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ManageMent of Psoriasis Vulgaris QuiCK referenCe for HealtHCare ProViDers
KEY MESSAGES• Psoriasisisageneticallydetermined,systemicimmune-mediatedchronicinflammatory
diseasethataffectsprimarilytheskinandjoints.
• Psoriasis Vulgaris is characterised by well-demarcated erythematous plaques withsilveryscalesonelbows,knees,lumbosacralregion,andscalp,andnailchanges.
• Erythrodermicpsoriasisaffectsmorethan80%bodysurfacearea.
• Generalised pustular psoriasis is widespread erythema studded with superficialpustuleswhichmaycoalescetoformlakesofpus.
• Psoriasiscanbeasmentallyandphysicallydisablingascancer,heartdisease,diabetes,hypertension,arthritisanddepression.
• Psoriaticarthritisaffectsabout16%ofMalaysianswithpsoriasis.Earlyrecognitionandtreatmentpreventdeformities.Assessmentshouldbeperformedatleastannuallybylookingforrelevantsignsandsymptoms:-
a.Jointswelling
b.Dactylitis
c.Significantearlymorningstiffness>1/2hour
• Psoriasispatientsaremorepronetocardiovasculardiseases,stroke,lymphomaandnon-melanomaskincancers,andincreasedmortality.
• Psoriasis patients should be screened for metabolic syndrome and risk factors ofatherosclerosis-relateddiseases.
• AssessphysicalseverityofpsoriasiswithPsoriasisAreaandSeverityIndex(PASI)orBodySurfaceArea(BSA).Assesstheimpactofpsoriasisonthequalityoflife(QoL)ofpatientswithDermatologyLifeQualityIndex(DLQI)
•Choiceoftreatmentforpregnantandlactatingwomenshouldbenefitthemotherandposeminimalrisktothefoetus/baby.
This Quick Reference provides key messages and a summary of the main recommendations in the Clinical Practice Guidelines (CPG) Management of Psoriasis Vulgaris.
Details of the evidence supporting these recommendations can be found in the above CPG, available on the following websites:Ministry of Health Malaysia : www.moh.gov.myAcademy of Medicine Malaysia : www.acadmed.org.myMalaysian Dermatology Society : www.dermatology.org.my
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ManageMent of Psoriasis Vulgaris QuiCK referenCe for HealtHCare ProViDers
PRINCIPLES OF TREATMENT
• Managementshouldstartwithpatienteducation.
• Treatmentofpsoriasisshouldbeacombineddecisionbetweenpatients&theirhealthcareproviders.
• Treatmentgoalandminimaltargetsetshouldbebasedondiseaseseverityandpatient’spreferences.
• Treatmentgoalachievedshouldbemonitoredregularlytodetectlossofresponsewhichmaynecessitatemodificationoftherapy.
ASSESSMENT OF SEVERITYGrading of Psoriasis Severity
Grade of severity Measurement tools Interpretation
Mild
• BSA≤10%• PGAmild• PASI≤10• DLQI≤10
Diseasewithaminimalimpactonthepatient’sQoLandpatient can achieve acceptable symptom control bystandardtopicaltherapy
Moderate
• BSA>10%to30%• PGAmoderate• PASI>10to20• DLQI>10to20
Diseasethatcannotbe,orwouldnotbeexpectedtobecontrolledtoanacceptabledegreebystandardtopicaltherapy, and/or disease that moderately affects thepatient’sQoL
Severe
• BSA>30%• PGAsevereorverysevere• PASI>20• DLQI>20
Diseasethatcannotbe,orwouldnotbeexpectedtobe controlledby topical therapyand that adverselyaffect patient’s QoL (this include erythrodermicpsoriasis,pustularpsoriasisandpsoriaticarthritis)
TREATMENT GOALS OF VARIOuS MOdALITIES
TREATMENT MINIMAL TARGETSTIME FOR
EVALuATION (wEEKS)
SubSEquENT EVALuATION (MONThS)
Topicaltherapy ↓BSA≥50orPASI≥50orDLQI≤5 6 6–12
PhototherapyMethotrexateCyclosporineAcitretin
↓ BSA≥75orPASI≥75orDLQI≤5
6161612
6
InfliximabAdalimumabUstekinumabEtanercept
PASI≥75ORPASI50to<75plusDLQI≤5
10161624
6
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ManageMent of Psoriasis Vulgaris QuiCK referenCe for HealtHCare ProViDers
TREATMENT MOdALITIES
• Patientswithmildormoderatepsoriasiswithminimal impairment inQoL (DLQI≤5)shouldbetreatedwithtopicalagents.
• Emollientshouldbeusedregularly.
• Tar-basedpreparationsmaybeusedasafirst-linetopicaltherapy.
• Short-termuseofpotentandverypotenttopicalcorticosteroidmaybeusedtoclearlimitedplaques.
•Mildpotencycorticosteroidmaybeusedforface,genitaliaandbodyfolds. • FixeddosecombinationofvitaminDanalogueandcorticosteroidmaybeusedforshort-termtreatment.
• TopicalvitaminDanaloguemaybeusedbutdoseshouldnotexceed100g/week.
• Phototherapyshouldbeofferedtopatientswhohavefailedtopicaltherapybeforestartingthemonsystemicagents.
• LifetimeexposuretopsoralenplusultravioletA(PUVA)andultravioletB(UVB)shouldnotexceed200and350sessionsrespectively.
• Systemic /biologic therapy formoderate toseverepsoriasisshouldbe initiatedbyadermatologist.
• Pre-treatmentassessmentandregularmonitoringfortoxicityshouldbedoneduringsystemic/biologictherapy.
• Methotrexateoracitretinshouldbeusedasfirst-linesystemictherapy.
• Cyclosporinemaybeusedassecond-linesystemictherapy.
• CyclosporineshouldNOTbeusedformorethan2yearsandavoided inpatientswithpreviousPUVAexposure.
• Biologicsshouldbeofferedtopatientswhofail,haveintoleranceorcontraindicationtoconventionalsystemictreatmentandphototherapy.
CRITERIA OF REFERRAL
1. dermatology Referral
Indications for referral
•Diagnosticuncertainty
• Erythrodermic or pustular psoriasis should be referred urgently for specialist assessment andtreatment
• Patientswhohavefailedadequatetrialoftopicaltherapyfor6-12weeks
• Severepsoriasisthatrequiresphototherapyorsystemictherapy
2. Rheumatology Referral
Indications for referral
• DiagnosticevaluationofpatientswithsuspectedPsoriaticArthritis(PsA)
• FormulatemanagementplanforPsA
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ManageMent of Psoriasis Vulgaris QuiCK referenCe for HealtHCare ProViDers
PSORIASIS PATIENT PRESENTING TO PRIMARY CARE
Articular symptoms / signs suggestive of PsA• Joint swelling • Dactylitis• Significant early morning stiffness >1/2 hour
1. Assess • Severity • Arthritis (PsA) • Co-morbidities
2. Educate patient
Presence of co-morbidities such as obesity,
hypertension, diabetes, depression etc.
MANAGE / REFER TORELEVANT SPECIALITYREFER TO RHEUMATOLOGIST
Mild(BSA ≤10% or PASI ≤10)
Moderate(BSA >10% to 30% or PASI >10 to 20)
Severe(BSA >30% or PASI >20)
Erythrodermic or generalised pustular psoriasis: urgent referral is indicated
SEVERITY
Assess DLQI REFER TO DERMATOLOGIST
Re-assess in 6 weeks
Topical Therapy
Regular follow-up as indicatedAnnual assessment:- • Document severity• Assess co-morbidities and articular symptoms• Optimise topical treatment
BSA - Body Surface AreaPASI - Psoriasis Area and Severity IndexDLQI - Dermatology Life Quality IndexResponder - BSA ≥50% reduction or PASI ≥50 achieved
Assess DLQI
Optimise topical therapy
RESPONDER
YES YES
DLQI ≤10 DLQI >10
NO DLQI >5
YES
DLQI ≤5
ALGORIThM 1: MANAGEMENT OF PSORIASIS VuLGARIS IN PRIMARY CARE
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ManageMent of Psoriasis Vulgaris QuiCK referenCe for HealtHCare ProViDers
PSORIASIS VULGARIS
Tar(First – line therapy)
Dithranol(Large plaque)
Corticosteroids(Short-term therapy)
Vitamin D analogues(<100g/week)
Calcineurin inhibitors (Face & Flexures only)
Topical Therapy Assess DLQI
Mild(BSA ≤10% or PASI ≤10)
Moderate(BSA >10% to 30% or
PASI >10 to 20)
Phototherapy
Systemic Therapy
Acitretin
Biologics
Ustekinumab Adalimumab Etanercept Infliximab
Methotrexate(First-line)
Cyclosporine(Short- term therapy)
Failed / contraindicated / not available
Failed / contraindicated / intolerant with BSA >30% or PASI >20 or DLQI >20
SevereBSA >30% or PASI >20
DLQI ≤10 DLQI >10
ALGORIThM 2: TREATMENT OF PSORIASIS VuLGARIS
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ManageMent of Psoriasis Vulgaris QuiCK referenCe for HealtHCare ProViDersRe
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