Psoriasis management. A/Prof Amanda Oakley Dermatologist, Waikato

Transcription

1 Psoriasis management A/Prof Amanda Oakley Dermatologist, Waikato AbbVie Breakfast Session, 14 June 2014

2 Disclosure This breakfast session is sponsored by Abbvie

3 Autoimmune skin disorders Psoriasis Eczema Vitiligo Alopecia areata Lichen sclerosus Morphoea Lichen planus Chronic spontaneous urticaria

4 Autoimmune skin disorders Psoriasis Eczema Vitiligo Alopecia areata Lichen sclerosus Morphoea Lichen planus Chronic spontaneous urticaria

5 What is psoriasis? Chronic skin disease Well-circumscribed, scaly plaques in symmetrical distribution

6 Psoriasis 1. Skin + nail disease Various types: genes + environment 2. Autoimmune disease Associated with psoriatic arthritis, spondyloarthropathy, Crohn disease, uveitis 3. Systemic disease Associated with metabolic syndrome: cardiovascular disease, hypertension, type 2 diabetes, gout, hyperlipidaemia, hyperuricaemia, obesity 4. Influenced by drugs + lifestyle choices Lithium, alcohol, smoking

7 Assessment To classify type of psoriasis

8 Classification Early onset >40 years or late onset >40 years Acute or chronic Localised or generalised Small plaque, large plaque or pustular

9 Acute psoriasis Guttate psoriasis post-streptococcal Exanthematic psoriasis Erythrodermic psoriasis Generalised pustular psoriasis Unstable plaque psoriasis.otherwise chronic psoriasis

10 Localised psoriasis Scalp Elbows, knees Flexures Palmoplantar Nails Otherwise generalised psoriasis

11 Plaque size Small plaque psoriasis <3 cm Large plaque psoriasis >3 cm

12 Example Early-onset, generalised, chronic large plaque psoriasis with nail dystrophy

13 Assessment To determine extent and severity Whole body examination Head/neck, upper limbs, trunk, lower limbs Nails Options: PASI PGA BSA

14 PASI score Psoriasis Area and Severity Index

15 PASI spreadsheet tool

16 PASI online tool - Corti

17 PASI online tool

18 PASI apps

19 PASI apps

20 PGA Physician s / patient s Global Assessment clear, nearly clear, mild, moderate, severe or very severe.

21 BSA Body surface area Patient s hand is 1% BSA Mild psoriasis: Moderate psoriasis: Severe psoriasis: <5% of BSA 5-10% of BSA >10% of BSA

22 BSA online training

23 BSA app

24 Assessment To assess co-morbidities BMI: height, weight, waist circumference Arthropathy BP HbA1c, lipids, CBC, LFT, renal function

25 Psoriatic arthropathy app

26 PASE & PEST

27 Assessment Impact of disease on patient DLQI

28 Treatment goals PASI 10 and DLQI 10: Treat with topical agents Remains mild, continue with topical agents Worsening, treat as for moderate/severe psoriasis

29 Treatment options mild psoriasis Emollient Topical corticosteroid short-term Topical calcipotriol Salicylic acid to descale Coal tar

30 Treatment goals PASI >10 or PASI 10 and DLQI >10 Refer: Treat with non-biologic systemic therapy and/or phototherapy

31 Treatment options mod/severe ps Phototherapy Generalised small plaque psoriasis does best Methotrexate Generalised large plaque psoriasis Exclude if baby-making (M+F) Caution if systemic disease Acitretin Generalised erythrodermic, pustular psoriasis Localised pustular psoriasis Exclude if baby-making (F) Ciclosporin Generalised acute psoriasis BP, renal function concerns

32 Shared care: monitoring UV >200 tx + fair skin / h/o skin cancer Regular skin checks Mtx, acitretin, ciclosporin Blood tests Severe psoriasis BP, cardiovascular assessment, lipids, HbA1c

33 Methotrexate: potential issues Teratogen and injures spermatazoa (3 months) Bone marrow suppression Acute hepatitis / chronic hepatic fibrosis Pneumonitis (rare) Methotrexate Folic acid

34 Prior to methotrexate CBC, LFT, renal function Hepatitis B/C serology P3NP collagen CXR if lung disease

35 Monitoring on methotrexate CBC, LFT, renal function Monthly x 3 3-monthly long-term P3NP collagen 6-monthly Transient elastography scan In first year, then every?3-5 years

36 Acitretin: potential issues Teratogen (2 years) Mucocutaneous adverse effects Tiredness, myalgia, arthralgia Hyperlipidaemia

37 Prior to acitretin CBC, LFT, lipids, βhcg

38 Monitoring on acitretin CBC, LFT, lipids 3-monthly x 2 Annually long-term Consider statin if hyperlipidaemia

39 Ciclosporin: potential issues Immunosuppressing Infection, skin cancer Hypertension Renal impairment Hirsutism, leg swelling, tremor, paraesthesias, nausea, headache

40 Prior to ciclosporin CBC, LFT, renal function (creatinine x 2) Hepatitis B/C serology, HIV, TB (Mantoux or QuantiFERON gold >$100) Ca, PO 4, Mg, uric acid, lipids CXR BP (x 2)

41 Monitoring on ciclosporin CBC, creatinine 2-weekly for 8 weeks Then less often: 3-monthly longterm Reduce dose if creatinine 30% above baseline The other bloods 3-6-monthly BP 2-weekly for 8 weeks Then less often: 3-monthly longterm Treat or reduce dose if diastolic 90

42 What else? Influenza virus vaccine Consider pneumococcal, varicella, zoster vaccines Ciclosporin increases risk of infection Examine carefully if patient presents with febrile illness Low threshold for antibiotics Ciclosporin increases risk of skin cancer Encourage sun protection Regular skin checks

43 Response at 6 months

44 Biologic therapy Infliximab Infusion every 8 weeks Adalimumab Subcut every 2 weeks Etanercept Subcut every week Ustekinumab (not funded) Subcut every 3 months

45 Biologic issues $$$ Special Authority criteria Increased risk of infections in first year Not as bad as systemic steroids or ciclosporin May increase risk of skin cancers Not as bad as ciclosporin TNF-α inhibitors may promote weight gain TNF-α inhibitors may promote heart failure

46 Prior to biologics CBC, LFT, renal function, ANA Hepatitis B/C serology, HIV, TB (Mantoux, QuantiFERON gold >$100) CXR

47 Monitoring on biologics CBC, LFT every?6 months Weight

48 More information