psoriasis complexities of and sensitivities to psoriasis...

PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting

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PSORIASISCollaboration for Optimal Management

in the Primary Care Setting

Michael Rosenblum, MD, PhDAssistant Professor of Dermatology

University of California, San Francisco

San Francisco, CA

Daniel Miller, MD, FAADBoston University Medical Center

Assistant Professor of Dermatology and Dermatopathology

Director, Inpatient Dermatology Consultation Service

Boston, MA

Complexities of and Sensitivities to Psoriasis Diagnosis

Michael Rosenblum, MD, PhDAssistant Professor of Dermatology

University of California, San FranciscoSan Francisco, CA

Best Practices PearlsThere are several variants of psoriasis; plaque psoriasis is the most common presentation

Comorbid conditions include psoriatic arthritis, inflammatory bowel disease, diabetes, and cardiovascular disease. Nail involvement has predictive value for the risk of developing psoriatic arthritis

Screen carefully and address or refer for management of all comorbidities

Patients often see psoriasis as incurable, uncontrollable, and incomprehensible

Good communication with your patients will help them manage both the physical and emotional aspects of psoriasis

Show empathy

Answer questions about disease

Address emotional and QOL concerns

Limited disease without evidence of arthritis can be managed with appropriate-strength topical steroids

Refer to a specialist when patient presents with moderate-to-severe disease, fails to respond to topical therapies, or presents with signs and symptoms of psoriatic arthritis

Psoriasis

Common, chronic, inflammatory, multisystem disease

2% of the population affected

Predominantly affects the skin and joints

Associated with psoriatic arthritis, inflammatory bowel disease, diabetes, cardiovascular disease, and lymphoma

Menter et al. J Am Acad Dermatol 2008;58:826-50.

Psoriasis - Clinical

Scaly, erythematous plaquesPainful or often severely itchyDisfiguringMay cause significant compromise in QOLUsually follows a chronic relapsing and remitting courseMultiple subtypesSYMMETRIC

Menter et al. J Am Acad Dermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Plaque Psoriasis

Most common form(80% - 90% of patients)

Well-defined, sharply demarcated, erythematous plaques (1cm to >10cm)

Dry, thin, silvery-white scale

Most often located on the scalp, trunk, buttocks, and limbs

Predilection for extensor surfaces such as the elbows and knees

Menter et al. J Am Acad Dermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.


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Inverse Psoriasis

Lesions in the skin folds

Axillary, genital, perineal, intergluteal, and inframammaryareas

Not scaly (due to increased moisture)

Presents as erythematous plaques with minimal scale

Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Erythrodermic Psoriasis

Generalized erythema covering nearly the entire BSA with varying degrees of scalingCan develop gradually from chronic plaque disease or acutely with little preceding psoriasisErythrodermic skin may lead to chills and hypothermiaFluid loss may lead to dehydrationFever and malaise are common

Menter et al. J Am Acad Dermatol 2008;58:826-50. Weigle et al. Am Fam Physician. 2013;87(9):626-633. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

Pustular Psoriasis

Characterized by collections of pus within erythematous plaques

May be generalized or localized

Acute generalized pustular PSO is severe and accompanied by fever and toxicity

Localized pustular variant involves the palms and soles, with or without evidence of classic plaque-type disease


Guttate Psoriasis

Rain drop-like, 0.1cm to 1cm, salmon-pink papules, usually with a fine scale

Primarily affects the trunk and the proximal extremities

Common in patients <30 years old

History of URI (usually GAS) approximately 2-3 weeks prior to onset of rash


Unpredictable clinical course – may spontaneously resolve or be the first stage in the development of chronic plaque PSO

Nail Psoriasis

Fingernails are involved in approximately 50% of all patients

Toenails are involved in approximately 35% of all patients

Common findings are pitting, onycholysis, subungualhyperkeratosis, and “oil-drop” spots

90% of patients with psoriatic arthritis may have nail changes

ONYCHOLYSIS

Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am AcadDermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

PITTING

Making a Diagnosis of Psoriasis

1) Clinical ExamSymmetric skin plaques with thick silvery scale

Nail involvement and involvement of the navel and gluteal cleft

Associated joint complaints

2) Skin BiopsyAvoid elbow and knees

Multiple biopsies if multiple skin morphologies

3) Labs and ImagingJoint complaints => plain films and bone scans

Guttate lesions => bacterial culture of throat and perianal area, ASO

Pustular lesions => bacterial and fungal culture from pustule

Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.


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Differential Diagnosis of Psoriasis

MalignancyCTCL (Mycosis Fungoides)

AutoimmuneCutaneous Lupus

InfectiousSecondary Syphilis

Skin RelatedLichen PlanusChronic Atopic DermatitisContact DermatitisSeborrheic DermatitisTinea Corporis

CTCL (Mycosis Fungoides)Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.

Psoriasis Comorbidities

Patients with psoriasis are at increased risk of a variety of medical conditions

The association may be based on pathophysiology, shared risk factors, or treatment for psoriasis

Social isolation may contribute to increased risk of certain medical conditions that are mediated by exercise and lifestyle factors, and may also contribute to decreased quality of life

The major medical comorbidities associated with psoriasis are:

1) Psoriatic Arthritis 2) Metabolic Syndrome

3) Coronary Artery Disease 4) Inflammatory Bowel Disease

5) Malignancy 6) Depression


Psoriasis and Psoriatic Arthritis

Classification Criteria for Psoriatic Arthritis

Established Inflammatory Articular DiseasePlus a score of 3 or more based on the following clinical findings:

Psoriasis- Current active psoriasis (2 points)- Negative test for rheumatoid factor (1 point)- Personal history of psoriasis (1 point)- Psoriasis in a first- or second-degree relative (1 point)- Typical psoriatic nail dystrophy (1 point)

Dactylitis- Current swelling of an entire digit (1 point)- History of dactylitis confirmed by a rheumatologist (1 point)- Plain radiography of hand or foot showing juxta-articular

new bone formation (ill defined ossification near joint margins excluding osteophyte; (1 point)

A member of the seronegativespondyloarthropathies

Develops an average of 12 years after the onset of skin lesions

Occurs in about 30% of patients with psoriasis

Men and women equally affected

Severity is not related to the severity of skin disease


1.4 million study participants

41,853 patients with psoriasis

Patients with psoriasis were 2.3x more likely to have the metabolic syndrome when compared to the general population

Patients with more severe psoriasis have greater odds of metabolic syndrome than those with milder psoriasis

Armstrong AW et al. J Am Acad Dermatol. 2013;68:654-662.

Psoriasis and the Metabolic Syndrome

Psoriasis and CAD

Relative risk of myocardial infarction is 1.3 in 30-year-old patients with mild psoriasis

Relative risk of myocardial infarction is 3.1 in 30-year-old patients with severe psoriasis

Elevated risk despite correcting for smoking, diabetes, obesity, hypertension, and hyperlipidemia

Most strongly related to chronic inflammation

Patients with both rheumatoid arthritis and systemic lupus erythematosus have similar increased risk

Treatment of psoriasis can decrease MI-related mortality


An Increased Risk of Cardiovascular Mortality

Severe psoriasis was an independent risk factor for CV mortality (HR 1.57) when adjusting for age, sex, smoking, diabetes, hypertension, and hyperlipidemia

Overall, severe psoriasis patients experienced one extra CV death per 283 patients per year, even when adjusting for major CV risk factors

The RR of CV death for a 40-year-old and 60-year-old with severe psoriasis was 2.69 and 1.92, respectively

Mehta NN et al. Eur Heart J. 2010;31:1000-1006.


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Psoriasis and IBD

Incidence of Crohn’s disease and ulcerative colitis is 5x greater in patients with psoriasis than in the general population

Shared genetic susceptibility loci with IBD and psoriasis

Treatment of IBD with TNF blockade can induce psoriasis

Weigle et al. Am Fam Physician. 2013;87(9):626-633. Bernstein CN, et al. Gastroenterology. 2005 Sep;129(3):827-36.

Psoriasis and Malignancy

Risk of lymphoma is increased 1.3- to 3.0-fold in persons with psoriasis

CTCL and Hodgkin’s Lymphoma may be increased over other types of cancers in patients with severe psoriasis

Risk of squamous cell carcinoma is increased 14-fold in white patients after 250 or more psoralen plus UVA (PUVA) treatments

Weigle et al. Am Fam Physician. 2013;87(9):626-633. Smedby KE et al. Cancer Epidemiol Biomarkers Prev November 2006 15; 2069-2077; Kim M, et al. Semin Cutan Med Surg 29:10-15.

Psoriasis and Depression

The prevalence of depression in patients with psoriasis may be as high as 60%

10% of psoriasis patients reported a wish to be dead

5% reported active suicidal ideation

Depression may improve with psoriasis treatment

Kim M, et al. Semin Cutan Med Surg 29:10-15.

Psychological and Emotional Burden of Psoriasis

Psychological and emotional impact is not always related to the extent of skin disease

Elevated rates of poor self-esteem, sexual dysfunction, and anxiety are strongly associated with psoriasis

SMOKING: 37% of patients with psoriasis were smokers vs 13% in the general population

ALCOHOL: Alcohol consumption is more prevalent in patients with psoriasis, and it may also increase severity

OBESITY: On average, patients with psoriasis are 14 lbs heavier than patients without psoriasis

Herron MD, et al. Arch Dermatol. 2005 Dec;141(12):1527-34.

Psoriasis – Quality of Life

The physical and mental disability experienced by patients with psoriasis is comparable or in excess of that found in patients with other chronic illnesses, such as cancer, arthritis, hypertension, heart disease, diabetes, and depression

Clinical decision-making must incorporate the impact of the skin lesions on patients’ lives

The QOL impact of psoriasis may be large even in patients with small areas of involvement => psoriasis of the palms and soles tends to have more impact than more extensive involvement on the trunk

Patients with limited skin disease should be considered candidates for systemic treatment

Higham R, et al. In Advance Healthcare Network 2010 http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Advocacy-for-Psoriasis-Patients.aspx

Psoriasis – Quality of Life

One survey found that more than one-half of patients with severe psoriasis thought physicians could do more to help, and 78% reported frustration with the effectiveness of treatment

One study found that psoriasis caused a greater negative effect on quality of life than life-threatening chronic diseases

Krueger G, et al. Arch Dermatol. 2001;137(3):280-284. Higham R, et al. In Advance Healthcare Network 2010 http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Advocacy-for-Psoriasis-Patients.aspx


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Patient Stratification for Treatment

Treatment goals include improvement of skin, nail, and joint lesions plus enhanced quality of life

Treatment must be individualized to incorporate patient preferences and the potential benefits and adverse effects of therapies

Consultation with a dermatologist may be warranted for patients with severe disease that require systemic therapy


Patient Stratification for Treatment

Practical Classification for PCP

1) Mild to Moderate Disease

Less than 5% of the body surface area and sparing the genitals, hands, feet, and face

Minimal impact on patient’s QOL

2) Severe Disease

Involving more than 5% of the body surface area or involving the hands, feet, face, or genitals

Significant impact on QOL


Collaborative Approach for Optimal Management

Daniel Miller, MD, FAADBoston University Medical Center

Assistant Professor of Dermatology and DermatopathologyDirector, Inpatient Dermatology Consultation Service

Boston, MA

Case Presentation

Anne is a 34-year-old female, previously diagnosed with plaque psoriasis by another physician, presenting with complaints of uncontrolled psoriasis, insomnia and shortness of breath

Her energy level has gone down recently, and she has concentration problems at work which she attributes to lack of sleep

As part of a swimming team, she used to exercise regularly, but she just does not “feel like it” anymore

She has gained about 20 pounds over the course of the past year

Understanding Psoriasis Patients

Physician interpersonal skills = strongest predictor of patient satisfaction in dermatology

Patient satisfaction significantly increased when:

1) Physician shows empathy for the skin disease

2) Physician gives effective explanations to questions

Lowest levels of satisfaction:

Patients whose self-reported QOL was worse than the physician’s assessment of clinical severity

Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145:617-623.

Key Point

Physicians who fail to recognize the impact of psoriasis on their patient’s

quality of life will have the most difficulty connecting with and helping

these patients.

Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145:617-623.


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Address the Emotional Impact of Psoriasis

Patient satisfaction is significantly increased with expressions of empathy

Simply acknowledging patient frustration and annoyance is often beneficial

Adherence and overall outcomes improve with increasing patient satisfaction

Visits in which physicians address emotional concerns are actually shorter

Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145:617-623. Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12.

Patient Perspectives

Psoriasis patients view their disease as:IncomprehensibleIncurableUncontrollable

Patients are seeking:Explanations with simple, everyday languageEmpathy and careful listening to emotional concernsReassurance when discouragedHope regarding disease prognosis

Linder D, Dall'olio E, Gisondi P et al. Am J Clin Dermatol. 2009;10:325-330.

Quality of Life Concerns

Common patient complaintsFrustration at incurability, depression

Unable to wear a bathing suit

Co-workers express disgust at appearance

Hairdressers refuse to perform services

Others think they have a contagious disease

Impact on sexual health and function

Hidden concernsPts think lifestyle choices may have caused psoriasisCancer risk, communicability

Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12.

Psoriasis Patient Perspectives

Patient wish listMore information on the disease

Etiology and causes

Triggers for disease flares

Treatment options, prognosis, and curability

Clear expectations at the onset of therapyWritten instructions regarding medications

Timeframe and results expected with treatment

Recognition by physicians of the emotional burden

Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12.

Strategies for Successful Visits

Express empathy, address quality of life issues

Elicit hidden fears, alleviate anxietyScreen for depression, alcohol abuse (both increased)

Communicate the basics about psoriasisPathophysiology, disease course, and treatmentUse simple, easy-to-understand languageVerbal education during the visit = gold standard

Offer adjunctive teaching aidesHandouts, visual aidesRecommend reliable internet resources

Hong J, Nguyen TV, Prose NS. J Am Acad Dermatol. 2013;68:364.e1-10.

Patient Resources

Encourage patients to join National Psoriasis Foundation (NPF)Helpful websites:

Psoriasis.org (NPF site)AAD.orgnlm.nih.gov (US National Library of Medicine)

Patient advocacy groupRedpatch.org

Hong J, Nguyen TV, Prose NS. J Am Acad Dermatol. 2013;68:364.e1-10.


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Natural History of Psoriasis

A chronic systemic inflammatory disorder Influenced by environmental factors

Flares can be triggered by infections, medications, weather changes, and stress

There is no cure for the disease

80% of patients have mild to moderate diseaseDisease defined by a waxing-waning course

Typical onset between ages 20-30

Disease course can be modified by therapy initiation

Many new therapy options in the past 10 years

Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58:826-850.

Help Set Patient Expectations

Patients who expect lifetime clearance with no flares will inevitably be disappointed

Psoriasis is managed, not cured

Ascertain patient’s goals, develop a strategySome patients like the simplicity and low risks of topical therapies and will tolerate flares

Others want very tight disease control and may consider systemic treatments with more side effects

Patients need to be realistic about outcomes and understand side effects of different therapies

Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60:643-659.

Psoriasis Treatment Algorithm


Treatment of LimitedPlaque Psoriasis

Patients with <5% total body surface area (TBSA)

Topical preparations and targeted phototherapy are both appropriate

Know classes of topical steroids and their uses

Recognize other helpful topical medicines

Know the basics of phototherapy and availability in your area


Topical Therapies

80% of patients have mild to moderate disease which can often be managed topically

Topical agents have high efficacy and safety

Topicals can be combined with phototherapy or systemic treatment in patients with more severe disease


Topical Steroids: General Principles

The best vehicle (ointment, cream, lotion, etc) is the one the patient will actually use

Elicit patient preferencesGive enough medication for sustained usage

Takes 400 grams to cover entire body for bid x 1 week

High potency steroids for thick, chronic plaquesUse intermittently to maximize safetyLimit to 2-to-4-week periods

Lower potency steroids for face, intertriginous, and other zones of thin skin



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Topical Steroids

Become familiar with 3-4 “go-to” agents High potency steroids (Class I and II):

Clobetasol (class I) and fluocinonide (class II)Initial therapy of chronic, thick plaques on non-sensitive sitesTwice daily usage for 2-4 weeks then treatment holiday

Mid-potency steroidsTriamcinolone 0.1% ointment or cream (classes III and IV)Maintenance therapyAlso for short periods (1-2 weeks only) on sensitive sites

Lower potency steroidsDesonide (class VI) and hydrocortisone 2.5% (class VII)Long term-use on sensitive sites such as face and groin


Other Topical Agents to Consider

Vitamin D analogues such as calcipotrieneAdjunctive therapy to topical steroidsExcellent safety profile

Topical retinoids (tazarotene)Useful in combination with topical steroidsMay cause skin irritation, rednessPregnancy category X

Coal tarMore than 100 years of use in treatment of psoriasisMany OTC preparations availableCosmetic concerns (smell, stains clothes) limit use for some

Nonmedicated emollients (moisturizers)


Phototherapy

Indications

>10% of total body surface area (TBSA) affected

Limited dz with severe QOL impact (eg hands, feet)

Benefits

Efficacious, cost-effective

Lacks systemic immunosuppressive properties

Drawbacks

Time consuming, not always available locally

Local side effects: itch, erythema, risk of burning

Caution in lupus, fair skin, any history of skin cancer


Phototherapy

Typical regimensnbUVB (narrow-band UVB) 2-3 times weekly

Response observed at 8-10 treatments

Single course is 15-20 treatments

Maintenance therapy may prolong remission

Targeted regimens available for limited disease Hand-foot nbUVB light boxes

Excimer 308nm laser – can target small lesions

Home nbUVB light sources (need MD surveillance)


Management Issues in Primary Care

Appropriate cardiovascular screening

Vaccine safety in immunosuppressed patients

Monitoring for adverse events while on immunosuppressive therapies

Knowing when to refer to specialists

Are PCPs Screening for CV Risks?

79 of 191 PCPs (42%) were aware that psoriasis patients have worse CV outcomesOnly a minority were screening appropriately based on current AHA guidelines for psoriasis:

43% were appropriately screening for HTNOnly 11% for dyslipidemia30% for obesity27% for type II diabetes

Parsi KK, Brezinski EA, Lin T-C et al. J Am Acad Dermatol. 2012;67:357-362.


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Cardiovascular Screening: Starting at Age 20 in Psoriasis Patients

Factor Baseline Frequency Targets

HypertensionBlood pressureFamily history

At each visitSBP < 130DBP < 85

DiabetesFasting glucoseFamily history

At least once every 3 years

<100 mm/dL

Dyslipidemia Fasting lipids AnnuallyTotal chol < 200LDL < 100 mg/dLHDL > 50 mg/dL

Obesity BMI measurement At each visit BMI < 25

Parsi KK, Brezinski EA, Lin T-C et al. J Am Acad Dermatol. 2012;67:357-362. Kimball AB, Gladman D, Gelfand JM et al. J Am Acad Dermatol. 2008;58:1031-1042.

Vaccines in Immunosuppressed Patients

Many vaccine-preventable diseases carry increased risks in immunosuppressed:

Influenza, pneumococcus, VZV (increased mortality)

Hepatitis B (increased morbidity)

But vaccination rates in these patients are poor:

Only 45% and 28% of IBD patients receive tetanus booster and annual influenza, respectively

Clinicians often worried about vaccine safety, efficacy and possibility of flaring underlying disease

Rahier JF, Moutschen M, Van Gompel A et al. Rheumatol. 2010;49:1815-1827.


Live vaccines contraindicatedduring therapy:

Measles-mumps-rubella

Poliomyelitis (live version)

Varicella/zoster

Typhoid fever

Yellow fever

Cholera



Non-live vaccines can safely be given:Diptheria-tetanus-pertussisPoliomyelitis (non-live version)PneumococcalInfluenzaHuman papillomavirusHepatitis A and B

Humoral response is diminished with certain drugs (MTX, TNF-inhibitors), but is usually adequateNo clear evidence that these vaccines cause dz flares


Best Practices Pearls

Vaccines in Psoriasis Patients on Immunotherapy

Best to vaccinate prior to starting immunotherapyLive vaccines safe: give 3-4 weeks before starting

MMR in high risk patients over 50VZV in patients over 60 or high risk

Best humoral response to inactivated vaccines

During therapyAnnual influenza vaccineDTP with booster every 10 yearsPoliomyelitis (inactivated for pts and household contacts)Consider: Hep B (if high risk), pneumococcal (if over 65)

Monitoring Patients on Immunotherapy

TNF- inhibitors (ex: etanercept, adalimumab, infliximab)

Baseline:CBC with platelets

Serum chemistry with LFTs

PPD or other TB screening

Follow up:CBC/chemistry/LFTs q2-6 months

Annual PPD or other TB screening

Lebwohl M, Bagel J, Gelfand JM et al. J Am Acad Dermatol. 2008;58:94-105.


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When to Refer to Dermatology

Diagnosis in question:Atypical plaques groin/buttocks

Need skin biopsy to rule out cutaneous T cell lymphoma

Other psoriasis mimickers:

Chronic eczematous dermatitisPityriasis rubra pilarisSeborrheic dermatitisSecondary syphilisNutritional deficiencies

Mycosis fungoides

Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

When to Refer?


When to Refer to Dermatology

Moderate-to-severe psoriasis:>5%-10% total body surface area (TBSA) affectedSkin sites with functional or cosmetic concerns:

FaceGenital skinPalms and soles

Failure to respond to topical therapiesPsoriatic arthritis

Kimball AB, Gladman D, Gelfand JM et al. J Am Acad Dermatol. 2008;58:1031-1042.

Conclusions

Top predictors of satisfaction in psoriasis visits:Good empathy and communication skills

Ability to answer patient questions about disease

Address emotional and QOL concerns

Evaluate and address comorbidities

Reassure patients and provide emotional support

Screen carefully for comorbidities

Find your comfort zone managing limited diseaseHave a set of topicals you can prescribe confidently

Know when to refer to your specialists

psoriasis complexities of and sensitivities to psoriasis...

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