5 PrevalencePrevalence Two-thirds of patients have mild disease Two-thirds of patients have mild disease One-third have moderate to severe disease One-third have moderate to severe disease Early onset (prior to age 15) Early onset (prior to age 15) –Associated with more severe disease –More likely to have a positive family history Life-long disease Life-long disease –Remitting and relapsing unpredictably –Spontaneous remissions of up to 5 years have been reported in approximately 5% of patients

6. 6 Psoriasis as a Systemic Disease Koebner Phenomenon Koebner Phenomenon Elevated ESR Elevated ESR Increased uric acid levels → gout Increased uric acid levels → gout Mild anemia Mild anemia Elevated α 2 -macroglobulin Elevated α 2 -macroglobulin Elevated IgA levels Elevated IgA levels Increased quantities of Immune Complexes Increased quantities of Immune Complexes

7. 7 Psoriasis as a Systemic Disease Psoriatic arthropathy Psoriatic arthropathy Aggravation of psoriasis by systemic factors Aggravation of psoriasis by systemic factors –Medication –Focal infections –Stress Life-threatening forms of psoriasis Life-threatening forms of psoriasis

8. 8 Characteristic Lesion of Psoriasis Sharply demarcated erythematous plaque with silvery white scale Sharply demarcated erythematous plaque with silvery white scale

9. 9 Clinical Variants of Psoriasis

10. 10 Chronic Plaque Psoriasis Chronic Plaque Psoriasis Guttate Psoriasis Guttate Psoriasis Psoriasis of the scalp Psoriasis of the scalp Psoriasis of the Nail Psoriasis of the Nail Psoriasis arthropathy Psoriasis arthropathy Pusutlar psoriasis Pusutlar psoriasis Psoriasis inversa Psoriasis inversa

11. 11 Chronic Plaque Psoriasis Most Common Variant Most Common Variant Plaques may be as large as 20 cm Plaques may be as large as 20 cm Symmetrical disease Symmetrical disease Sites of Predilection Sites of Predilection –Elbows –Knees –Presacrum –Scalp –Hands and Feet

12. 12 Chronic Plaque Psoriasis

13. 13 Chronic Plaque Psoriasis

14. 14 Chronic Plaque Psoriasis

15. 15 Chronic Plaque Psoriasis

16. 16 Chronic Plaque Psoriasis

17. 17 Chronic Plaque Psoriasis

18. 18 Chronic Plaque Psoriasis May be widespread – up to 90% BSA May be widespread – up to 90% BSA Genitalia involved in up to 30% of patients Genitalia involved in up to 30% of patients Most patients have nail changes Most patients have nail changes –Nail pitting –“Oil Spots” –Involvement of the entire nail bed  Onychodystrophy  Loss of nail plate

19. 19 Widespread Chronic Plaque Psoriasis

20. 20 Chronic Psoriasis

21. 21

22. 22

23. 23 Psoriasis of the Nail

24. 24 Psoriasis of the Nail

25. 25

26. 26

27. 27 Symptoms of Chronic Plaque Psoriasis Pruritus Pruritus Pain Pain Excessive heat loss Excessive heat loss Patient Complaints Patient Complaints –Unsightliness of the lesions –Low self-esteem –Feelings of being socially outcast –Excessive scale

28. 28 Guttate Psoriasis Characterized by numerous 0.5 to 1.5 cm papules and plaques Characterized by numerous 0.5 to 1.5 cm papules and plaques Early age of onset Early age of onset Most common form in children Most common form in children Streptococcal throat infection often a trigger Streptococcal throat infection often a trigger Spontaneous remissions in children Spontaneous remissions in children Often chronic in adults Often chronic in adults

29. 29 Guttate Psoriasis

30. 30 Guttate Psoriasis

31. 31 Guttate Psoriasis

32. 32 Guttate Psoriasis

33. 33 Psoriasis inversa

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35. 35

36. 36 Psoriasis arthropatica

37. 37

38. 38 Psoriasis aggravated by sun

39. 39 Pustular psoriasis

40. 40 Pustular psoriasis

41. 41 Pustular psoriasis

42. 42 Pustular psoriasis

43. 43 Acrodermatitis continua of hallopeau

44. 44 Pustular psoriasis

45. 45 Life–Threatening Forms of Psoriasis Generalized Pustular Psoriasis Generalized Pustular Psoriasis Erythrodermic Psoriasis Erythrodermic Psoriasis

46. 46 Generalized Pustular Psoriasis Unusual manifestation of psoriasis Unusual manifestation of psoriasis Can have a gradual or an acute onset Can have a gradual or an acute onset Characterized by waves of pustules on erythematous skin often after short episodes of fever of 39˚ to 40˚C Characterized by waves of pustules on erythematous skin often after short episodes of fever of 39˚ to 40˚C Weight loss Weight loss Muscle Weakness Muscle Weakness Hypocalcemia Hypocalcemia Leukocytosis Leukocytosis Elevated ESR Elevated ESR

47. 47 Generalized Pustular Psoriasis Cause is obscure Cause is obscure Triggering Factors Triggering Factors –Infection –Pregnancy –Lithium –Hypocalcemia secondary to hypoalbuminemia –Irritant contact dermatitis –Withdrawal of glucocorticosteroids, primarily systemic

48. 48 Generalized Pustular Psoriasis

49. 49

50. 50 Erythrodermic Psoriasis Classic lesion is lost Classic lesion is lost Entire skin surface becomes markedly erythematous with desquamative scaling. Entire skin surface becomes markedly erythematous with desquamative scaling. Often only clues to underlying psoriasis are the nail changes and usually facial sparing Often only clues to underlying psoriasis are the nail changes and usually facial sparing

51. 51 Erythrodermic Psoriasis Triggering Factors Triggering Factors –Systemic Infection –Withdrawal of high potency topical or oral steroids –Withdrawal of Methotrexate –Phototoxicity –Irritant contact dermatitis

52. 52 Erythrodermic Psoriasis

53. 53

54. 54 TherapyTherapy Wide range of therapies for the treatment of moderate to severe psoriasis Wide range of therapies for the treatment of moderate to severe psoriasis None induce a permanent remission None induce a permanent remission All have side effects that can place limits on their use All have side effects that can place limits on their use

55. 55 Therapies Therapies –Topical Corticosteroids –Topical Vitamin D 3 Analogues –Topical Retinoids –Photo(chemo)therapy –Systemic Therapies  Oral  Parenteral

56. 56 Topical Corticosteroids High potency and Super potent topical steroids High potency and Super potent topical steroids These include These include –Fluocinonide family (cream, ointment, gel) –Betamethasone dipropionate cream –Clobetasol propionate family (cream, ointment, gel, foam, lotion) –Diflorasone diacetate ointment –Betamethasone dipropionate ointment

57. 57 Topical Corticosteroids Side effects associated with use Side effects associated with use –Skin atrophy –Burning and stinging –Suppression of the hypothalamic- pituitary-adrenal (HPA) axis  This may occur after 2 weeks of use with certain topical corticosteroids

58. 58 Topical Vitamin D 3 Analogues Prototype for this group is calcipotriene Prototype for this group is calcipotriene 3 formulations – cream, ointment, and scalp solution 3 formulations – cream, ointment, and scalp solution Former two are approved for plaque psoriasis Former two are approved for plaque psoriasis Latter for moderate to severe psoriasis of the scalp Latter for moderate to severe psoriasis of the scalp

59. 59 Topical Vitamin D 3 Analogues Side Effects Side Effects –Cutaneous  Burning  Stinging  Pruritus  Skin irritation

60. 60 Topical Retinoids Tazarotene Gel and Cream Tazarotene Gel and Cream –Available in two strengths  0.05% and 0.1% –Side Effects  Pruritus  Burning/Stinging  Erythema  Worsening of psoriasis  Irritation  Skin pain  Hypertriglyceridemia

61. 61 Topical Tazarotene (con’t) Both products are pregnancy category X Both products are pregnancy category X Are contraindicated in women who are or may become pregnant Are contraindicated in women who are or may become pregnant Requirements before and during therapy Requirements before and during therapy –A negative pregnancy test 2 weeks prior –Therapy initiated during a normal menses –Women of childbearing potential should use adequate birth control

62. 62 Photo(chemo)therapyPhoto(chemo)therapy Two types of phototherapy Two types of phototherapy –Ultraviolet B (UVB) –Ultraviolet A + psoralen (PUVA)

63. 63 UVBUVB Two types Two types –Broadband UVB –Narrowband UVB (311-313 nm) Treatment is time consuming Treatment is time consuming –2-3 visits/week for several months Side effect – possibility of experiencing an acute sunburn reaction Side effect – possibility of experiencing an acute sunburn reaction

64. 64 PUVAPUVA Consists of ingestion of or topical treatment with a psoralen followed by UVA Consists of ingestion of or topical treatment with a psoralen followed by UVA Usually reserved for severe, recalcitrant, disabling psoriasis Usually reserved for severe, recalcitrant, disabling psoriasis Time consuming – 2-3 visits/wk; at least 6 weeks Time consuming – 2-3 visits/wk; at least 6 weeks Precautions Precautions –Patients must be protected from further UV light for 24 hours post treatment –With oral psoralen, wrap around UV-blocking glasses must be worn for 24 hours post treatment

65. 65 PUVAPUVA Side effects with oral psoralen Side effects with oral psoralen –Nausea –Dizziness –Headache Side effects with PUVA Side effects with PUVA –Early  Pruritus –Late  Skin damage  Increased risk for skin cancer, particularly squamous cell (SCC) and after 200 - 250 treatments, increased risk for melanoma

66. 66 Contraindications to PUVA Patients less than 12 years of age Patients less than 12 years of age Patients with a history of light sensitive disease states Patients with a history of light sensitive disease states Patients with, or with a history of melanoma Patients with, or with a history of melanoma Patients with invasive SCC Patients with invasive SCC

67. 67 Systemic Therapies Oral Oral –Methotrexate –cyclosporine –Acitretin Parenteral –Amevive (alefacept) –Raptiva (efalizimab) –Enbrel (etanercept)

68. 68 MethotrexateMethotrexate Folic acid antagonist Folic acid antagonist Usually reserved for severe, recalcitrant, disabling psoriasis Usually reserved for severe, recalcitrant, disabling psoriasis Maximum improvement can be expected after 8 -12 weeks Maximum improvement can be expected after 8 -12 weeks

69. 69 Contraindications - Methotrexate Nursing mothers Nursing mothers Patients with alcoholism Patients with alcoholism Alcoholic liver disease Alcoholic liver disease Other chronic liver disease Other chronic liver disease Patients with overt or laboratory evidence of immunodeficiency syndromes Patients with overt or laboratory evidence of immunodeficiency syndromes Patients who have preexisting blood dyscrasias Patients who have preexisting blood dyscrasias

70. 70 MethotrexateMethotrexate Pregnancy Category X drug product Pregnancy Category X drug product –Contraindicated in pregnant women with psoriasis –Pregnancy must be excluded in women of childbearing potential –Pregnancy should be avoided if either partner is receiving MTX during and for a minimum of 3 months after therapy for male patients and for at least one ovulatory cycle after therapy for female patients

71. 71 Methotrexate – Side Effects Acute or chronic hepatotoxicity Acute or chronic hepatotoxicity Hepatic cirrhosis Hepatic cirrhosis Leukopenia Leukopenia Thrombocytopenia Thrombocytopenia Anemia, including aplastic anemia Anemia, including aplastic anemia Rarely, interstitial pneumonitis Rarely, interstitial pneumonitis Stomatitis Stomatitis Nausea/vomiting Nausea/vomiting Alopecia Alopecia Photosensitivity Photosensitivity Burning of skin lesions Burning of skin lesions

72. 72 CyclosporineCyclosporine Potent Immunosuppressive Potent Immunosuppressive Adult, non-immunocompromised patients with severe, recalcitrant plaque psoriasis Adult, non-immunocompromised patients with severe, recalcitrant plaque psoriasis Maximum efficacy achieved at 16 weeks of therapy Maximum efficacy achieved at 16 weeks of therapy

73. 73 Contraindications - Cyclosporine Concomitant PUVA or UVB therapy Concomitant PUVA or UVB therapy Methotrexate or other immunosuppressive agents Methotrexate or other immunosuppressive agents Coal tar or radiation therapy Coal tar or radiation therapy Patients with abnormal renal function Patients with abnormal renal function Patients with uncontrolled hypertension Patients with uncontrolled hypertension Patients with malignancies Patients with malignancies Nursing mothers Nursing mothers

74. 74 Cyclosporine– Side Effects Possibility of Irreversible renal damage Possibility of Irreversible renal damage Hypertension Hypertension Headache Headache Hypertriglyceridemia Hypertriglyceridemia Hirsutism/hypertrichosis Hirsutism/hypertrichosis Paresthesia/hyperesthesia Paresthesia/hyperesthesia Influenza-like symptoms Influenza-like symptoms Nausea/vomiting Nausea/vomiting Diarrhea Diarrhea Arthralgia Arthralgia

75. 75 CyclosporineCyclosporine Multiple prescreening tests are required Multiple prescreening tests are required

76. 76 AcitretinAcitretin Oral retinoid approved for the treatment of severe psoriasis in adults Oral retinoid approved for the treatment of severe psoriasis in adults Significant improvement can be achieved with 8 weeks of therapy Significant improvement can be achieved with 8 weeks of therapy

77. 77 Acitretin - Contraindications Patients with severely impaired liver or kidney function Patients with severely impaired liver or kidney function Patients with chronic abnormally elevated blood lipid values Patients with chronic abnormally elevated blood lipid values Patients who are taking methotrexate Patients who are taking methotrexate Ethanol use when on therapy and for 2 months following therapy in female patients Ethanol use when on therapy and for 2 months following therapy in female patients

78. 78 AcitretinAcitretin Pregnancy Category X drug product as it is a human teratogen Pregnancy Category X drug product as it is a human teratogen Contraindicated in pregnant females or those who intend to become pregnant during therapy or any time up to three years post therapy Contraindicated in pregnant females or those who intend to become pregnant during therapy or any time up to three years post therapy

79. 79 Acitretin– Side Effects Those associated with retinoid therapy Those associated with retinoid therapy –Cheilitis –Alopecia –Skin peeling –Dry skin –Pruritus –Rhinitis –Xeropthalmia –Arthralgia

80. 80 Acitretin– Side Effects Laboratory Abnormalities Laboratory Abnormalities –Hypertriglyceridemia (66%) –Decreased HDL (40%) –Hypercholesterolemia (33%) –Elevated liver function tests (33%) –Elevated alkaline phosphatase (10-25%) –Hyperglycemia (10-25%) –Elevated CPK (10-25%) Hepatitis and jaundice occurred in < 1% of patients in clinical trials on Soriatane Hepatitis and jaundice occurred in < 1% of patients in clinical trials on Soriatane

81. 81 AcitretinAcitretin Multiple prescreening tests must be obtained Multiple prescreening tests must be obtained Continued monitoring throughout therapy necessary with possible dosage adjustment Continued monitoring throughout therapy necessary with possible dosage adjustment

82. 82 Thank you for your attention!