PSORIASIS

Diagnosis and management

Dr.Md. Shshidul Islam

Assistant professor

Dermatology & VD, CBMC’B

OVERVIEW

5. Case studies

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4. Managing psoriasis

3. Diagnosing psoriasis

2. Clinical presentation

1. Epidemiology and pathophysiology

WHAT IS PSORIASIS?

– Inflammatory and hyperplastic disease of skin

– Characterised by erythema and elevated scaly plaques

– Chronic, relapsing condition

– Course of disease often unpredictable

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SYMPTOMS OF PSORIASIS

Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.

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Most frequently experienced symptoms

SOCIAL IMPACT OF PSORIASIS

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0 10 20 30 40 50 60Percentage of respondents with severe psoriasis (n = 502)

Adapted from Krueger G et al. Arch Dermatol 2001; 137: 280–4.

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Psoriasis mistaken for other disease

Trouble receiving equal treatment in service

establishments (e.g. hair salons,

public pools)

Psoriasis mistaken as contagious

PSORIASIS AFFECTS EMOTIONAL STATE 6

EPIDEMIOLOGY

• Common skin disorder

• Prevalence variable: ~ 0.3–2.5%

• Prevalence equal in males and females

• Estimated incidence: ~ 60 per 100,000 per year

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AGE OF ONSET

• Mean age: ~ 23–37 years

• Current theory: 2 distinct peaks with possible genetic associations

– Early onset (16–22 years)

• More severe and extensive

• More likely to have affected first-degree family member

– Late onset (57–60 years)

• Milder form

• Affected first-degree family members nearly absent

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GENETIC INFLUENCE

• Evidence suggests strong genetic association

– Studies of monozygotic twins show concordance

for psoriasis (e.g. 64% in a Danish Study)

– Multiple susceptibility loci have been identified

• Disease expression – likely result of genetic and environmental factors

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COMMON TRIGGER FACTORS FOR PSORIASIS

• Infections (e.g. streptococcal, viral)

• Skin trauma (Koebner phenomenon)

• Psychological stress

• Drugs (e.g. lithium, beta blockers)

• Sunburn

• Metabolic factors (e.g. calcium deficiency)

• Hormonal factors (e.g. pregnancy)

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PSORIASIS IS A T-CELL MEDIATED, AUTOIMMUNE DISEASE1

Current hypothesis:

– Unknown skin antigens stimulate immune response

• Antigen-specific memory T-cells are primary mediators

• Leads to impaired differentiation and

hyperproliferation of keratinocytes

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CLINICAL PRESENTATION: CLASSIC PSORIASIS

– Well-defined and sharply demarcated

– Round/oval-shaped lesions

– Usually symmetrical

– Erythematous, raised plaques

– Covered by white, silvery scales

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COMMON SITES AFFECTED BY PSORIASIS

• Can affect any part of the body – typically scalp, elbow, knees and sacrum

• Extent of disease varies

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TYPES OF PSORIASIS

• Chronic plaque

• Guttate

• Flexural

• Erythrodermic

• Pustular– Localised and generalised

• Local forms– Palmoplantar

– Scalp

– Nail (psoriatic onychodystrophy)

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CHRONIC PLAQUE PSORIASIS

– Most common type – affects approximately 85%

– Features pink, well-defined plaques with silvery scale

– Lesions may be single or numerous

– Plaques may involve large areas of skin

– Classically affects elbows, knees, buttocks and scalp

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CHRONIC PLAQUE PSORIASIS 16

CHRONIC PLAQUE PSORIASIS 17

CHRONIC PLAQUE PSORIASIS 18

CHRONIC PLAQUE PSORIASIS 19

GUTTATE PSORIASIS

– Numerous and small lesions – ~ 1 cm diameter

– Pink with less scale than plaque psoriasis

– Commonly found on trunk and proximal limbs

– Typically seen in individuals < 30 years

– Often preceded by an upper respiratory tract streptococcal infection

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FLEXURAL PSORIASIS

– Lesions in skin folds

articularly groin, gluteal cleft, axillae and submammary regions

– Often minimal or absent scaling

– May cause diagnostic difficulty when genital or perianal region is affected in isolation

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ERYTHRODERMIC PSORIASIS

– Generalised erythema covering entire skin surface

– May evolve slowly from chronic plaque psoriasis or appear as eruptive phenomenon

– Patients may become febrile, hypo/hyperthermic and dehydrated

– Complications include cardiac failure, infections, malabsorption and anaemia

– Relatively uncommon

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PUSTULAR PSORIASIS

– Two forms:

• Localised form

• More common

• Presents as deep-seated lesions with multiple small pustules on palms and soles

• Generalised form

• Uncommo Associated with fever and widespread pustules across the body

• inflamed body surface

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PALMOPLANTAR PSORIASIS

– Can be hyperkeratotic or pustular

– May mimic dermatitis – look for psoriatic manifestations elsewhere to aid diagnosis

– Possibly aggravated by trauma

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SCALP PSORIASIS

– Varies from minor scaling with erythema to thick hyperkeratotic plaques

– May extend beyond hairline

– Patient scratching may produce asymmetric plaques

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NAIL PSORIASIS

– May be present in patients with any type of psoriasis

– Can take several forms:

• Pitting: discrete, well-circumscribed depressions on nail surface

• Subungual hyperkeratosis: silvery white crusting under free edge of nail with some thickening of nail plate

• Onycholysis: nail separates from nail bed at free edge

• ‘Oil-drop sign’: pink/red colour change on nail surface

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NAIL PSORIASIS 27

NAIL PSORIASIS 28

NAIL PSORIASIS 29

PSORIATIC ARTHRITIS

– Approximately 5–20% have associated arthritis

– Five major patterns of psoriatic arthritis:

• Distal interphalangeal involvement

• Symmetrical polyarthritis

• Psoriatic spondylarthropathy

• Arthritis mutilans

• Oligoarticular, asymmetrical arthritis

– Clinical expressions often overlap

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DIAGNOSING PSORIASIS

• Other dermatological disorders can resemble psoriasis

• Diagnosed clinically according to appearance, distribution, history of lesions and family history

• Important to consider non-cutaneous complications

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DIFFERENTIAL DIAGNOSIS

• Localised patches/plaques– Tinea– Eczema– Superficial basal cell

carcinoma and Bowen’s disease

– Seborrhoeic dermatitis– Cutaneous T-cell lymphoma

(mycosis fungoides)

• Guttate– Pityriasis rosea– Drug eruption– Secondary syphilis

• Flexural– Tinea– Eczema– Candidiasis– Seborrhoeic dermatitis

• Erythrodermic– Eczema– Cutaneous T-cell lymphoma– Pityriasis rubra pilaris– Lichen planus– Drug

• Palmoplantar– Tinea

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LOCALISED PATCHES/PLAQUES

Tinea corporis

• Affects body

• Lacks symmetrical lesions

• Presence of peripheral scale and central clearing

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Tinea coporis Psoriasis

LOCALISED PATCHES/PLAQUES

– Discoid eczema

• Individualised patches more pruritic than psoriasis

• Lack silvery scale

• Less vivid colour than psoriasis

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Discoid eczema Psoriasis

LOCALISED PATCHES/PLAQUES

– Superficial basal cellcarcinoma/Bowen’s disease

• Asymmetrical lesions, either single or few in number

• Perform biopsy if lesions resistant to topical psoriasis treatment, or to confirm diagnosis

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Bowen’s disease Psoriasis

LOCALISED PATCHES/PLAQUES

– Seborrhoeic dermatitis

• Characterised by yellowish scaling and erythema

– Localised to many of the same areas as psoriasis

• Diffuse scaling differs from sharply defined psoriasis plaques

• Affects furrows of face (facial psoriasis is generally restricted to hairline)

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Dermatitis

Psoriasis

LOCALISED PATCHES/PLAQUES

– Cutaneous T-cell lymphoma (mycosis fungoides)

• Red, discoid lesions

• Asymmetrical and less scaly than psoriasis

• Lesions may present with fine atrophy and be resistant to antipsoriatic therapy

• Biopsy to confirm diagnosis

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Mycosis fungoides

Psoriasis

GUTTATE PSORIASIS

– Pityriasis rosea

• Difficult to distinguish from acute guttate psoriasis

• Presents first as single large patch, progresses to a truncal rash of multiple red scaly plaques (‘Christmas tree’ distribution)

• Resolves over 8–12 weeks

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< Psoriasis ^ Pityriasis rosea

GUTTATE PSORIASIS

– Secondary syphilis• Search for characteristic primary

syphilitic lesion, lymphadenopathy, and lesions of face, palm and soles

• Conduct serology and skin biopsies to confirm

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< Psoriasis ^ Secondary syphilis

FLEXURAL PSORIASIS

– Tinea cruris

• Affects groin area

• Characterised by central clearing with advancing edge

• Non-silvery lesion with fine scale, particularly at periphery

• Lesion frequently extends more on left side

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< Psoriasis ^ Tinea cruris

FLEXURAL PSORIASIS

– Atopic eczema

• Often associated with asthma and hay fever

• Lacks classic psoriatic nail involvement and sharply demarcated scaly plaques

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< Psoriasis ^ Atopic eczema

FLEXURAL PSORIASIS

– Candidiasis

• Characteristic peripheral pustules and scaling differ to psoriasis

• Yeast cultures are diagnostic

– Seborrhoeic dermatits

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Flexural psoriasis

PALMOPLANTAR PSORIASIS

– Tinea manum• Ringworm of hands

• Fine powdery scale, particularly involving palms and palmar creases

• Usually asymmetrical

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Tinea corporis Psoriasis

PALMOPLANTAR PSORIASIS

– Hand and foot eczema

• Hyperkeratotic forms difficult to distinguish from psoriasis

• Biopsies can assist diagnosis

• Look for history of atopy, a lack of psoriasis elsewhere on body, and evidence of eczema elsewhere on skin

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Eczema

Psoriasis

PALMOPLANTAR PSORIASIS

– Pompholyx of palms and soles (dishydrotic eczema)

• Presents as clear vesicles – contrast to white/yellow pustules in pustular psoriasis

• Accompanied by intense pruritus

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Eczema

Psoriasis

DETERMINING PSORIASIS SEVERITY

• Psoriasis Area and Severity Index (PASI)– Score indicates severity of disease at a given time

– Single number that considers severity of lesions and extent of disease across four major body sites (head, trunk, upper limbs and lower limbs)

– Score ranges from 0 (no disease) to 72 (maximal disease)

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MANAGING PSORIASIS

• Before starting treatment– Establish relationship of trust with patient

– Provide patient with information

• Emphasise benign nature of disease

• Explain that psoriasis tends to be chronic and recurrent

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MANAGING PSORIASIS

• Determine clinical setting before selecting treatment, considering– Disease pattern, severity and extent

– Sites of disease

– Coexistent medical conditions

– Patient’s perception of disease severity

– Time commitments and treatment expense

– Previous treatments for psoriasis

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MANAGING PSORIASIS

• Goals of management– Tailor management to individual and address both

medical and psychological aspects

– Improve quality of life

– Achieve long-term remission and disease control

– Minimise drug toxicity

– Evaluate and monitor efficacy and suitability of individual treatments

– Remain flexible and respond to changing needs

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TREATMENT OPTIONS FOR PSORIASIS

• Stepwise approach is advised

• Treatments include:

– General measures and topical therapy

– Phototherapy

– Systemic and biological therapies

• Combination therapies : may reduce toxicity and improve outcomes

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TREATING PSORIASIS: GENERAL MEASURES

• Reduce/eliminate potential trigger factors:– Stress

– Smoking

– Alcohol

– Trauma

– Drugs

– Infections

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TOPICAL THERAPIES

• Approximately 70% of patients with mild-to-moderate psoriasis can be managed with topical therapies alone

• Tailor to needs of patient

• Potency, delivery vehicle and patient motivation may affect compliance

• Application may be time-consuming for patients

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TOPICAL THERAPIES: EMOLLIENTS

• Include aqueous cream, sorbolene cream, white soft paraffin and wool fats

• Regular use can:– alleviate pruritus

– reduce scale

– enhance penetration of concomitant topical therapy

– hydrate dry and cracked skin

• Soap should be avoided

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TOPICAL THERAPIES: KERATOLYTICS

• Over-the-counter products include:– Salicylic acid

– Urea

• Help dissolve keratin to soften and lift psoriasis scales

• May enhance penetration of other actives

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TOPICAL THERAPIES: COAL TAR

• Help reduce inflammation and pruritus

• May induce longer remissions

• Use limited by distinctive smell and ability to stain clothing and skin

• May cause local skin irritation

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TOPICAL THERAPIES: DITHRANOL

• Anti-proliferative properties

• Particularly effective in thick plaque psoriasis

• Initiate therapy at very low concentrations – can burn skin

• Not suitable for face, flexures or genitals

• Stains clothes permanently and skin temporarily

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TOPICAL THERAPIES: TAZAROTENE

• Topical synthetic retinoid

• For treatment of chronic plaque psoriasis

• Applied once daily in evening

• Commonly causes local irritation

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TOPICAL THERAPIES: CORTICOSTEROIDS

• Possess anti-inflammatory, antiproliferative and immunomodulatory properties

• Reduce superficial inflammation within plaques

• Potency choice depends on disease severity, location and patient preference

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TOPICAL THERAPIES: CORTICOSTEROIDS

• Adverse effects associated with long-term use include:– Skin atrophy and telangiectasia

– Hypopigmentation

– Striae

– Rapid relapse or rebound on stopping therapy

– Precipitation of pustular psoriasis

– Pituitary-adrenal axis suppression through significant systemic absorption (rare)

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TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX®)

• Synthetic vitamin D analogue

• For chronic plaque-type psoriasis

• Reverses abnormal keratinocyte changes by:– Inducing differentiation

– Suppressing proliferation of keratinocytes

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TOPICAL THERAPIES: CALCIPOTRIOL (DAIVONEX®)

• Response may require 4–6 weeks

• Adverse effects include erythema and irritation

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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET®)

• For plaque-type psoriasis

• Combination of calcipotriol and a potent topical corticosteroid (betamethasone dipropionate)– Stable formulation for both actives

• Provides rapid, effective psoriasis control

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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET®)

– Combination of calcipotriol and betamethasone dipropionate in Daivobet is more effective than either active constituent used alone

• 39.2% mean reduction in PASI score after 1 week

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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE OINTMENT (DAIVOBET®)

• Once-daily treatment with the potential to improve compliance

• Can be used intermittently in 4-weekly cycles with Daivonex® used in between for maintenance

• Most common adverse events include pruritus, rash and burning sensation

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TOPICAL THERAPIES: CALCIPOTRIOL/BETAMETHASONE DIPROPIONATE GEL

• Newly TGA approved product not yet available in Australia

• Specially formulated for the scalp

• Provides rapid, effective control of scalp psoriasis– More effective than treatment with individual actives alone

– 53.2% (more than half) of patients had absent or very mild disease after just two weeks of gel application

• Once-daily formulation may encourage compliance

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OTHER THERAPIES

• Phototherapy

• Systemic therapies

• Biological agents

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PHOTOTHERAPY

• For psoriasis resistant to topical therapy and covering > 10% of body surface area

• Immunomodulatory and anti-inflammatory effects

• Three main types of phototherapy:– Broadband UVB

– Narrowband UVB

– PUVA (administration of psoralen before UVA exposure)

• Treatment usually administered 2–3 times/week

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SYSTEMIC THERAPIES

• Reserved for patients with widespread or severe psoriasis

• Potentially serious adverse effects and drug interactions

• Many require PBS authority prescription from dermatologist

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SYSTEMIC THERAPIES: METHOTREXATE

• Most commonly used systemic treatment for psoriasis

• Slows epidermal cell proliferation and acts as immunosuppressant

• Closely monitor kidney, liver and bone-marrow function

• Perform PASI score before starting treatment

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SYSTEMIC THERAPIES: CYCLOSPORIN

• Immunosuppressive agent

• For patients with severe psoriasis that is refractory to other treatments

• Requires ongoing monitoring of blood elements, and renal and liver function

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SYSTEMIC THERAPIES: ACITRETIN

• Oral retinoid

• For treatment of all forms of severe psoriasis

• Once-daily oral therapy

• Teratogenic – pregnancy must be avoided

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BIOLOGICAL AGENTS

• Proteins derived from living organisms that exert pharmacological actions

• For adults with moderate-to-severe chronic plaque-type psoriasis who are candidates for phototherapy or systemic therapy

• Most administered sub-cutaneously

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BIOLOGICAL AGENTS

• Target key parts of immune system that drive psoriasis

• Biological agents include:– Tumour necrosis factor-alpha inhibitors

• Etanercept

• Adalimumab

• Infliximab

– Interleukin (IL-12 and IL-32) inhibitor

• Ustekinumab

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CASE STUDY 1

• ((insert image of condition))

• ((insert information under headings below))

• Presentation

• Clinical examination

• Diagnosis

• Management

• ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred))

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CASE STUDY 2

• ((insert image of presenting condition))

• ((insert information under headings below))

• Presentation

• Clinical examination

• Diagnosis

• Management

• ((Diagnosis and management can appear on following screen as ‘builds’ after audience discussion, if preferred))

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DIAGNOSIS AND MANAGEMENT OF PSORIASIS: SUMMARY

• Chronic, inflammatory disease of skin

• T-cell mediated disorder

• Classic presentation characterised by red, scaly plaques

• Management should address both medical and psychological aspects

• Treatments include topical therapy, phototherapy, systemic therapy and biological agents

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THANK

YOU

ALL

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