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Psoriasis and Management in Primary Care

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Psoriasis and Management in Primary Care

  2. 2.  Chronic skin disorder  Psora = itch  Also termed psoriasis vulgaris  T-cell mediated inflammatory disease  Accelerated epidermal turnover with hyperproliferation 2O to activation of immune system  Altered maturation of epidermal keratinocytes  Inflammation  Vascular changes
  3. 3. N Disorganized O R M A L 4 DERMIS STRATUM CORNEUM STRATUM GRANULOSUM STRATUM SPINOSUM STRATUM BASALE Neutrophil accumulation Immaturity Proliferation P S O R I A S I S
  4. 4.  Psoriasis occurs in 2% of the world’s population Highest in Caucasians (Scandinavian/European descent)  In Africans, African Americans and Asians between 0.4% and 0.7% Equal frequency in males and females May occur at any age from infancy to the 10th decade of life  First signs of psoriasis  Females mean age of 27 years  Males mean age of 29 years
  5. 5. Two Peaks of Occurrence  One at 20-30 years  One at 50-60 years 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
  6. 6.  Two-thirds of patients have mild disease  One-third have moderate to severe disease  Early onset (prior to age 15)  Associated with more severe disease  More likely to have a positive family history  Life-long disease  Remitting and relapsing unpredictably  Spontaneous remissions of up to 5 years have been reported in approximately 5% of patients
  7. 7. If you have psoriasis, what is the risk to: Your unrelated neighbor? About 2% Your sibling? 15-20% Your identical twin? 65-70% Your child? 25%
  8. 8. Genetic Factors: - 30% of people with psoriasis have had psoriasis in family - Autosomal dominant inheritance Nongenetic Factors: - Mechanical, ultraviolet, chemical injury - Infections: Strep, viral, HIV - Prescription drugs, stress, endocrine, hormonal, obesity, alcohol, smoking
  9. 9. 1. Immune abnormalities are profound 2. Psoriasis severity is associated with greater levels of systemic inflammation (e.g. CRP, Th-1 cytokines) 3. Inflammation may be a common pathway to a variety of diseases including atherosclerosis, obesity, and insulin resistance Krueger JG, Bowcock, A. Ann Rheum Dis 2005;64:30-36.
  10. 10.  Koebner Phenomenon  Elevated ESR  Increased uric acid levels → gout  Mild anemia  Elevated α2-macroglobulin  Elevated IgA levels  Increased quantities of Immune Complexes  Psoriatic arthropathy  Aggravation of psoriasis by systemic factors  Medication  Focal infections  Stress  Life-threatening forms of psoriasis
  11. 11.  Although psoriatic arthritis sometimes causes an increased erythrocyte sedimentation rate (ESR), mild anemia, and elevated blood uric acid levels, these symptoms are also associated with other rheumatic diseases, including gout  ESR and CRP can be normal in psoriatic arthritis Psoriatic arthritis, CP Rajendran, SG Ledge, Kanaka P Rani, Radha Madhavan JAPI • VOL. 51 • NOVEMBER 2003  Increasing PASI was linked to increasing CRP and a trend to higher elastase and lactoferrin. CRP levels were shown to correlate with PASI, total leucocytes, neutrophils, elastase, lactoferrin and α1-antitrypsin. Journal of the European Academy of Dermatology & Venereology , 24(7):789- 796
  12. 12.  Disease severity  85% Mild, 10% Moderate, 5% severe  Control of severe disease  50% of patients intensively treated continue to have very active disease (PUVA cohort)  75% of patients with severe disease are not receiving appropriate therapies (NPF survey)  Pathways affected and possible outcomes  Inflammatory atherosclerosis, thrombosis  Angiogenesis endothelial (endothelial progenitor cells)dysfunction  Metabolic oxidative stress
  14. 14. Risk factors •Genes •Environment Outcomes • Cancer • Cardiovascular disease • Metabolic disease • Arthritis • Mortality Mediating Factors • Pathophysiology (inflammation, hyper-proliferation, angiogenesis) • Treatment • Psychosocial impact
  15. 15. • Smoking • Obesity • Dyslipidemia • Hypertension • Diabetes Neiman AN, Porter S, and Gelfand JM. Expert Review of Derm. 2006;1:63-75
  16. 16. Psoriasis CAD MI Smoking HTN DM Obesity Lipids
  17. 17.  Psoriasis is independently associated with carotid atherosclerotic disease and impaired endothelial function Balci DD et al, Increased carotid artery intima-media thickness and impaired endothelial function in psoriasis JEADV ISSN 1468-3083  In patients with Psoriatic arthritis, psoriasis severity is an independent predictor of cardiovascular disease Gladman, DD et al. Cardiovascular morbidity in psoriatic arthritis. Ann Rheum Dis 2008.094839
  18. 18.  Sharply demarcated ERYTHEMATOUS plaque with silvery white scales typically on extensor surfaces  Symmetric  Pruritic/ Painful  Pitting Nails  Inflammatory arthropathy in 10-20% of patients, which in severe cases may be the dominant cause of morbidity  Histopathology  Thickening of the epidermis  Tortuous and dilated blood vessels  Inflammatory infiltrate primarily of lymphocytes
  19. 19. Type Characteristics Plaque psoriasis Guttate psoriasis Erythrodermic psoriasis Flexural psoriasis Pustular psoriasis Nail psoriasis Palmar/Plantar psoriasis Psoriatic arthritis Scalp psoriasis Dry scaling patches (AKA common psoriasis) 75% Drop-like dots, occurs after strep or viral infection 12% Exfoliation of fine scales (total body “dandruff”), widespread, often accompanied by severe itching and pain 7% Smooth, dry, red inflamed, lack of scales, appear on skin folds (underarm, buttocks, groin, breasts) Pus-like blisters, noninfectious, fluid contains white blood cells 2% Seen on toenails and fingernails, starts as numerous pits, at times progresses to yellowing, crumbly, and thickened nail; nails may slough Erythema, thickening and peeling of the skin, blistering is often present. Can lead to disability. Inflammation, swelling, and joint destruction Plaque-type lesion
  20. 20. AKA psoriasis vulgaris is the most common form of psoriasis.  It affects 80 to 90% of people with psoriasis.  Typically appears as raised areas of inflamed skin covered with silvery white scaly skin (plaques)
  21. 21. Plaques may be as large as 20 cm Symmetrical disease Sites of predilection Elbows Knees  Presacrum  Scalp Hands and Feet
  22. 22. Pruritus Pain Excessive heat loss Patient Complaints Unsightliness of the lesions Low self-esteem  Feelings of being socially outcast Excessive scale
  23. 23.  May be widespread – up to 90% BSA  Genitalia involved in up to 30% of patients Most patients have nail changes  Nail pitting  “Oil Spots”  Involvement of the entire nail bed Onychodystrophy Loss of nail plate
  24. 24. 28
  25. 25. 30
  26. 26.  Characterized by numerous 0.5 to 1.5 cm small oval (tear drop shaped) papules and plaques Appear over large areas of the body, such as the trunk, limbs, and scalp. Early age of onset Most common form in children  Streptococcal throat infection often a trigger and rashes develop 1-2 weeks following infection Spontaneous remissions in children  Often chronic in adults
  27. 27. 32 Guttate Psoriasis
  28. 28.  AKA inverse psoriasis appears as smooth inflamed patches of skin.  Occurs in skin folds, particularly around the genitals (between the thigh and groin), the armpits, under an overweight stomach (pannus), and under the breasts (inframammary fold).  It is aggravated by friction and sweat, and is vulnerable to fungal infections.
  29. 29.  appears as raised bumps that are filled with non-infectious pus (pustules).  skin under and surrounding pustules is red and tender.  can be localised, commonly to the hands and feet , or generalised with widespread patches occurring randomly on any part of the body.  May cause long lasting disability include palmoplantar chronic pustular psoriasis (palmoplantar pustulosis), acrodermatitis continua of Hallopeau (acropustulosis)
  30. 30.  Changes in the appearance of finger and toe nails including discolouring under the nail plate, pitting of the nails, lines going across the nails, thickening of the skin under the nail, and the loosening (onycholysis) and crumbling of the nail.
  31. 31.  Psoriatic arthritis involves joint and connective tissue inflammation.  Psoriatic arthritis can affect any joint but is most common in the joints of the fingers and toes.  This can result in a sausage-shaped swelling of the fingers and toes known as dactylitis.  Psoriatic arthritis can also affect the hips, knees and spine (spondylitis). About 10-15% of people who have psoriasis also have psoriatic arthritis.
  32. 32. 38
  33. 33. 1. Generalized Pustular Psoriasis 2. Erythrodermic Psoriasis  May be complicated by high-output cardiac failure, temperature dysregulation, and septicaemia, particularly in elderly patients.
  34. 34.  Unusual manifestation of psoriasis  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  Weight loss  Muscle Weakness  Hypocalcemia  Leukocytosis  Elevated ESR
  35. 35. Cause is obscure Triggering Factors  Infection  Pregnancy  Lithium  Hypocalcemia secondary to hypoalbuminemia  Irritant contact dermatitis Withdrawal of glucocorticosteroids, primarily systemic
  36. 36. Classic lesion is lost Entire skin surface becomes markedly erythematous with desquamative scaling. It may be accompanied by severe itching, swelling and pain. Often only clues to underlying psoriasis are the nail changes and usually facial sparing
  37. 37.  Triggering Factors  Systemic Infection  Withdrawal of high potency topical or oral steroids  Withdrawal of Methotrexate  Phototoxicity  Irritant contact dermatitis  Often the result of an exacerbation of unstable plaque psoriasis, particularly following the abrupt withdrawal of systemic treatment.  This form of psoriasis can be fatal, as the extreme inflammation and exfoliation disrupt the body's ability to regulate temperature and for the skin to perform barrier functions.
  38. 38.  In 78% of psoriatic patients  Fingernails>Toenails  Four changes 1. Onycholysis (= separation from nail bed) 2. Pitting* 3. Subungual debris accumulation 4. Color alterations *Pitting rules out a fungal infection
  39. 39. 47
  40. 40. In 10-20% of psoriasis patients Often seen in patients with nail and scalp psoriasis Peripheral interphalangeal joints No elevated serum levels of rheumatoid factors (as seen in rheumatoid arthritis, yet has all other features)
  41. 41. Diagnosis: 1. Based on the appearance of the skin. 2. There are no special blood tests or diagnostic procedures. 3. A skin biopsy (or scraping) may be needed to rule out other disorders and to confirm the diagnosis. 4. When the plaques are scraped, one can see pinpoint bleeding from the skin below (Auspitz's sign) University of Jordan/Faculty of Pharmacy 27/03/2011
  42. 42.  Three Cardinal Signs of Psoriatic Lesions  Plaque elevation  Erythema  Scale  Body Surface Area
  43. 43.  The Psoriasis Area Severity Index (PASI): - The most widely used measurement tool for psoriasis. - Combines the assessment of the severity of lesions and the area affected into a single score in the range 0 (no disease) to 72 (maximal disease). http://www.pasitraining.com/pasi_score/ http://pasi.corti.li/  Severity: - Mild - Moderate - Severe
  44. 44. 52
  45. 45.  Explanation/no cure  Treatment options (including none)  Patient’s expectation 1. Diagnostic difficulty 2. Education 3. Failed Topical 4. >30% skin surface 5. Increasing steroids 6. Pustular/erythrodermic 7. Systemic therapy
  46. 46.  50% of patients with moderate or worse disease are currently untreated  46% have topical therapy only  Reason dermatologists do not use more aggressive therapies  Safety concerns  Time consuming  Cost 1 Leonardi, 2003; 2 Market Measures/Cozint LLP, June 2003. Other therapies 54% Topicals only 46%
  47. 47. 1. Ryan S. Br J Nurs 2010;19:822-5 Two key disease processes underlie psoriasis1 Cell proliferation AIM: Reduced cell turnover time and reduce scale AIM: Prevent the infiltration of inflammatory cells into the epidermis Inflammation
  48. 48. Step 1- Topical1 • First step of treatment for mild-to-moderate plaque psoriasis • Calcipotriol + betamethasone dipropionate combination (Dovobet®) is recommended first-line therapy by the PCDS for most patients Step 2 – Second line1 • Patients with moderate-severe psoriasis at onset or patients with inadequate response to topicals • Phototherapy or oral agents i.e. methotrexate, acitretin, ciclosporin Step 3 – Biologics1 • Etanercept, infliximab, adalimumab, ustekinumab • If 2nd-line treatments ineffective or not tolerated – as per NICE guidance 1. Adapted from Primary Care Dermatology Society (PCDS) 2010. Available from www.pcds.org.uk (Last accessed 24 January 2012)
  49. 49. Treatment type Mode of action Treats inflammation Treats cell proliferation Emollients1 Reduce dryness, scaling and cracking  ? Topical corticosteroids2 Dampen down inflammation   Tar preparations1 Remove loose scales may act as an anti-inflammatory   Dithranol2 Suppresses production of skin cells   Vitamin D analogues2 Reduce excessive skin cell production   Vitamin D + steroid combination3 Reduce excessive skin cell production + dampen down inflammation   Tazarotene2 Slows production of skin cells   1.British National Formulary (BNF) BNF 62 Section 13.5.2; September 2011: 62. Available from www.bnf.org (Last accessed 19 January 2012) 2.Menter A et al. J Am Acad Dermatol 2009:60;643-659 3.Dovobet® Gel Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 9 January 2012)
  50. 50. Bandwidth Characteristics Narrowband UVB (311nm) • Patients receive TL01 narrowband UVB1 • UVB slows keratinocyte proliferation and differentiation2 • 3x weekly for 6-8 weeks (max. once weekly) • Equivalent to a two week holiday in the Mediterranean PUVA (Psoralen + UVA) • Penetrates skin more deeply than UVB3 • Used for those with a long history of PsO unresponsive to NBUVB3 – or considered first line for palmoplantar PsO • Maximum 150 exposures in a lifetime • Twice weekly for 5-10 weeks . 1. Gambichler T et al. J Am Acad Dermatol 2005:52;660-670 2. Menter A et al. J Am Acad Dermatol 2010:62;114-135 3. Lapolla, W et al. J Am Acad Dermatol 2011:64:936-949
  51. 51. Treatment Action Systemics Methotrexate1 5-25mg weekly (PO or SC) Folate antagonist with immunosuppressive, cytostatic and anti-inflammatory effects Acitretin1 (10-75mg OD) Retinoid – reduces keratinocyte production/turnover. Anti-inflammatory effects. Can combine with TLO1 Ciclosporin1 (3-5mg/kg/day) Calcineurin inhibitor – prevents T-cell activation from translation into the release of inflammatory cytokines Others Fumaric acid esters, Mycophenolate mofetil, Calcitriol Biologics TNF-α blockers2 Etanercept, Adalimumab, Infliximab Block activity of TNF alpha – the master regulator (central cytokine) involved in psoriasis2 Anti IL-12/23p40 Ustekinumab Neutralises all Th1(IL-12) and Th17(IL-23) cell-mediated responses 1. Menter A et al. J Am Acad Dermatol 2009;61:451-485 2. Menter A et al. J Am Acad Dermatol 2008;58:826-850
  52. 52.  Medications with the least potential for adverse reactions are preferentially employed.  As a first step, medicated ointments or creams are applied to the skin. If topical treatment fails to achieve the desired goal then the next step would be to expose the skin to ultraviolet (UV) radiation. This type of treatment is called phototherapy.  The third step involves the use of medications which are taken internally by pill or injection : systemic treatment.  Over time, psoriasis can become resistant to a specific therapy. Treatments may be periodically changed to prevent resistance developing (tachyphylaxis) and to reduce the chance of adverse reactions occurring: treatment rotation.
  55. 55.  Lubrication  Removal of scales  Slow down lesion proliferation  Pruritus management  Prevent complications  Lessen patient stress  Season and climate
  56. 56.  Aqueous cream  Hydrocortisone cream 1%  Betamethasone cream 0.025%  Betamethasone cream 0.1%  Clobetasol propionate cream 0.05%
  57. 57.  Moisturizes, lubricates and soothes dry and flaky skin *Recommended*  May be the only treatment for mild psoriasis  ?Minimises Koebner phenomenon  Produces occlusive film to limit water evaporation from skin/by osmotic effect increased hydration allows stratum corneum to swell scaling decreases, skin is more pliable, less itch, less scaling  Adverse Effect : contact dermatitis, folliculitis (rare)  When in control of psoriasis, regular use of emollients should continue to be encouraged  The only option available in our KK  AQUEOUS CREAM
  58. 58.  Reduce inflammation, itching and scaling  Anti-inflammatory effect  Decrease in vascular permeability, decreasing dermal edema and leukocyte penetration into skin  Antiproliferative effect  Immunosuppressive effect 69
  59. 59.  Not indicated for widespread psoriasis – careful supervision  Can enhance effects by occlusion ONLY in suitable patients  Reduce inflammation, itching and scaling  Anti-inflammatory effect  Decrease in vascular permeability, decreasing dermal edema and leukocyte penetration into skin  Antiproliferative effect  Immunosuppressive effect  Use for specific targeted flares, e.g. scalp (Dovobet® gel, Etrivex® Shampoo)  Consider combination products, e.g. Diprosalic® ointment for thick scale  Maybe hazardous for a number of reasons including:  Rebound relapses  Development of tolerance  Risk of generalised pustular psoriasis  Development of local/systemic toxicity due to impaired barrier function
  60. 60.  Ointments: helps hydrate; good for dry, hyperkeratotic, scaly lesions  Cream: for use on all areas, useful for infected lesions  Solutions: for scalp psoriasis, often contain alcohols which can be painful with open lesions 71
  61. 61.  Adverse Effects: (esp. with occlusion)  Systemic absorption  Dermal atrophy  Telangiectasis  Ecchymoses  Peri-orbital acne  Poor wound healing  Pyogenic infections