Best Practices Pearls

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1 PSORIASIS Collaboration for Optimal Management in the Primary Care Setting Michael Rosenblum, MD, PhD Assistant Professor of Dermatology University of California, San Francisco San Francisco, CA Daniel Miller, MD, FAAD Boston University Medical Center Assistant Professor of Dermatology and Dermatopathology Director, Inpatient Dermatology Consultation Service Boston, MA Complexities of and Sensitivities to Psoriasis Diagnosis Michael Rosenblum, MD, PhD Assistant Professor of Dermatology University of California, San Francisco San Francisco, CA Best Practices Pearls Psoriasis There are several variants of psoriasis; plaque psoriasis is the most common presentation Comorbid conditions include psoriatic arthritis, inflammatory bowel disease, diabetes, and cardiovascular disease. Nail involvement has predictive value for the risk of developing psoriatic arthritis Screen carefully and address or refer for management of all comorbidities Patients often see psoriasis as incurable, uncontrollable, and incomprehensible Good communication with your patients will help them manage both the physical and emotional aspects of psoriasis Show empathy Answer questions about disease Address emotional and QOL concerns Limited disease without evidence of arthritis can be managed with appropriate-strength topical steroids Refer to a specialist when patient presents with moderate-to-severe disease, fails to respond to topical therapies, or presents with signs and symptoms of psoriatic arthritis Common, chronic, inflammatory, multisystem disease 2% of the population affected Predominantly affects the skin and joints Associated with psoriatic arthritis, inflammatory bowel disease, diabetes, cardiovascular disease, and lymphoma Menter et al. J Am Acad Dermatol 2008;58: Psoriasis - Clinical Scaly, erythematous plaques Painful or often severely itchy Disfiguring May cause significant compromise in QOL Usually follows a chronic relapsing and remitting course Multiple subtypes SYMMETRIC Menter et al. J Am Acad Dermatol 2008;58: Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; Plaque Psoriasis Most common form (80% - 90% of patients) Well-defined, sharply demarcated, erythematous plaques (1cm to >10cm) Dry, thin, silvery-white scale Most often located on the scalp, trunk, buttocks, and limbs Predilection for extensor surfaces such as the elbows and knees Menter et al. J Am Acad Dermatol 2008;58: Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins;

2 Lesions in the skin folds Inverse Psoriasis Axillary, genital, perineal, intergluteal, and inframammary areas Not scaly (due to increased moisture) Presents as erythematous plaques with minimal scale Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; Erythrodermic Psoriasis Generalized erythema covering nearly the entire BSA with varying degrees of scaling Can develop gradually from chronic plaque disease or acutely with little preceding psoriasis Erythrodermic skin may lead to chills and hypothermia Fluid loss may lead to dehydration Fever and malaise are common Menter et al. J Am Acad Dermatol 2008;58: Weigle et al. Am Fam Physician. 2013;87(9): Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; Pustular Psoriasis Characterized by collections of pus within erythematous plaques May be generalized or localized Acute generalized pustular PSO is severe and accompanied by fever and toxicity Localized pustular variant involves the palms and soles, with or without evidence of classic plaquetype disease Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; Guttate Psoriasis Rain drop-like, 0.1cm to 1cm, salmon-pink papules, usually with a fine scale Primarily affects the trunk and the proximal extremities Common in patients <30 years old History of URI (usually GAS) approximately 2-3 weeks prior to onset of rash Unpredictable clinical course may spontaneously resolve or be the first stage in the development of chronic plaque PSO Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; Nail Psoriasis Fingernails are involved in approximately 50% of all patients Toenails are involved in approximately 35% of all patients Common findings are pitting, onycholysis, subungual hyperkeratosis, and oil-drop spots 90% of patients with psoriatic arthritis may have nail changes PITTING ONYCHOLYSIS Weigle et al. Am Fam Physician. 2013;87(9): Menter et al. J Am Acad Dermatol 2008;58: Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; Making a Diagnosis of Psoriasis 1) Clinical Exam Symmetric skin plaques with thick silvery scale Nail involvement and involvement of the navel and gluteal cleft Associated joint complaints 2) Skin Biopsy Avoid elbow and knees Multiple biopsies if multiple skin morphologies 3) Labs and Imaging Joint complaints => plain films and bone scans Guttate lesions => bacterial culture of throat and perianal area, ASO Pustular lesions => bacterial and fungal culture from pustule 2

3 Differential Diagnosis of Psoriasis Malignancy CTCL (Mycosis Fungoides) Autoimmune Cutaneous Lupus Infectious Secondary Syphilis Skin Related Lichen Planus Chronic Atopic Dermatitis Contact Dermatitis Seborrheic Dermatitis Tinea Corporis Weigle et al. Am Fam Physician. 2013;87(9): Menter et al. J Am Acad Dermatol 2008;58: CTCL (Mycosis Fungoides) Psoriasis Comorbidities Patients with psoriasis are at increased risk of a variety of medical conditions The association may be based on pathophysiology, shared risk factors, or treatment for psoriasis Social isolation may contribute to increased risk of certain medical conditions that are mediated by exercise and lifestyle factors, and may also contribute to decreased quality of life The major medical comorbidities associated with psoriasis are: 1) Psoriatic Arthritis 2) Metabolic Syndrome 3) Coronary Artery Disease 4) Inflammatory Bowel Disease 5) Malignancy 6) Depression A member of the seronegative spondyloarthropathies Develops an average of 12 years after the onset of skin lesions Occurs in about 30% of patients with psoriasis Men and women equally affected Severity is not related to the severity of skin disease Psoriasis and Psoriatic Arthritis Classification Criteria for Psoriatic Arthritis Established Inflammatory Articular Disease Plus a score of 3 or more based on the following clinical findings: Psoriasis - Current active psoriasis (2 points) - Negative test for rheumatoid factor (1 point) - Personal history of psoriasis (1 point) - Psoriasis in a first- or second-degree relative (1 point) - Typical psoriatic nail dystrophy (1 point) Dactylitis - Current swelling of an entire digit (1 point) - History of dactylitis confirmed by a rheumatologist (1 point) - Plain radiography of hand or foot showing juxta-articular new bone formation (ill defined ossification near joint margins excluding osteophyte; (1 point) Psoriasis and the Metabolic Syndrome 1.4 million study participants 41,853 patients with psoriasis Patients with psoriasis were 2.3x more likely to have the metabolic syndrome when compared to the general population Patients with more severe psoriasis have greater odds of metabolic syndrome than those with milder psoriasis Armstrong AW et al. J Am Acad Dermatol. 2013;68: Psoriasis and CAD Relative risk of myocardial infarction is 1.3 in 30-year-old patients with mild psoriasis Relative risk of myocardial infarction is 3.1 in 30-year-old patients with severe psoriasis Elevated risk despite correcting for smoking, diabetes, obesity, hypertension, and hyperlipidemia Most strongly related to chronic inflammation Patients with both rheumatoid arthritis and systemic lupus erythematosus have similar increased risk Treatment of psoriasis can decrease MI-related mortality An Increased Risk of Cardiovascular Mortality Severe psoriasis was an independent risk factor for CV mortality (HR 1.57) when adjusting for age, sex, smoking, diabetes, hypertension, and hyperlipidemia Overall, severe psoriasis patients experienced one extra CV death per 283 patients per year, even when adjusting for major CV risk factors The RR of CV death for a 40-year-old and 60-year-old with severe psoriasis was 2.69 and 1.92, respectively Mehta NN et al. Eur Heart J. 2010;31:

4 Psoriasis and IBD Incidence of Crohn s disease and ulcerative colitis is 5x greater in patients with psoriasis than in the general population Shared genetic susceptibility loci with IBD and psoriasis Treatment of IBD with TNF blockade can induce psoriasis Psoriasis and Malignancy Risk of lymphoma is increased 1.3- to 3.0-fold in persons with psoriasis CTCL and Hodgkin s Lymphoma may be increased over other types of cancers in patients with severe psoriasis Risk of squamous cell carcinoma is increased 14-fold in white patients after 250 or more psoralen plus UVA (PUVA) treatments Weigle et al. Am Fam Physician. 2013;87(9): Bernstein CN, et al. Gastroenterology Sep;129(3): Weigle et al. Am Fam Physician. 2013;87(9): Smedby KE et al. Cancer Epidemiol Biomarkers Prev November ; ; Kim M, et al. Semin Cutan Med Surg 29: Psoriasis and Depression The prevalence of depression in patients with psoriasis may be as high as 60% 10% of psoriasis patients reported a wish to be dead 5% reported active suicidal ideation Depression may improve with psoriasis treatment Kim M, et al. Semin Cutan Med Surg 29: Psychological and Emotional Burden of Psoriasis Psychological and emotional impact is not always related to the extent of skin disease Elevated rates of poor self-esteem, sexual dysfunction, and anxiety are strongly associated with psoriasis SMOKING: 37% of patients with psoriasis were smokers vs 13% in the general population ALCOHOL: Alcohol consumption is more prevalent in patients with psoriasis, and it may also increase severity OBESITY: On average, patients with psoriasis are 14 lbs heavier than patients without psoriasis Herron MD, et al. Arch Dermatol Dec;141(12): Psoriasis Quality of Life The physical and mental disability experienced by patients with psoriasis is comparable or in excess of that found in patients with other chronic illnesses, such as cancer, arthritis, hypertension, heart disease, diabetes, and depression Clinical decision-making must incorporate the impact of the skin lesions on patients lives The QOL impact of psoriasis may be large even in patients with small areas of involvement => psoriasis of the palms and soles tends to have more impact than more extensive involvement on the trunk Patients with limited skin disease should be considered candidates for systemic treatment Psoriasis Quality of Life One survey found that more than one-half of patients with severe psoriasis thought physicians could do more to help, and 78% reported frustration with the effectiveness of treatment One study found that psoriasis caused a greater negative effect on quality of life than life-threatening chronic diseases Higham R, et al. In Advance Healthcare Network Krueger G, et al. Arch Dermatol. 2001;137(3): Higham R, et al. In Advance Healthcare Network Psoriasis-Patients.aspx 4

5 Patient Stratification for Treatment Treatment goals include improvement of skin, nail, and joint lesions plus enhanced quality of life Treatment must be individualized to incorporate patient preferences and the potential benefits and adverse effects of therapies Consultation with a dermatologist may be warranted for patients with severe disease that require systemic therapy Patient Stratification for Treatment Practical Classification for PCP 1) Mild to Moderate Disease Less than 5% of the body surface area and sparing the genitals, hands, feet, and face Minimal impact on patient s QOL 2) Severe Disease Involving more than 5% of the body surface area or involving the hands, feet, face, or genitals Significant impact on QOL Case Presentation Collaborative Approach for Optimal Management Daniel Miller, MD, FAAD Boston University Medical Center Assistant Professor of Dermatology and Dermatopathology Director, Inpatient Dermatology Consultation Service Boston, MA Anne is a 34-year-old female, previously diagnosed with plaque psoriasis by another physician, presenting with complaints of uncontrolled psoriasis, insomnia and shortness of breath Her energy level has gone down recently, and she has concentration problems at work which she attributes to lack of sleep As part of a swimming team, she used to exercise regularly, but she just does not feel like it anymore She has gained about 20 pounds over the course of the past year Understanding Psoriasis Patients Key Point Physician interpersonal skills = strongest predictor of patient satisfaction in dermatology Patient satisfaction significantly increased when: 1) Physician shows empathy for the skin disease 2) Physician gives effective explanations to questions Lowest levels of satisfaction: Patients whose self-reported QOL was worse than the physician s assessment of clinical severity Physicians who fail to recognize the impact of psoriasis on their patient s quality of life will have the most difficulty connecting with and helping these patients. Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145: Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145:

6 Address the Emotional Impact of Psoriasis Patient satisfaction is significantly increased with expressions of empathy Simply acknowledging patient frustration and annoyance is often beneficial Adherence and overall outcomes improve with increasing patient satisfaction Visits in which physicians address emotional concerns are actually shorter Patient Perspectives Psoriasis patients view their disease as: Incomprehensible Incurable Uncontrollable Patients are seeking: Explanations with simple, everyday language Empathy and careful listening to emotional concerns Reassurance when discouraged Hope regarding disease prognosis Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145: Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12. Linder D, Dall'olio E, Gisondi P et al. Am J Clin Dermatol. 2009;10: Quality of Life Concerns Psoriasis Patient Perspectives Common patient complaints Frustration at incurability, depression Unable to wear a bathing suit Co-workers express disgust at appearance Hairdressers refuse to perform services Others think they have a contagious disease Impact on sexual health and function Hidden concerns Pts think lifestyle choices may have caused psoriasis Cancer risk, communicability Patient wish list More information on the disease Etiology and causes Triggers for disease flares Treatment options, prognosis, and curability Clear expectations at the onset of therapy Written instructions regarding medications Timeframe and results expected with treatment Recognition by physicians of the emotional burden Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12. Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12. Strategies for Successful Visits Patient Resources Express empathy, address quality of life issues Elicit hidden fears, alleviate anxiety Screen for depression, alcohol abuse (both increased) Communicate the basics about psoriasis Pathophysiology, disease course, and treatment Use simple, easy-to-understand language Verbal education during the visit = gold standard Offer adjunctive teaching aides Handouts, visual aides Recommend reliable internet resources Encourage patients to join National Psoriasis Foundation (NPF) Helpful websites: Psoriasis.org (NPF site) AAD.org nlm.nih.gov (US National Library of Medicine) Patient advocacy group Redpatch.org Hong J, Nguyen TV, Prose NS. J Am Acad Dermatol. 2013;68:364.e1-10. Hong J, Nguyen TV, Prose NS. J Am Acad Dermatol. 2013;68:364.e

7 Natural History of Psoriasis Help Set Patient Expectations A chronic systemic inflammatory disorder Influenced by environmental factors Flares can be triggered by infections, medications, weather changes, and stress There is no cure for the disease 80% of patients have mild to moderate disease Disease defined by a waxing-waning course Typical onset between ages Disease course can be modified by therapy initiation Many new therapy options in the past 10 years Patients who expect lifetime clearance with no flares will inevitably be disappointed Psoriasis is managed, not cured Ascertain patient s goals, develop a strategy Some patients like the simplicity and low risks of topical therapies and will tolerate flares Others want very tight disease control and may consider systemic treatments with more side effects Patients need to be realistic about outcomes and understand side effects of different therapies Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58: Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60: Psoriasis Treatment Algorithm Treatment of Limited Plaque Psoriasis Patients with <5% total body surface area (TBSA) Topical preparations and targeted phototherapy are both appropriate Know classes of topical steroids and their uses Recognize other helpful topical medicines Know the basics of phototherapy and availability in your area Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58: Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58: Topical Therapies 80% of patients have mild to moderate disease which can often be managed topically Topical agents have high efficacy and safety Topicals can be combined with phototherapy or systemic treatment in patients with more severe disease Topical Steroids: General Principles The best vehicle (ointment, cream, lotion, etc) is the one the patient will actually use Elicit patient preferences Give enough medication for sustained usage Takes 400 grams to cover entire body for bid x 1 week High potency steroids for thick, chronic plaques Use intermittently to maximize safety Limit to 2-to-4-week periods Lower potency steroids for face, intertriginous, and other zones of thin skin Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60: Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60:

8 Topical Steroids Become familiar with 3-4 go-to agents High potency steroids (Class I and II): Clobetasol (class I) and fluocinonide (class II) Initial therapy of chronic, thick plaques on non-sensitive sites Twice daily usage for 2-4 weeks then treatment holiday Mid-potency steroids Triamcinolone 0.1% ointment or cream (classes III and IV) Maintenance therapy Also for short periods (1-2 weeks only) on sensitive sites Lower potency steroids Desonide (class VI) and hydrocortisone 2.5% (class VII) Long term-use on sensitive sites such as face and groin Other Topical Agents to Consider Vitamin D analogues such as calcipotriene Adjunctive therapy to topical steroids Excellent safety profile Topical retinoids (tazarotene) Useful in combination with topical steroids May cause skin irritation, redness Pregnancy category X Coal tar More than 100 years of use in treatment of psoriasis Many OTC preparations available Cosmetic concerns (smell, stains clothes) limit use for some Nonmedicated emollients (moisturizers) Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60: Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60: Phototherapy Phototherapy Indications >10% of total body surface area (TBSA) affected Limited dz with severe QOL impact (eg hands, feet) Benefits Efficacious, cost-effective Lacks systemic immunosuppressive properties Drawbacks Time consuming, not always available locally Local side effects: itch, erythema, risk of burning Caution in lupus, fair skin, any history of skin cancer Typical regimens nbuvb (narrow-band UVB) 2-3 times weekly Response observed at 8-10 treatments Single course is treatments Maintenance therapy may prolong remission Targeted regimens available for limited disease Hand-foot nbuvb light boxes Excimer 308nm laser can target small lesions Home nbuvb light sources (need MD surveillance) Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2010;62: Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2010;62: Management Issues in Primary Care Appropriate cardiovascular screening Vaccine safety in immunosuppressed patients Monitoring for adverse events while on immunosuppressive therapies Knowing when to refer to specialists Are PCPs Screening for CV Risks? 79 of 191 PCPs (42%) were aware that psoriasis patients have worse CV outcomes Only a minority were screening appropriately based on current AHA guidelines for psoriasis: 43% were appropriately screening for HTN Only 11% for dyslipidemia 30% for obesity 27% for type II diabetes Parsi KK, Brezinski EA, Lin T-C et al. J Am Acad Dermatol. 2012;67:

9 Cardiovascular Screening: Starting at Age 20 in Psoriasis Patients Factor Baseline Frequency Targets Hypertension Diabetes Blood pressure Family history Fasting glucose Family history At each visit At least once every 3 years Dyslipidemia Fasting lipids Annually SBP < 130 DBP < 85 <100 mm/dl Total chol < 200 LDL < 100 mg/dl HDL > 50 mg/dl Obesity BMI measurement At each visit BMI < 25 Vaccines in Immunosuppressed Patients Many vaccine-preventable diseases carry increased risks in immunosuppressed: Influenza, pneumococcus, VZV (increased mortality) Hepatitis B (increased morbidity) But vaccination rates in these patients are poor: Only 45% and 28% of IBD patients receive tetanus booster and annual influenza, respectively Clinicians often worried about vaccine safety, efficacy and possibility of flaring underlying disease Parsi KK, Brezinski EA, Lin T-C et al. J Am Acad Dermatol. 2012;67: Kimball AB, Gladman D, Gelfand JM et al. J Am Acad Dermatol. 2008;58: Rahier JF, Moutschen M, Van Gompel A et al. Rheumatol. 2010;49: Vaccines in Immunosuppressed Patients Live vaccines contraindicated during therapy: Measles-mumps-rubella Poliomyelitis (live version) Varicella/zoster Typhoid fever Yellow fever Cholera Vaccines in Immunosuppressed Patients Non-live vaccines can safely be given: Diptheria-tetanus-pertussis Poliomyelitis (non-live version) Pneumococcal Influenza Human papillomavirus Hepatitis A and B Humoral response is diminished with certain drugs (MTX, TNF -inhibitors), but is usually adequate No clear evidence that these vaccines cause dz flares Rahier JF, Moutschen M, Van Gompel A et al. Rheumatol. 2010;49: Rahier JF, Moutschen M, Van Gompel A et al. Rheumatol. 2010;49: Best Practices Pearls Vaccines in Psoriasis Patients on Immunotherapy Best to vaccinate prior to starting immunotherapy Live vaccines safe: give 3-4 weeks before starting MMR in high risk patients over 50 VZV in patients over 60 or high risk Best humoral response to inactivated vaccines During therapy Annual influenza vaccine DTP with booster every 10 years Poliomyelitis (inactivated for pts and household contacts) Consider: Hep B (if high risk), pneumococcal (if over 65) Monitoring Patients on Immunotherapy TNF- inhibitors (ex: etanercept, adalimumab, infliximab) Baseline: CBC with platelets Serum chemistry with LFTs PPD or other TB screening Follow up: CBC/chemistry/LFTs q2-6 months Annual PPD or other TB screening Lebwohl M, Bagel J, Gelfand JM et al. J Am Acad Dermatol. 2008;58:

10 When to Refer to Dermatology Diagnosis in question: Atypical plaques groin/buttocks Need skin biopsy to rule out cutaneous T cell lymphoma Other psoriasis mimickers: Chronic eczematous dermatitis Pityriasis rubra pilaris Seborrheic dermatitis Secondary syphilis Nutritional deficiencies Mycosis fungoides When to Refer? Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58: When to Refer to Dermatology Conclusions Moderate-to-severe psoriasis: >5%-10% total body surface area (TBSA) affected Skin sites with functional or cosmetic concerns: Face Genital skin Palms and soles Failure to respond to topical therapies Psoriatic arthritis Top predictors of satisfaction in psoriasis visits: Good empathy and communication skills Ability to answer patient questions about disease Address emotional and QOL concerns Evaluate and address comorbidities Reassure patients and provide emotional support Screen carefully for comorbidities Find your comfort zone managing limited disease Have a set of topicals you can prescribe confidently Know when to refer to your specialists Kimball AB, Gladman D, Gelfand JM et al. J Am Acad Dermatol. 2008;58: