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PsoriasisDiagnosis and treatment

PsoriasisDiagnosis and treatment

Dr Tang Min MoonMD(UKM) MRCP(UK) AdvMDerm(UKM)

Fellow(NSC, Singapore) Fellow(Bern University Hospital, Switzerland) Department of Dermatology

Hospital Kuala Lumpur21st July 2018

How frequently do you expect to see a patient with psoriasis in your clinic ?How frequently do you expect to see a patient with psoriasis in your clinic ?• Psoriasis 1 ‐ 3% of world population

– prevalence varies greatly among different countries – 0.2% in China ‐ 4.8% in Norway – Ethnicities FREE of psoriasis American Samoa & Mapuche in Chile

• No population‐based prevalence study on psoriasis in Malaysia – 2‐6% of yearly dermatology new clinic attendees in Malaysia– 9.54% of skin clinic attendees in Hospital Kuala Lumpur

Gudjonsson JE et.al, Clin Dermatol.2007;25:535‐546.Tsai TF et.al J Dermatol Sci.2011 63(1):40‐46.

Farber EM et al. Psoriasis. New York: Dekkar 1988. p107‐57Valenzuela F et al. Int J Dermatol 2012;51:1005‐6

Choon SE et.al International J Dermatol.2013Siow KY et al. MJM.2004 59(3):330 ‐ 334.

Heah SK et al. Malaysian J Dermatol 2017;38:19‐24

Is it Psoriasis?Is it Psoriasis?

How do you recognize psoriasis??How do you recognize psoriasis??

• Elevated plaques• Scaly erythematous • sharply demarcated • Coarse & thick scales • extend 1‐2 cm beyond the hairline

• Koebner’s phenomenon

The many faces of PsoriasisThe many faces of Psoriasis

Palmoplantar psoriasis Scalp psoriasis


Guttate psoriasis

Inverse psoriasis


Erythrodermic psoriasis Pustular psoriasis


GPP – annular type GPP – Von Zumbusch

LPP – acrodermatitis continua of Hallopeau

LPP – palmoplantar pustulosis

Patient: Are you sure this is psoriasis? Why me? None of my family has it.

Patient: Are you sure this is psoriasis? Why me? None of my family has it.

What is Psoriasis?What is Psoriasis?

Environment

GeneticGeneticHyperactive Immunesystem

Hyperactive Immunesystem

Systemic chronic inflammatory disease predominantly affects the skin and joints

What is Psoriasis?What is Psoriasis?

Environment

GeneticGenetic

Hyperactive Immune system Dysregulated

interaction of innate and addaptiveimmune system

Hyperactive Immune system Dysregulated

interaction of innate and addaptiveimmune system

• 30% positive family history (70% with childhood psoriasis)

• 40 susceptibility loci HLA‐cw6 located on PSOR1 locus (50‐60 % susceptibility)

• Trauma• Koebner’s phenomenon• Infection (Streptococcus, HIV,

chikungunya)• Drugs (Lithium, β‐blockers,

antimalarials, NSAIDs, ACE inhibitors, gemfibrosil, interferon, IL2, G‐CSF)

• Lifestyle (Smoking, Alcohol)• Psychogenic‐Stress• Pregnancy• Obesity Boehncke WH. Rheum Dis Clin N Am 2015;41:665‐75

Patient: You have no idea what am I going through…Patient: You have no idea what am I going through…

Physical discomfort1. Pruritus2. Scaling3. Tightness4. Pain5. Bleeding


5%

19%

29%

21%

31%

71%

79%

94%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Other

Fatique

Bleeding

Burning sensation

Skin tightness

Skin Redness

Itching

Scaling

Kruger G et al. Arch dermatol 2001;137:280‐4


Kruger G et al. Arch dermatol 2001;137:280‐4

10%

54%

75%

81%

88%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Comtemplation of suicide

Depression

Feeling of unattractiveness

Feeling of Embarassment

Fear disease worsen

Patient: Is it only the skin?Patient: Is it only the skin?

• Higher risk (2‐3x) of metabolic syndrome– Obesity, DM, dyslipidaemia, hypertension

• Severe psoriasis– 3 fold increased risk of developing MI especially young

– 3‐4 year ↓ in life expectancy

• Lymphoma, NMSC

How do you manage Psoriasis?a highly visible disease

How do you manage Psoriasis?a highly visible disease

First, assess the severityFirst, assess the severityPhysical severity1. BSA (% of body surface

involvement)2. PASI (Psoriasis Area and

Severity Index)3. PGA (Physician Global

Assessment)

Quality of Life1. Dermatology Life Quality

Index (DLQI)2. Psoriasis Disability Index

(PDI)3. Short Form 36 (SF36)

First, assess the severityFirst, assess the severityPhysical severity1. BSA (% of body surface

involvement)2. PASI (Psoriasis Area and

Severity Index)3. PGA (Physician Global

Assessment)

Quality of Life1. Dermatology Life Quality

Index (DLQI)2. Psoriasis Disability Index

(PDI)3. Short Form 36 (SF36)

• Area of palm plus 5 fingers ≈ 1% of total BSA– Head and Neck = 10% (10 palms)– Upper extremities = 20% (20 palms)– Trunk (axillae and groin) = 30% (30

palms)– Lower extremities (buttocks) = 40% (40

palms)– Total BSA = 100% (100 palms)

~1% BSA

First, assess the severityFirst, assess the severity

Grade Definition of severityMild BSA ≤ 10% or

PASI ≤ 10 orDLQI ≤ 10

Moderate BSA >10% to 30% orPASI >10 to 20 orDLQI >10 to 20

Severe BSA > 30% orPASI > 20 orDLQI >20

Malaysian Clinical Practice Guideline on the Management of Psoriasis VulgarisDefinition of Psoriasis Severity

Second, set a goal of treatmentSecond, set a goal of treatmentTreatment Minimal targets Time for Evaluation

(Induction phase)(weeks)

Subsequent Evaluation(Maintenance phase)

(months)

Topical therapy ↓ BSA ≥ 50% orPASI ≥ 50 orDLQI ≤ 5

6 6 ‐12

Phototherapy↓BSA ≥ 75% orPASI ≥ 75 orDLQI ≤ 5

6 6 Methotrexate 16

Cyclosporin 16Acitretin 24Infliximab ↓PASI ≥ 75% or

PASI 50 to <75 plus DLQI ≤ 5

10 6

Adalimumab 16Ustekinumab 16Etanercept 24

Third, choose the best available treatment modality


• Share decision between patients and cliniciansTopical Rx Phototherapy Systemic Rx BiologicsCoal Tar

Keratolytics

Topical steroids*

Vit D3 analogues

Dithranol(anthralin)

Emollients

NB‐UVB

Oral PUVA

Bath PUVA

Topical PUVA

Methotrexate

Acitretin (Retinoid)

Sulphasalazine

Cyclosporin

Hydroxyurea

Systemic steroids*

Etanercept

Infliximab

Adalimumab

Ustekinumab

Secukinumab

Safe Still safe Potential risk Higher risk



Topical treatment



Topical treatment

Emollient• Moisturizer• Restore normal hydration & epidermal barrier function

• May have steroid‐sparing effect

• Use regularly



Topical treatmentDithranol (Anthralin)• Anti‐proliferative & anti‐inflammatory drugs

• Short contact therapy (20‐30min)

• Apply accurately to affected large thick plaques, remove with liquid paraffin



Topical treatment

Topical tar• Reduce cell turnover, anti‐inflammatorym antikeratotic

• Available as shampoo, bath additives, ointment, lotions, pastes

• Avoid body folds, face & genitalia

• No increase in cancer



Topical treatmentTopical corticosteroids• Anti‐inflammatory, antiproliferative, immunosuppressive, vasoconstrictive

• cream, ointment, gel, spray, lotion• Short term potent/superpotentcorticosteroids rapid clearance of psoriasis with limited plaques• Avoid face, genitalia, body folds• Limit super potent steroid <30g/week• Limit potent steroid <60g/week

• Use on extensive lesions /large areas skin atrophy & systemic absorption



Topical treatment

Calcipotriol (Vitamin D analogues)• Enhances normal keratinization, inhibit epidermal proliferation

• Do not >100g/wk to avoid hypercalcemia

• Avoid face

Topical salicylic acid• Keratolytics↓scaling & softening of psoriatic plaques

• Used in combination with topical steroids



PhototherapyUltraviolet B• Broad band UVB (290‐320nm)

• Narrow band UVB (311nm)

Psoralen + Ultraviolet A• Topical PUVA (320‐400nm)• Oral PUVA• Bath PUVA• Hand & foot PUVA



Phototherapy



Phototherapy – NBUVB in Psoriasis

Before treatment 10 week6 week



Phototherapy – Oral PUVA in Psoriasis

Before treatment 6 week (5MOP, 4x/week)

Systemic treatment & BiologicsSystemic treatment & Biologics

……to be continued tomorrow ..…..

Take home messageTake home message

• Psoriasis ~2% of population• Chronic immune‐mediated inflammatory disease involving skin & joint disfiguring

• Treatment should be personalized, tailored to disease severity with a goal set

• Psoriasis higher risk of metabolic syndrome• Young, severe psoriasis higher risk of myocardial infarction

Thank youThank you

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