Psoriasis - UCSF Dermatology

Psoriasis
UCSF Dermatology
Last updated 10.25.10
Module Instructions
 The following module contains a number of
green, underlined terms which are
hyperlinked to the dermatology glossary, an
illustrated interactive guide to clinical
dermatology and dermatopathology.
 We encourage the learner to read all the
hyperlinked information.
Goals and Objectives
 The purpose of this module is to help medical
students develop a clinical approach to the
evaluation and initial management of patients
presenting with psoriasis.
 After completing this module, the medical student
will be able to:
•
•
•
•
•
Identify and describe the morphology of psoriasis
Describe the clinical features of psoriatic arthritis
List the basic principles of treatment for psoriasis
Discuss the psychosocial impact of psoriasis
Develop an initial treatment plan, including patient
education
• Discuss when to refer to a dermatologist
Psoriasis: The Basics
 Psoriasis is a chronic multisystem disease with
predominantly skin and joint manifestations
 Affects approximately 2% of the U.S. population
 Age of onset occurs in two peaks: ages 20-30 and ages
50-60, but can be seen at any age
 Waxes and wanes during a patient’s lifetime, is often
modified by treatment initiation and cessation and has
few spontaneous remissions
 There is a strong genetic component
• About 30% of patients with psoriasis have a first-degree
relative with the disease
Classification of Psoriasis
 Classification is based on morphological descriptions
 The types of psoriasis are:
• Plaque: scaly, erythematous patches, papules, and plaques that are
sometimes pruritic
• Inverse/Flexural: lesions are located in the skin folds
• Erythrodermic: generalized erythema covering nearly the entire
body surface area with varying degrees of scaling
• Pustular: clinically apparent pustules
• Rare, acute generalized variety called “von Zumbusch variant”
• Palmoplantar – localized involving palms and soles
• Guttate: presents with drop lesions, 1-10mm salmon-pink papules
with a fine scale
 Clinical findings in patients frequently overlap in more than
one category
 Different types of psoriasis may require different treatment
What Type of Psoriasis?
B
A
C
D
Guttate Psoriasis
Acute onset of raindropsized lesions on trunk
and extremities in
young adults, often
preceded by
streptococcal
pharyngitis
Inverse/Flexural Psoriasis
Erythematous plaques
in the axilla, groin,
inframammary region,
and other flexural areas.
May lack scale due to
moistness of area.
Pustular Psoriasis
Characterized by psoriatic lesions with pustules. Often
triggered by corticosteroid withdrawal. When
generalized, pustular psoriasis can be a lifethreatening. These patients should be hospitalized and
a dermatologist consulted.
Palmoplantar Psoriasis
May occur as either plaque type or pustular type.
Often very functionally disabling for the patient.
The skin lesions of reactive arthritis typically occur
on the palms and soles and are indistinguishable
from this form of psoriasis.
Psoriatic Erythroderma
Involves almost the entire
skin surface; skin is bright
red. Associated with fever,
chills, and malaise. Like
pustular psoriasis,
hospitalization is sometimes
required.
* See module on
erythroderma for more
information
Question
 How would you describe these lesions?
 What type of psoriasis does this patient have?
Plaque Psoriasis
 Well-demarcated plaques with overlying silvery
scale and underlying erythema
 Chronic plaque psoriasis is typically symmetric
and bilateral
 Plaques may exhibit:
• Auspitz sign (bleeding
after removal of scale)
• Koebner phenomenon
(lesions induced by
trauma)
Examples of Plaque Psoriasis
Plaque Psoriasis: The Basics
 PLAQUE PSORIASIS is the most common form,
affecting 80-90% of patients
 Approximately 80% of patients with plaque
psoriasis have mild to moderate disease –
localized or scattered lesions covering less than
5% of the body surface area (BSA)
 20% have moderate to severe disease affecting
more than 5% of the BSA or affecting crucial
body areas such as the hands, feet, face, or
genitals
Psoriasis: Pathogenesis
 Psoriasis is a hyperproliferative state
resulting in thick skin and excess scale
 Skin proliferation is caused by cytokines
released by immune cells
 Systemic treatments of psoriasis target
these cytokines and immune cells
Case One
Mr. Ronald Gilson
Case One: History
 HPI: Mr Gilson is a 24 year-old gentleman
who presents with a red lesion around his
belly button that has been present for one
month with occasional itching.
 He has been reading on the internet and
asks: “Do I have psoriasis?”
Case One, Question 1
 What elements in the history are important
to ask when considering the diagnosis of
psoriasis?
a.
b.
c.
d.
e.
Recent illnesses / Past medical history
Medications
Family history
Social history
All of the above
Case One, Question 1
Answer: e
 What elements in the history are important to
ask in this case to arrive at a diagnosis of
psoriasis?
a.
b.
c.
d.
e.
Recent illnesses / Past medical history
Medications
Family history
Social history
All of the above
Ask About Past Medical History
 Psoriasis can be triggered by infections, especially





streptococcal pharyngitis
More severe in patients with HIV
Up to 20% of psoriasis patients have psoriatic arthritis,
which can lead to joint destruction
There is a positive correlation between increased BMI
and both prevalence and severity of psoriasis
Patients with psoriasis may have an increased risk for
cardiovascular disease and should be encouraged to
address their modifiable cardiovascular risk factors
Psoriasis has a serious impact on health-related quality
of life (QOL)
Ask About Medication History
 Psoriasis can be triggered or exacerbated by a
number of medications including:
• Systemic corticosteroid withdrawal
• Beta blockers
• Lithium
• Antimalarials
• Interferons
Ask About Family History
 There is a strong genetic predisposition to
developing psoriasis
 1/3 of psoriasis patients have a positive family
history
• However, this means up to 2/3 of patients with
psoriasis do not have a family history of
psoriasis, so a negative family history does
not rule it out
Ask about Health-Related Behaviors
 Studies have revealed smoking as a risk factor for
psoriasis
 Alcohol consumption is more prevalent in patients
with psoriasis and it may increase the severity of
psoriasis
 A higher BMI is associated with an increase
prevalence and severity of psoriasis
Back to Case One
Mr. Ronald Gilson
Twenty-one Year-old Gentleman With Red Lesion
Around His Umbilicus
Case One: History Continued




PMH: no major illnesses or hospitalizations
Medications: none
Allergies: none
Family history: adopted, does not know his family
history
 Social history: lives with roommates in an
apartment, graduate student in physics
 Health-related behaviors: no tobacco or drug use.
Drinks 3-6 beers on weekends.
 ROS: negative
Psoriasis: Clinical Evaluation
 Although you should perform a full body skin
exam, plaque psoriasis tends to appear in
characteristic locations
• Key Areas: scalp, ears, elbows and knees
(extensor surfaces), umbilicus, gluteal cleft,
nails, and sites of recent trauma
• Observation of psoriatic lesions in these
locations helps distinguish psoriasis from other
papulosquamous (scaly) skin disorders
Back to Case One: Skin Exam
Erythematous plaque
with small amount of
fine overlying scale
around the umbilicus
Erythematous plaque
with overlying silvery
scale is present in the
gluteal cleft
DDx of Psoriasis
 Mr Gilson is given a diagnosis of psoriasis based
on the clinical evaluation
 Psoriasis is typically diagnosed on clinical exam
because of its characteristic location and
appearance
 Other conditions to be considered in the patient
with chronic plaque psoriasis are:
•
•
•
•
•
Tinea corporis
Nummular eczema
Seborrheic dermatitis
Secondary syphilis
Drug eruption
Case Two
Mr. Bruce Laney
Case Two: History
 HPI: Mr. Laney is a 68 year-old gentleman with a
history of psoriasis who presents with increased joint
pain and joint changes. He currently uses a topical
steroid to treat his psoriasis.
 PMH: psoriasis x 40yrs (difficult to control).
Hypertension x 20 years, well-controlled with thiazide
 Medications: topical clobetasol for psoriasis,
hydrochlorothiazide for blood pressure
 Allergies: none
 FH: mother and father both had psoriasis
 SH: lives with his wife in a house, retired, no children
 ROS: negative
Case Two: Skin Exam
Large erythematous
plaque with overlying
silvery scale on
anterior scalp
Erythematous plaque
with overlying silvery
scale at the external
auditory meatus and
behind the ear
Case Two: Exam Continued
Extensor surface of the
left arm has
erythematous plaques
with overlying silvery
scale
Also with vitiligo and
macular depigmentation
in the same region
Nail pitting
Case Two: Exam Continued
Erythematous and
edematous foot, with
dactylitis of the 2nd digit,
and destruction of the
DIP joints
Onychodystrophy: nail
pitting and onycholysis
Case Two, Question 1
 Mr Laney has psoriasis complicated by psoriatic
arthritis. What part of his history or exam are most
characteristic of a patient with psoriatic arthritis?
a.
b.
c.
d.
history of extensive psoriasis
presence of nail pitting
use of clobetasol
none of the above
Case Two, Question 1
Answer: b
 Mr Laney has psoriasis complicated by psoriatic
arthritis. What part of his history/exam is most
consistent with this diagnosis?
a. history of extensive psoriasis
b. presence of nail pitting (up to 90% of patients with
psoriatic arthritis may have nail changes)
c. use of clobetasol
d. none of the above
Psoriatic Onychodystrophy
 Nail psoriasis can occur in all psoriasis subtypes
 Fingernails are involved in ~ 50% of all patients with
psoriasis
 Toenails in 35%
 Changes include:
• Pitting: punctate depressions of the nail
plate surface
• Onycholysis: separation of the nail
plate from the nail bed
• Subungual hyperkeratosis: abnormal
keratinization of the distal nail bed
• Trachyonychia: rough nails as if
scraped with sandpaper longitudinally
Psoriatic Arthritis (PsA)
 Arthritis in the presence of psoriasis
• A member of the seronegative spondyloarthropathies
 Symptoms can range from mild to severe
 Occurs in 10-25 percent of patients with psoriasis
• Can occur at any age, but for most it appears between the ages of
30 and 50 years
• It is NOT related to the severity of psoriasis
 Five clinical patterns of arthritis occur
• Most common is oligoarthritis with swelling and tenosynovitis of
one or a few hand joints
 Flares and remissions usually characterize the course
of psoriatic arthritis
Psoriatic Arthritis Continued
 Health care providers are encouraged to actively
seek signs and symptoms of PsA at each visit
 PsA may appear before the diagnosis of psoriasis
 If psoriatic arthritis is diagnosed, treatment should be
initiated to:
• Alleviate signs and symptoms of arthritis
• Inhibit structural damage
• Maximize quality of life
 Diagnosis is based on clinical judgment
• Specific patterns of joint inflammation, absence of
rheumatoid factor, and the presence of skin and nail
lesions of psoriasis aid clinicians in making the diagnosis of
PsA
Psoriatic Arthritis
Desquamation of the overlying
skin as well as joint swelling and
deformity (arthritis mutilans) of
both feet
Swelling of the PIP joints of
the 2-4th digits, DIP
involvement of the 2nd digit
Case Three
Ms. Sonya Hagerty
Case Three: History
 HPI: Ms. Hagerty is an 18 year old healthy woman with a
new diagnosis of psoriasis reports lesions localized to her
knees with no other affected areas. She has not tried any
therapy.
 PMH: no major illnesses or hospitalizations
 Medications: occasional multivitamin
 Allergies: none
 Family history: not-contributory
 Social history: lives in the city with her parents and attends
high school
 Health-related behaviors: reports no tobacco, alcohol, or
drug use
 ROS: slight pruritus
Case Three: Skin Exam
Erythematous plaques
with overlying silvery
scale on the extensor
surface of the knee.
Case Three, Question 1
 Which of the following would you recommend to
start treatment for Ms. Hagerty’s psoriasis?
a.
b.
c.
d.
e.
systemic steroids
biologic
high potency topical steroid
low potency topical steroid
topical clotrimazole
Case Three, Question 1
Answer: c
 Which of the following would you recommend to
start treatment for Ms. Hagerty’s psoriasis?
a.
b.
c.
d.
e.
systemic steroids
biologic
high potency topical steroid
low potency topical steroid
topical clotrimazole
Psoriasis: Treatment
 Since the psoriasis is localized (less than
5% body surface area), topical treatment is
appropriate
 First line agents: High potency topical
steroid in combination with calcipotriene
(vitamin D analog)
 Other topical options: tazarotene, salicylic or
lactic acid, tar, calcineurin inhibitors
Psoriasis: Treatment
 Factors that influence type of treatment:
• Age
• Type of psoriasis:
• plaque, guttate, pustular, erythrodermic psoriasis
• Site and extent of psoriasis:
• localized = <5% of BSA
• generalized = diffuse or >30% involvement
• Previous treatment
• Other medical conditions
 Patients with localized plaque psoriasis can be
managed by a primary care provider
 Psoriasis of all other types should be evaluated by a
dermatologist
Psoriasis: Topical Treatment
Medication
Uses in Psoriasis
Side Effects
Topical steroids
Plaque-type psoriasis
Skin atrophy,
hypopigmentation, striae
Calcipotriene
(Vitamin D derivative)
Use in combination with topical
steroids for added benefit
Skin irritation, photosensitivity
(but no contraindication with
UVB phototherapy)
Tazarotene
(Topical retinoid)
Plaque-type psoriasis. Best when
used with topical corticosteroids.
Skin irritation, photosensitivity
Salicylic or Lactic acid
(Keratolytic agents)
Plaque-type psoriasis to reduce
scaling and soften plaques
Systemic absorption can occur
if applied to > 20% BSA.
Decreases efficacy of UVB
phototherapy
Coal tar
Plaque-type psoriasis
Skin irritation, odor, staining of
clothes
Calcineurin inhibitors
Off-label use for facial and
intertriginous psoriasis
Skin burning and itching
Estimating BSA via Palm of Hand
1 Palm = 1%
BSA
Estimating topicals: Fingertip unit
Quantity of topical
medication placed on
pad of finger from distal
tip to DIP joint
Fingertip unit = 500 mg
= treats 2% BSA
Estimating Topical Therapy Amounts
2% BSA = 500mg = 0.5g
 2% BSA bid x 1 month = 0.5 g x 2 x 30 = 30 g
 5% BSA bid x 1 month = 1.25 g x 2 x 30 = 75 g
Can also use the “Rule of 15”
%BSA x 15 = grams needed to treat bid x 1 month
 10% BSA bid x 1 month = 150 g
 100% BSA bid x 1 month = 1500 g
Case Three, Question 2
 Which of the following
prescriptions would you
give Ms Hagerty?
a. Clobetasol 0.05% ointment,
applied to affected area BID
b. Tacrolimus 0.1% ointment,
applied BID
c. Coal tar solution 10%,
applied at bedtime
d. Etanercept 50mg,
subcutaneous, twice per
week
Case Three, Question 2
Answer: a
 Which of the following
prescriptions would you
use for Ms Hagerty?
a. Clobetasol 0.05%
ointment, applied to
affected area BID
b. Tacrolimus 0.1% ointment,
applied BID
c. Coal tar solution 10%,
applied at bedtime
d. Etanercept 50mg,
subcutaneous, twice per
week
Case Three, Question 3
 Which of the following prescriptions is correct for
topical clobetasol 0.05% ointment for a 3 month
supply?
a. Clobetasol 0.05%, apply twice a day to the affected areas,
dispense 30 grams
b. Clobetasol 0.05%, apply twice day to the affected areas,
dispense 3 grams
c. Clobetasol 0.05%, apply twice a day to the affected areas,
dispense 90 grams
d. Clobetasol 0.05%, apply twice a day to the affected areas,
dispense 9 grams
Case Three, Question 3
Answer: c
 Which of the following prescriptions is correct for
topical clobetasol 0.05% ointment for a 3 month
supply?
a. Clobetasol 0.05%, apply twice a day to the affected areas,
dispense 30 grams
b. Clobetasol 0.05%, apply twice day to the affected areas,
dispense 3 grams
c. Clobetasol 0.05%, apply twice a day to the affected areas,
dispense 90 grams (2% BSA x 15 = 30 grams/month x 3 months
= 90 grams)
d. Clobetasol 0.05%, apply twice a day to the affected areas,
dispense 9 grams
Clinical Pearl
 Topical medications for psoriasis are more
effective when used with occlusion which
allows for better penetration
 A bandage, saran-wrap, gloves, or socks
placed over the medication can serve this
purpose
Case Three, Question 4
 What would be an appropriate
treatment if a patient had
presented with this skin exam?
a. systemic steroid
b. topical steroid
c. topical steroid and systemic
steroid
d. topical steroid and UV light
therapy
e. all of the above
Case Three, Question 4
Answer: d
 What would be an appropriate
treatment if a patient had
presented with this skin exam?
a. systemic steroid
b. topical steroid
c. topical steroid and systemic
steroid
d. topical steroid and UV light
therapy
e. all of the above
Psoriasis: System Treatment
 In patients with moderate to severe disease,
systemic treatment can be considered and should
be supplemented with topical treatment
 Many patients with moderate to severe psoriasis
are only given topical therapy and experience little
treatment success
• Undertreating the patient can lead to a loss of
hope regarding their disease
 Oral steroids should never be used in psoriasis as
they can severely flare psoriasis upon
discontinuation
Systemic Treatment
 There are 3 choices for systemic treatment:
1. Phototherapy: narrow-band ultraviolet B light (nbUVB),
broad-band ultraviolet B light (bbUVB), or psoralen plus
ultraviolet A light (PUVA)
2. Oral medications: methotrexate, acitretin, cyclosporine
3. Biologic Agents: T- cell blocker (alefacept), TNF-α inhibitors
(infliximab, etanercept, adalumimab), IL 12/23 blocker
(ustekinumab)
 The choice of systemic therapy depends on
multiple factors: convenience, side effect risk
profile, presence or absence of psoriatic arthritis
(PsA), co-morbidities
 Systemic treatment for psoriasis should be given
only after consultation with a dermatologist
The Patient’s Experience
 A successful treatment regimen should include
patient education as well as provider awareness of
the patient’s experience
• Find out the patients’ views about their disease
• Ask the patient how psoriasis affects their daily living
• Ask about symptoms such as pain, itching, burning,
and dry skin
• Ask patients about their experience with previous
treatments
• Important to ask patients about their hopes and
expectations for treatment
• Provide time for patients to ask questions
Psoriasis and QOL
 Psoriasis is a lifelong disease and can affect all
aspects of a patient’s QOL (even in patients with
limited skin involvement)
 Remember to address both the physical and
psychosocial aspects of psoriasis
 Many patients with psoriasis:
•
•
•
•
•
Feel socially stigmatized
Have high stress levels
Are physically limited by their disease
Have higher incidences of depression and alcoholism
Struggle with their employment status
Take Home Points
 Psoriasis is a chronic multisystem disease with
predominantly skin and joint manifestations
 About 1/3 of patients with psoriasis have a 1st-degree
relative with psoriasis
 Different types of psoriasis are based on morphology:
plaque, guttate, inverse, pustular, and erythrodermic
 Plaque psoriasis is the most common, affecting 80-90%
of patients
 A detailed history should be taken in patients with
psoriasis
 Plaque psoriasis is often diagnosed clinically
 Nail disease is common in patients with psoriasis
 Psoriatic arthritis is a member of the seronegative
spondyloarthropathies
Take Home Points
 Health care providers are encouraged to actively seek signs
and symptoms of psoriatic arthritis at each visit
 Topical treatment alone is used when the psoriasis is localized
 Topical medications for psoriasis are more effective when used
with occlusion, which allows for better penetration
 Patients with moderate to severe disease often require
systemic treatment in addition to topical therapy
 Oral steroids should never be used in psoriasis
 Systemic treatment includes phototherapy, oral medications
and biologic agents.
 A successful treatment plan should include patient education
as well as provider awareness of the patient’s experience
 Psoriasis is a lifelong disease and can affect all aspects of a
patient’s quality of life
End of the Module
 Abdelaziz A, Burge S. What should undergraduate medical students
know about psoriasis? Involving patients in curriculum development:
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 Bremmer S et al. Obesity and psoriasis: From the Medical Board of
the National Psoriasis Foundation. J Am Acad Dermatol 2009 article
in press.
 Gelfand JM, et al. Risk of Mycocardial Infarction in Patients With
Psoriasis. JAMA 2006;296:1735-41.
 Gottlieb et al. Guidelines of care for the management of psoriasis
and psoriatic arthritis. Section 2. Psoriatic arthritis: Overview and
guidelines of care for treatment with an emphasis on biologics. J Am
Acad Dermatol 2008;58:851-864.
 Gudjonsson Johann E, Elder James T, "Chapter 18. Psoriasis"
(Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS,
Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2983780.
End of the Module
 James WD, Berger TG, Elston DM, “Chapter 13. Acne” (chapter). Andrews’
Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders
Elsevier; 2006: 231-239, 245-248.
 Jobling R. A Patient’s Journey. Psoriasis. BMJ 2007;334:953-4.
 Kimball AB et al. The Pyschosocial Burden of Psoriasis. Am J Clin Dermatol
2005;6:383-392.
 Luba KM, Stulberg DL. Chronic Plaque Psoriasis. Am Fam Physician
2006;73:636-44.
 Menter A et al. Guidelines of care for the management of psoriasis and psoriatic
arthritis. Section 1. Overview of psoriasis and guideline of acre for the treatment
of psoriasis with biologics. J Am Acad Dermatol 2008;58:826-850.
 Menter A et al. Guidelines of care for the management of psoriasis and psoriatic
arthritis. Section 3. Guidelines of care for the management and treatment of
psoriasis with topical therapies. J Am Acad Dermatol 2009;60:643-659.
 Smith CH. Clinical Review. Psoriasis and its management. BMJ 2006;333:380-4.