management of psoriasis vulgaris quick reference for ... · • psoriasis vulgaris is characterised...

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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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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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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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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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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 ... · • psoriasis vulgaris is characterised...

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