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Which of the following is NOT an associated comorbidity of Psoriasis?

Which of the following is NOT an associated comorbidity of Psoriasis?. Inflammatory Arthritis Inflammatory Bowel Disease Atopic Dermatitis Metabolic Syndrome. Which of the following is the only FDA approved biologic available for patients suffering from moderate to severe atopic dermatitis?.

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Which of the following is NOT an associated comorbidity of Psoriasis?

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  1. Which of the following is NOT an associated comorbidity of Psoriasis? • Inflammatory Arthritis • Inflammatory Bowel Disease • Atopic Dermatitis • Metabolic Syndrome

  2. Which of the following is the only FDA approved biologic available for patients suffering from moderate to severe atopic dermatitis? • Adalimumab (Humira) • Omalizumab (Xolair) • Dupilumab (Dupixent) • Secukinumab (Cosentyx)

  3. An Update on Commonly Encountered Dermatologic Diseases Rocco Serrao MD FAAD Dermatologists of southwestern ohio

  4. Faculty Disclosures • Abbvie– speaker’s bureau • Eli Lilly – clinical research • Foamix- clinical research • Pfizer – speaker’s bureau • Regeneron – speaker’s bureau • Sanofi-Genzyme - speaker’s bureau

  5. Presentation Outline • Discuss common dermatologic conditions encountered by the primary care provider and provide insight into diagnosis and current management strategies • Atopic Dermatitis • Psoriasis • HidradrenitisSuppuritiva

  6. Adaptive Immune System - Th1 vs. Th2 Psoriasis HS AD An. Bras. Dermatol. vol.87 no.5 Rio de Janeiro Sept/Oct. 2012

  7. Atopic Dermatitis • Inflammatory immune mediated skin disease • Affects 20-30% of children/adolescents and 2-10% of adults • Atopic tetrad • Atopic dermatitis • Allergic Rhinitis (40-50%) • Asthma (25-30%) • Eosinophilic esophagitis (<5%) Ring, J. (2016) Atopic Dermatitiis:Eczema. New York, New York: Springer.

  8. Atopic Dermatitis - Overview • Typically presents around 2 mos of age (not at birth) • 80-90% of cases are diagnosed by adolescence • Present in adulthood in 2/3 of cases • 1/3 resolve in childhood • 1/3 persist into adulthood • 1/3 remit in childhood and relapse in adulthood Kissling A, Wuthrich B. Verlauf der atopischen Dermatitis nachdemKleinkindesalter. Hautarzt. 1993;44:569-73

  9. Atopic Dermatitis - Diagnosis • Rajka and Hanifin Criteria • Is the dermatitis in an age appropriate morphology and distribution? • Does it itch? • Is it chronic? • Is there an associated family or personal hx of atopy?

  10. Atopic Dermatitis • Morphology • Acute: weepy, erythematous, ill defined papules and plaques • excoriation • Chronic: lichenifiedplaques • excoriation • Distribution • Infantile: extensor • Childhood: flexural • Adult: flexural, hands, feet, upper back/neck/chest

  11. Atopic Dermatitis – Debilitating ITCH • Pruritus is the single most troublesome aspect of disease to patients • “Itch that Rashes” • Need to break the ”itch-scratch cycle” Koblenzer, C. Itching and the atopic skin. J Allergy ClinImmunol 1999;104:S109-13.

  12. Atopic Dermatitis – Treatment Strategies • Need to treat all aspects of disease • Restoring skin barrier • Trigger avoidance • Dermatitis • Pruritus • Antihistamines do not target itch • Sedating anti-histamines aid in sleep • Treat secondary infections • Impetigo • Eczema herpeticum • Eczema coxsackium Ring, J. (2016) Atopic Dermatitiis:Eczema. New York, New York: Springer.

  13. Atopic Dermatitis – Restoring Skin Barrier/Trigger Avoidance • Bathing “Strategy” • Short (<5 minute) Cool bath or shower • Gentle cleanser (i.e. Dove Sensitive BAR soap, Cetaphil Gentler Liquid skin cleanser • Gentle shampoo (i.e. Dermarest, Free and Clear) • Bleach Bath (1/2 cup bleach to a full tub of water) • Emollients • Ointments > Creams; Avoid Lotions(i.e. Vaseline, Aquaphor, CeraVe healing ointment, CeraVe cream, Cetaphil cream) • At least twice daily

  14. Atopic Dermatitis – Restoring Skin Barrier/Trigger Avoidance • Miscellaneous • Linens and clothing to be laundered with hypoallergenic detergent, fabric softener as well as dryer sheets; extra rinse cycle • Water softener • Common Triggers include dust mite, mold, pet dander • Dust mite mattress covers Ring, J. (2016) Atopic Dermatitiis:Eczema. New York, New York: Springer.

  15. Atopic Dermatitis – targeting dermatitis and itch • Topical treatments • Topical corticosteroids • Topical calcineurin inhibitors • *Topical phosphodiesterase inhibitors • crisaborole • Systemic treatments • Phototherapy (nb-UVB) • Immunosuppresants– prednisone, cyclosporine, MTX, MMF • Biologics –dupilumab (Il-4r⍺ antagonist) • Anti-histamines • Use first generation sedating (i.e. hydroxyzine)

  16. Atopic Dermatitis – Treating Secondary Infections • Colonization with MSSA, MRSA, Strep. very common in pt’s with AD (>60%) • Tx impetigo with tetracycline(MCN/DCN)>Bactrim>Clindamycin; topical mupirocin, ozenoxacin* • Disrupted skin barrier makes secondary viral infection more common • Eczema herpeticum* • HSV-1, HSV-2 • Acyclovir (IV) • Eczema coxsackium • Tx as EH until culture results obtained

  17. Atopic Dermatitis – Novel Treatment • Crisiborole • Non-steroidal PDE4 inhibitor • Mild to Moderate Atopic Dermatitis • Age 2 y/o + • Can be applied “nose to toes” • No limitation for duration of treatment • Stinging and burning seen in up to 20% of patients • Usually on initial application; resolved in 75% of patients upon second application • Improves dermatitis and pruritus* • Incorporate into overall treatment strategy (combined with topical corticosteroid) Paller, A. et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol. 2016 Sep;75(3):494-503.e6.

  18. Atopic Dermatitis – Novel Therapy • Dupilumab • Game Changer – targets both pruritus and dermatitis • Moderate to severe AD in adults • IL-4R⍺ inhibitor (Th2 suppression) • Asthma indication (12 y/o +) • Not an immunosuppresent • Injection • Eye issues • Conjuctivitis >>>>>>keratitis Simpson, E. et al. Two Phase 3 Trials of Dupilumab versus Placebo in Atopic Dermatitis. N Engl J Med 2016; 375:2335-2348DOI: 10.1056/NEJMoa1610020

  19. Atopic Dermatitis • Associated diseases excluding atopicconditions: • Depression • Attention deficit hyperactivity disorder • Obesity Nahm DH. Associations of atopic dermatitis with obesity and unmarried status in young adults: Evidence for atopic dermatitis as a life-style disorder with high social impact. Allergy Asthma Immunol Res. 2016;8(2):89–91.

  20. Psoriasis vulgaris • Immune mediated chronic inflammatory disorder • Affects 2% of the population • Bimodal onset 25-30 yrs 50-55 yrs • Great treatment options to minimize morbidity and mortality James, W., Berger, T., Elston, D. Andrew’s Diseases of the Skin (2011)

  21. Psoriasis vulgaris • Morphology: well demarcated plaques with overlying silvery scale • Distribution: • Extensor • Scalp • Fingernails • Folds/Creases (inverse) • Types: • Vulgaris (90%) • Erythrodermic • Pustular • Guttate James, W., Berger, T., Elston, D. Andrew’s Diseases of the Skin (2011)

  22. Psoriasis vulgaris –Distribution and Morphology

  23. Psoriasis Vulgaris –Treatment Strategy • Topical Treatments • Topical steroids • Topical vitamin D3 analogues • Topical coal tar/salicylic acid • Phototherapy • Systemic Treatments • Immunosuppresants • (i.e. adalimumab, etanercept, infliximab, certolizumab, secukinumab, ixekizumab, brodalumab, ustekinumab, guselkulmab) • Immunomodulators - • (i.e. alefacept) James, W., Berger, T., Elston, D. Andrew’s Diseases of the Skin (2011)

  24. Psoriasis vulgaris – Immunotherapy Targets (Simplified!) Allows us to taylor treatments based on patient characteristics

  25. Psoriasis Vulgaris – Treatment Strategy • Managing associated diseases • Metabolic syndrome (40%) • Psoriatic Arthritis (10-30%) • IBD (2%) • Depression • CAD • DM Aurangabadkar SJ. Comorbidities in psoriasis. Indian J DermatolVenereolLeprol 2013;79, Suppl S1:10-7

  26. HidadrenitisSuppuritiva • Chronic inflammatory disease characterized by recurrent abscess formation, primarily within skin folds (aprocrine rich areas) • Non-infectious inflammatory skin disorder • Characterized by tender red nodules, abscesses, sinus tracts and scarring James, W., Berger, T., Elston, D. Andrew’s Diseases of the Skin (2011)

  27. HidadrenitisSuppuritiva • Delayed diagnosis can lead to long term sequelae • Lymphatic obstruction • Squamous cell carcinoma • Scarring with join limitation • Secondary infection James, W., Berger, T., Elston, D. Andrew’s Diseases of the Skin (2011)

  28. HidadrenitisSuppuritiva Management • Lifestyle change • Smoking cessation, weight loss • Pharmacological • BPO, clindamycin lotion, spironolactone, oral abx (tetracycline class), adalimumab* • Surgical (apocrine glad removal) • Laser destruction, excision Kimball AB, Okun MM, Williams DA et al. Two phase 3 trials of adalimumab for hidradenitis suppurativa. N Engl J Med. 2016;375(5):422–434.

  29. HidadrentitsSuppuriviva– Associated Diseases • Psoriatic arthritis/ankylosing spondylitis • Obesity • Metabolic syndrome • Depression • IBD Shlyankevich J, Chen AJ, Kim GE, Kimball AB. Hidradenitis suppurativa is a systemic disease with substantial comorbidity burden: a chart-verified case-control analysis. J Am AcadDermatol. 2014;71(6):1144–1150.

  30. Take Home Message • AD, Psoriasis and HS are all inflammatory meditated chronic dermatoses • It is important to recognize and treat these conditions early to reduce disease burden • Novel treatments are available to target patients in need • It is important for the dermatologist to communicate with the PCP to manage associated diseases • You can co-manage patients with a dermatologist

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