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Introduction to Psoriasis

Introduction to Psoriasis. Denise Cook, M.D. Medical Officer Division of Dermatology and Dental Drug Products. Introduction to Psoriasis. Prevalence Genetics and Pathogenesis Clinical Variants of Psoriasis State of the Armamentarium. Prevalence.

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Introduction to Psoriasis

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  1. Introduction to Psoriasis Denise Cook, M.D. Medical Officer Division of Dermatology and Dental Drug Products

  2. Introduction to Psoriasis • Prevalence • Genetics and Pathogenesis • Clinical Variants of Psoriasis • State of the Armamentarium

  3. Prevalence • Psoriasis occurs in 2% of the world’s population • Prevalence in the U.S may be as high as 4.6% • Highest in Caucasians • In Africans, African Americans and Asians between 0.4% and 0.7%

  4. Prevalence • Equal frequency in males and females • May occur at any age from infancy to the 10th decade of life • First signs of psoriasis • Females mean age of 27 years • Males mean age of 29 years

  5. Prevalence • Two Peaks of Occurrence • One at 20-30 years • One at 50-60 years • Psoriasis in children • Low – between 0.5 and 1.1% in children 16 years old and younger • Mean age of onset - between 8 and 12.5 years

  6. Prevalence • Two-thirds of patients have mild disease • One-third have moderate to severe disease • Early onset (prior to age 15) • Associated with more severe disease • More likely to have a positive family history • Life-long disease • Remitting and relapsing unpredictably • Spontaneous remissions of up to 5 years have been reported in approximately 5% of patients

  7. Genetics and Pathogenesis • Psoriasis and the Immune System • The major histocompatibility complex (MHC) • Short arm of chromosome 6 • Histocompatibility Antigens (HLA) • HLA-Cw6 • HLA-B13, -B17, -B37, -Bw16 • T-lymphocyte-mediated mechanism

  8. Psoriasis as a Systemic Disease • Koebner Phenomenon • Elevated ESR • Increased uric acid levels → gout • Mild anemia • Elevated α2-macroglobulin • Elevated IgA levels • Increased quantities of Immune Complexes

  9. Psoriasis as a Systemic Disease • Psoriatic arthropathy • Aggravation of psoriasis by systemic factors • Medication • Focal infections • Stress • Life-threatening forms of psoriasis

  10. Clinical Variants of Psoriasis

  11. Characteristic Lesion of Psoriasis • Sharply demarcated erythematous plaque with micaceous silvery white scale • Histopathology • Thickening of the epidermis • Tortuous and dilated blood vessels • Inflammatory infiltrate primarily of lymphocytes

  12. Psoriatic Plaque

  13. Severity of Disease • Three Cardinal Signs of Psoriatic Lesions • Plaque elevation • Erythema • Scale • Body Surface Area

  14. Chronic Plaque Psoriasis • Most Common Variant • Plaques may be as large as 20 cm • Symmetrical disease • Sites of Predilection • Elbows • Knees • Presacrum • Scalp • Hands and Feet

  15. Chronic Plaque Psoriasis

  16. Chronic Plaque Psoriasis

  17. Chronic Plaque Psoriasis • May be widespread – up to 90% BSA • Genitalia involved in up to 30% of patients • Most patients have nail changes • Nail pitting • “Oil Spots” • Involvement of the entire nail bed • Onychodystrophy • Loss of nail plate

  18. Widespread Chronic Plaque Psoriasis

  19. Chronic Psoriasis

  20. Psoriasis of the Nail

  21. Psoriasis of the Nail

  22. Symptoms of Chronic Plaque Psoriasis • Pruritus • Pain • Excessive heat loss • Patient Complaints • Unsightliness of the lesions • Low self-esteem • Feelings of being socially outcast • Excessive scale

  23. Guttate Psoriasis • Characterized by numerous 0.5 to 1.5 cm papules and plaques • Early age of onset • Most common form in children • Streptococcal throat infection often a trigger • Spontaneous remissions in children • Often chronic in adults

  24. Guttate Psoriasis

  25. Life–Threatening Forms of Psoriasis • Generalized Pustular Psoriasis • Erythrodermic Psoriasis

  26. Generalized Pustular Psoriasis • Unusual manifestation of psoriasis • Can have a gradual or an acute onset • Characterized by waves of pustules on erythematous skin often after short episodes of fever of 39˚ to 40˚C • Weight loss • Muscle Weakness • Hypocalcemia • Leukocytosis • Elevated ESR

  27. Generalized Pustular Psoriasis • Cause is obscure • Triggering Factors • Infection • Pregnancy • Lithium • Hypocalcemia secondary to hypoalbuminemia • Irritant contact dermatitis • Withdrawal of glucocorticosteroids, primarily systemic

  28. Generalized Pustular Psoriasis

  29. Erythrodermic Psoriasis • Classic lesion is lost • Entire skin surface becomes markedly erythematous with desquamative scaling. • Often only clues to underlying psoriasis are the nail changes and usually facial sparing

  30. Erythrodermic Psoriasis • Triggering Factors • Systemic Infection • Withdrawal of high potency topical or oral steroids • Withdrawal of Methotrexate • Phototoxicity • Irritant contact dermatitis

  31. Erythrodermic Psoriasis

  32. State of the Armamentarium • Wide range of therapies for the treatment of moderate to severe psoriasis • None induce a permanent remission • All have side effects that can place limits on their use

  33. State of the Armamentarium • Therapies • Topical Corticosteroids • Topical Vitamin D3 Analogues • Topical Retinoids • Photo(chemo)therapy • Systemic Therapies • Oral • Parenteral

  34. Topical Corticosteroids • High potency and Super potent topical steroids • These include • Fluocinonide family (cream, ointment, gel) • Betamethasone dipropionate cream • Clobetasol propionate family (cream, ointment, gel, foam, lotion) • Diflorasone diacetate ointment • Betamethasone dipropionate ointment

  35. Topical Corticosteroids • Side effects associated with use • Skin atrophy • Burning and stinging • Suppression of the hypothalamic-pituitary-adrenal (HPA) axis • This may occur after 2 weeks of use with certain topical corticosteroids

  36. Topical Vitamin D3 Analogues • Prototype for this group is calcipotriene • 3 formulations – cream, ointment, and scalp solution • Former two are approved for plaque psoriasis • Latter for moderate to severe psoriasis of the scalp

  37. Topical Vitamin D3 Analogues • Side Effects • Cutaneous • Burning • Stinging • Pruritus • Skin irritation • Tingling of the skin

  38. Topical Retinoids • Tazarotene Gel and Cream • Available in two strengths • 0.05% and 0.1% • Side Effects • Pruritus • Burning/Stinging • Erythema • Worsening of psoriasis • Irritation • Skin pain • Hypertriglyceridemia

  39. Topical Tazarotene • Additional Indications • 0.1% gel - approved for the treatment of facial acne vulgaris of mild to moderate severity • 0.1% cream approved as an adjunctive agent for use in the mitigation of facial fine wrinkling, facial mottled hyper- and hypopigmentation, and benign facial lentigines in patients who use comprehensive skin care and sunlight avoidance programs

  40. Topical Tazarotene (con’t) • Both products are pregnancy category X • Are contraindicated in women who are or may become pregnant • Requirements before and during therapy • A negative pregnancy test 2 weeks prior • Therapy initiated during a normal menses • Women of childbearing potential should use adequate birth control

  41. Photo(chemo)therapy • Two types of phototherapy • Ultraviolet B (UVB) • Ultraviolet A + psoralen (PUVA)

  42. UVB • Two types • Broadband UVB • Narrowband UVB (311-313 nm) • Treatment is time consuming • 2-3 visits/week for several months • Side effect – possibility of experiencing an acute sunburn reaction

  43. PUVA • Consists of ingestion of or topical treatment with a psoralen followed by UVA • Usually reserved for severe, recalcitrant, disabling psoriasis • Time consuming – 2-3 visits/wk; at least 6 weeks • Precautions • Patients must be protected from further UV light for 24 hours post treatment • With oral psoralen, wrap around UV-blocking glasses must be worn for 24 hours post treatment

  44. PUVA • Side effects with oral psoralen • Nausea • Dizziness • Headache • Side effects with PUVA • Early • Pruritus • Late • Skin damage • Increased risk for skin cancer, particularly squamous cell (SCC) and after 200 - 250 treatments, increased risk for melanoma

  45. Contraindications to PUVA • Patients less than 12 years of age • Patients with a history of light sensitive disease states • Patients with, or with a history of melanoma • Patients with invasive SCC • Patients with aphakia

  46. Systemic Therapies • Oral • Methotrexate • Neoral (cyclosporine) • Soriatane (acitretin) • Parenteral • Amevive (alefacept) • Raptiva (efalizimab) • Enbrel (etanercept)

  47. Methotrexate • Folic acid antagonist • Usually reserved for severe, recalcitrant, disabling psoriasis • Maximum improvement can be expected after 8 -12 weeks

  48. Contraindications - Methotrexate • Nursing mothers • Patients with alcoholism • Alcoholic liver disease • Other chronic liver disease • Patients with overt or laboratory evidence of immunodeficiency syndromes • Patients who have preexisting blood dyscrasias

  49. Methotrexate • Pregnancy Category X drug product • Contraindicated in pregnant women with psoriasis • Pregnancy must be excluded in women of childbearing potential • Pregnancy should be avoided if either partner is receiving MTX during and for a minimum of 3 months after therapy for male patients and for at least one ovulatory cycle after therapy for female patients

  50. Methotrexate – Side Effects • Acute or chronic hepatotoxicity • Hepatic cirrhosis • Leukopenia • Thrombocytopenia • Anemia, including aplastic anemia • Rarely, interstitial pneumonitis • Stomatitis • Nausea/vomiting • Alopecia • Photosensitivity • Burning of skin lesions

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