1 PsoriasisPsoriasis Dr. Majdy Naim. 2 PrevalencePrevalence Psoriasis occurs in 2% of the world’s...

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PsoriasisPsoriasisPsoriasisPsoriasis

Dr. Majdy Naim

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PrevalencePrevalencePrevalencePrevalence

Psoriasis occurs in 2% of the world’s Psoriasis occurs in 2% of the world’s populationpopulation

Prevalence in the U.S may be as high Prevalence in the U.S may be as high as 4.6%as 4.6%

Highest in CaucasiansHighest in Caucasians In Africans, African Americans and In Africans, African Americans and

Asians between 0.4% and 0.7%Asians between 0.4% and 0.7%

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Equal frequency in males and femalesEqual frequency in males and females May occur at any age from infancy to May occur at any age from infancy to

the 10the 10thth decade of life decade of life

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PrevalencePrevalencePrevalencePrevalence

Two Peaks of OccurrenceTwo Peaks of Occurrence

– One at 20-30 yearsOne at 20-30 years

– One at 50-60 yearsOne at 50-60 years Psoriasis in childrenPsoriasis in children

– Low – between 0.5 and 1.1% in Low – between 0.5 and 1.1% in children 16 years old and youngerchildren 16 years old and younger

– Mean age of onset - between 8 and Mean age of onset - between 8 and 12.5 years12.5 years

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PrevalencePrevalencePrevalencePrevalence

Two-thirds of patients have mild diseaseTwo-thirds of patients have mild disease One-third have moderate to severe diseaseOne-third have moderate to severe disease Early onset (prior to age 15)Early onset (prior to age 15)

– Associated with more severe diseaseAssociated with more severe disease– More likely to have a positive family historyMore likely to have a positive family history

Life-long diseaseLife-long disease– Remitting and relapsing unpredictablyRemitting and relapsing unpredictably– Spontaneous remissions of up to 5 years have Spontaneous remissions of up to 5 years have

been reported in approximately 5% of patientsbeen reported in approximately 5% of patients

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Psoriasis as a Systemic Psoriasis as a Systemic DiseaseDiseasePsoriasis as a Systemic Psoriasis as a Systemic DiseaseDisease

Koebner PhenomenonKoebner Phenomenon Elevated ESRElevated ESR Increased uric acid levels Increased uric acid levels →→ gout gout Mild anemiaMild anemia Elevated Elevated αα22-macroglobulin-macroglobulin Elevated IgA levels Elevated IgA levels Increased quantities of Immune Increased quantities of Immune

ComplexesComplexes

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Psoriasis as a Systemic Psoriasis as a Systemic DiseaseDiseasePsoriasis as a Systemic Psoriasis as a Systemic DiseaseDisease

Psoriatic arthropathyPsoriatic arthropathy Aggravation of psoriasis by systemic Aggravation of psoriasis by systemic

factorsfactors

– MedicationMedication

– Focal infectionsFocal infections

– StressStress Life-threatening forms of psoriasisLife-threatening forms of psoriasis

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Characteristic Lesion of Characteristic Lesion of PsoriasisPsoriasisCharacteristic Lesion of Characteristic Lesion of PsoriasisPsoriasis

Sharply demarcated erythematous Sharply demarcated erythematous plaque with silvery white scaleplaque with silvery white scale

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Clinical Variants of Clinical Variants of PsoriasisPsoriasisClinical Variants of Clinical Variants of PsoriasisPsoriasis

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Chronic Plaque PsoriasisChronic Plaque Psoriasis Guttate PsoriasisGuttate Psoriasis Psoriasis of the scalpPsoriasis of the scalp Psoriasis of the NailPsoriasis of the Nail Psoriasis arthropathyPsoriasis arthropathy Pusutlar psoriasisPusutlar psoriasis Psoriasis inversaPsoriasis inversa

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

Most Common VariantMost Common Variant Plaques may be as large as 20 cmPlaques may be as large as 20 cm Symmetrical diseaseSymmetrical disease Sites of PredilectionSites of Predilection

– ElbowsElbows– KneesKnees– PresacrumPresacrum– ScalpScalp– Hands and FeetHands and Feet

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

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Chronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque PsoriasisChronic Plaque Psoriasis

May be widespread – up to 90% BSAMay be widespread – up to 90% BSA Genitalia involved in up to 30% of patientsGenitalia involved in up to 30% of patients Most patients have nail changesMost patients have nail changes

– Nail pittingNail pitting– ““Oil Spots”Oil Spots”– Involvement of the entire nail bedInvolvement of the entire nail bed

OnychodystrophyOnychodystrophyLoss of nail plateLoss of nail plate

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Widespread Chronic Plaque Widespread Chronic Plaque PsoriasisPsoriasisWidespread Chronic Plaque Widespread Chronic Plaque PsoriasisPsoriasis

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Chronic PsoriasisChronic PsoriasisChronic PsoriasisChronic Psoriasis

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Psoriasis of the NailPsoriasis of the NailPsoriasis of the NailPsoriasis of the Nail

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Psoriasis of the NailPsoriasis of the NailPsoriasis of the NailPsoriasis of the Nail

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Symptoms of Chronic Symptoms of Chronic Plaque PsoriasisPlaque PsoriasisSymptoms of Chronic Symptoms of Chronic Plaque PsoriasisPlaque Psoriasis

PruritusPruritus PainPain Excessive heat lossExcessive heat loss Patient ComplaintsPatient Complaints

– Unsightliness of the lesionsUnsightliness of the lesions– Low self-esteemLow self-esteem– Feelings of being socially outcastFeelings of being socially outcast– Excessive scaleExcessive scale

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Guttate PsoriasisGuttate PsoriasisGuttate PsoriasisGuttate Psoriasis

Characterized by numerous 0.5 to 1.5 Characterized by numerous 0.5 to 1.5 cm papules and plaquescm papules and plaques

Early age of onsetEarly age of onset Most common form in childrenMost common form in children Streptococcal throat infection often a Streptococcal throat infection often a

triggertrigger Spontaneous remissions in childrenSpontaneous remissions in children Often chronic in adultsOften chronic in adults

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Guttate PsoriasisGuttate PsoriasisGuttate PsoriasisGuttate Psoriasis

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Guttate PsoriasisGuttate PsoriasisGuttate PsoriasisGuttate Psoriasis

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Guttate PsoriasisGuttate PsoriasisGuttate PsoriasisGuttate Psoriasis

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Guttate PsoriasisGuttate PsoriasisGuttate PsoriasisGuttate Psoriasis

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Psoriasis inversaPsoriasis inversaPsoriasis inversaPsoriasis inversa

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Psoriasis arthropaticaPsoriasis arthropaticaPsoriasis arthropaticaPsoriasis arthropatica

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Psoriasis aggravated by Psoriasis aggravated by sun sun Psoriasis aggravated by Psoriasis aggravated by sun sun

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Pustular psoriasisPustular psoriasisPustular psoriasisPustular psoriasis

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Pustular psoriasisPustular psoriasisPustular psoriasisPustular psoriasis

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Pustular psoriasisPustular psoriasisPustular psoriasisPustular psoriasis

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Pustular psoriasisPustular psoriasisPustular psoriasisPustular psoriasis

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Acrodermatitis continua of Acrodermatitis continua of hallopeauhallopeauAcrodermatitis continua of Acrodermatitis continua of hallopeauhallopeau

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Pustular psoriasisPustular psoriasisPustular psoriasisPustular psoriasis

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Life–Threatening Forms of Life–Threatening Forms of PsoriasisPsoriasisLife–Threatening Forms of Life–Threatening Forms of PsoriasisPsoriasis

Generalized Pustular PsoriasisGeneralized Pustular Psoriasis Erythrodermic PsoriasisErythrodermic Psoriasis

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Generalized Pustular Generalized Pustular PsoriasisPsoriasisGeneralized Pustular Generalized Pustular PsoriasisPsoriasis

Unusual manifestation of psoriasisUnusual manifestation of psoriasis Can have a gradual or an acute onsetCan have a gradual or an acute onset Characterized by waves of pustules on Characterized by waves of pustules on

erythematous skin often after short episodes erythematous skin often after short episodes of fever of 39of fever of 39˚̊ to 40 to 40˚C˚C

Weight lossWeight loss Muscle WeaknessMuscle Weakness HypocalcemiaHypocalcemia LeukocytosisLeukocytosis Elevated ESRElevated ESR

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Generalized Pustular Generalized Pustular PsoriasisPsoriasisGeneralized Pustular Generalized Pustular PsoriasisPsoriasis

Cause is obscureCause is obscure Triggering FactorsTriggering Factors

– InfectionInfection– PregnancyPregnancy– LithiumLithium– Hypocalcemia secondary to Hypocalcemia secondary to

hypoalbuminemiahypoalbuminemia– Irritant contact dermatitisIrritant contact dermatitis– Withdrawal of glucocorticosteroids, Withdrawal of glucocorticosteroids,

primarily systemicprimarily systemic

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Generalized Pustular Generalized Pustular PsoriasisPsoriasisGeneralized Pustular Generalized Pustular PsoriasisPsoriasis

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Erythrodermic PsoriasisErythrodermic PsoriasisErythrodermic PsoriasisErythrodermic Psoriasis

Classic lesion is lostClassic lesion is lost Entire skin surface becomes markedly Entire skin surface becomes markedly

erythematous with desquamative erythematous with desquamative scaling.scaling.

Often only clues to underlying psoriasis Often only clues to underlying psoriasis are the nail changes and usually facial are the nail changes and usually facial sparingsparing

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Erythrodermic PsoriasisErythrodermic PsoriasisErythrodermic PsoriasisErythrodermic Psoriasis

Triggering FactorsTriggering Factors

– Systemic InfectionSystemic Infection

– Withdrawal of high potency topical or Withdrawal of high potency topical or oral steroidsoral steroids

– Withdrawal of MethotrexateWithdrawal of Methotrexate

– PhototoxicityPhototoxicity

– Irritant contact dermatitisIrritant contact dermatitis

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Erythrodermic PsoriasisErythrodermic PsoriasisErythrodermic PsoriasisErythrodermic Psoriasis

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TherapyTherapyTherapyTherapy

Wide range of therapies for the Wide range of therapies for the treatment of moderate to severe treatment of moderate to severe psoriasispsoriasis

None induce a permanent remissionNone induce a permanent remission All have side effects that can place All have side effects that can place

limits on their uselimits on their use

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TherapiesTherapies– Topical CorticosteroidsTopical Corticosteroids– Topical Vitamin DTopical Vitamin D3 3 AnaloguesAnalogues– Topical RetinoidsTopical Retinoids– Photo(chemo)therapyPhoto(chemo)therapy– Systemic TherapiesSystemic Therapies

OralOralParenteralParenteral

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Topical CorticosteroidsTopical CorticosteroidsTopical CorticosteroidsTopical Corticosteroids

High potency and Super potent topical High potency and Super potent topical steroids steroids

These includeThese include– Fluocinonide family (cream, ointment, gel)Fluocinonide family (cream, ointment, gel)– Betamethasone dipropionate creamBetamethasone dipropionate cream– Clobetasol propionate family (cream, Clobetasol propionate family (cream,

ointment, gel, foam, lotion)ointment, gel, foam, lotion)– Diflorasone diacetate ointmentDiflorasone diacetate ointment– Betamethasone dipropionate ointmentBetamethasone dipropionate ointment

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Topical CorticosteroidsTopical CorticosteroidsTopical CorticosteroidsTopical Corticosteroids

Side effects associated with useSide effects associated with use

– Skin atrophySkin atrophy

– Burning and stingingBurning and stinging

– Suppression of the hypothalamic-Suppression of the hypothalamic-pituitary-adrenal (HPA) axispituitary-adrenal (HPA) axisThis may occur after 2 weeks of This may occur after 2 weeks of

use with certain topical use with certain topical corticosteroidscorticosteroids

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Topical Vitamin DTopical Vitamin D33 AnaloguesAnaloguesTopical Vitamin DTopical Vitamin D33 AnaloguesAnalogues

Prototype for this group is calcipotrienePrototype for this group is calcipotriene 3 formulations – cream, ointment, and 3 formulations – cream, ointment, and

scalp solutionscalp solution Former two are approved for plaque Former two are approved for plaque

psoriasispsoriasis Latter for moderate to severe psoriasis Latter for moderate to severe psoriasis

of the scalpof the scalp

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Topical Vitamin DTopical Vitamin D33 AnaloguesAnaloguesTopical Vitamin DTopical Vitamin D33 AnaloguesAnalogues

Side EffectsSide Effects

– CutaneousCutaneousBurningBurningStingingStingingPruritusPruritusSkin irritationSkin irritation

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Topical RetinoidsTopical RetinoidsTopical RetinoidsTopical Retinoids Tazarotene Gel and CreamTazarotene Gel and Cream

– Available in two strengthsAvailable in two strengths0.05% and 0.1%0.05% and 0.1%

– Side Effects Side Effects PruritusPruritusBurning/StingingBurning/StingingErythemaErythemaWorsening of psoriasisWorsening of psoriasisIrritationIrritationSkin painSkin painHypertriglyceridemiaHypertriglyceridemia

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Topical Tazarotene Topical Tazarotene (con’t)(con’t)Topical Tazarotene Topical Tazarotene (con’t)(con’t)

Both products are pregnancy category X Both products are pregnancy category X Are contraindicated in women who are or may Are contraindicated in women who are or may

become pregnantbecome pregnant Requirements before and during therapyRequirements before and during therapy

– A negative pregnancy test 2 weeks priorA negative pregnancy test 2 weeks prior– Therapy initiated during a normal mensesTherapy initiated during a normal menses– Women of childbearing potential should Women of childbearing potential should

use adequate birth control use adequate birth control

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Photo(chemo)therapyPhoto(chemo)therapyPhoto(chemo)therapyPhoto(chemo)therapy

Two types of phototherapyTwo types of phototherapy

– Ultraviolet B (UVB)Ultraviolet B (UVB)

– Ultraviolet A + psoralen (PUVA)Ultraviolet A + psoralen (PUVA)

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UVBUVBUVBUVB

Two typesTwo types

– Broadband UVBBroadband UVB

– Narrowband UVB (311-313 nm)Narrowband UVB (311-313 nm) Treatment is time consumingTreatment is time consuming

– 2-3 visits/week for several months2-3 visits/week for several months Side effect – possibility of experiencing Side effect – possibility of experiencing

an acute sunburn reactionan acute sunburn reaction

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PUVAPUVAPUVAPUVA

Consists of ingestion of or topical treatment with a Consists of ingestion of or topical treatment with a psoralen followed by UVApsoralen followed by UVA

Usually reserved for severe, recalcitrant, disabling Usually reserved for severe, recalcitrant, disabling psoriasispsoriasis

Time consuming – 2-3 visits/wk; at least 6 weeksTime consuming – 2-3 visits/wk; at least 6 weeks PrecautionsPrecautions

– Patients must be protected from further UV light Patients must be protected from further UV light for 24 hours post treatmentfor 24 hours post treatment

– With oral psoralen, wrap around UV-blocking With oral psoralen, wrap around UV-blocking glasses must be worn for 24 hours post treatmentglasses must be worn for 24 hours post treatment

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PUVAPUVAPUVAPUVA Side effects with oral psoralenSide effects with oral psoralen

– NauseaNausea– DizzinessDizziness– HeadacheHeadache

Side effects with PUVASide effects with PUVA– EarlyEarly

PruritusPruritus– LateLate

Skin damageSkin damage Increased risk for skin cancer, particularly Increased risk for skin cancer, particularly

squamous cell (SCC) and after 200 - 250 squamous cell (SCC) and after 200 - 250 treatments, increased risk for melanomatreatments, increased risk for melanoma

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Contraindications to Contraindications to PUVAPUVAContraindications to Contraindications to PUVAPUVA

Patients less than 12 years of agePatients less than 12 years of age Patients with a history of light sensitive Patients with a history of light sensitive

disease statesdisease states Patients with, or with a history of Patients with, or with a history of

melanomamelanoma Patients with invasive SCCPatients with invasive SCC

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Systemic TherapiesSystemic TherapiesSystemic TherapiesSystemic Therapies

OralOral– Methotrexate Methotrexate – cyclosporinecyclosporine– AcitretinAcitretin

ParenteralParenteral– Amevive (alefacept)Amevive (alefacept)– Raptiva (efalizimab)Raptiva (efalizimab)– Enbrel (etanercept)Enbrel (etanercept)

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MethotrexateMethotrexateMethotrexateMethotrexate

Folic acid antagonistFolic acid antagonist Usually reserved for severe, Usually reserved for severe,

recalcitrant, disabling psoriasisrecalcitrant, disabling psoriasis Maximum improvement can be Maximum improvement can be

expected after 8 -12 weeksexpected after 8 -12 weeks

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Contraindications - Contraindications - MethotrexateMethotrexateContraindications - Contraindications - MethotrexateMethotrexate

Nursing mothersNursing mothers Patients with alcoholismPatients with alcoholism Alcoholic liver diseaseAlcoholic liver disease Other chronic liver diseaseOther chronic liver disease Patients with overt or laboratory evidence of Patients with overt or laboratory evidence of

immunodeficiency syndromesimmunodeficiency syndromes Patients who have preexisting blood Patients who have preexisting blood

dyscrasiasdyscrasias

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MethotrexateMethotrexateMethotrexateMethotrexate

Pregnancy Category X drug productPregnancy Category X drug product– Contraindicated in pregnant women with Contraindicated in pregnant women with

psoriasispsoriasis– Pregnancy must be excluded in women of Pregnancy must be excluded in women of

childbearing potentialchildbearing potential– Pregnancy should be avoided if either Pregnancy should be avoided if either

partner is receiving MTX during and for a partner is receiving MTX during and for a minimum of 3 months after therapy for minimum of 3 months after therapy for male patients and for at least one ovulatory male patients and for at least one ovulatory cycle after therapy for female patientscycle after therapy for female patients

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Methotrexate – Side Methotrexate – Side EffectsEffectsMethotrexate – Side Methotrexate – Side EffectsEffects

Acute or chronic hepatotoxicityAcute or chronic hepatotoxicity Hepatic cirrhosisHepatic cirrhosis LeukopeniaLeukopenia ThrombocytopeniaThrombocytopenia Anemia, including aplastic anemiaAnemia, including aplastic anemia Rarely, interstitial pneumonitisRarely, interstitial pneumonitis StomatitisStomatitis Nausea/vomitingNausea/vomiting AlopeciaAlopecia PhotosensitivityPhotosensitivity Burning of skin lesionsBurning of skin lesions

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CyclosporineCyclosporineCyclosporineCyclosporine

Potent ImmunosuppressivePotent Immunosuppressive Adult, non-immunocompromised Adult, non-immunocompromised

patients with severe, recalcitrant plaque patients with severe, recalcitrant plaque psoriasispsoriasis

Maximum efficacy achieved at 16 Maximum efficacy achieved at 16 weeks of therapyweeks of therapy

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Contraindications - Contraindications - CyclosporineCyclosporineContraindications - Contraindications - CyclosporineCyclosporine

Concomitant PUVA or UVB therapyConcomitant PUVA or UVB therapy Methotrexate or other immunosuppressive Methotrexate or other immunosuppressive

agentsagents Coal tar or radiation therapyCoal tar or radiation therapy Patients with abnormal renal functionPatients with abnormal renal function Patients with uncontrolled hypertensionPatients with uncontrolled hypertension Patients with malignanciesPatients with malignancies Nursing mothersNursing mothers

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Cyclosporine– Side Cyclosporine– Side EffectsEffectsCyclosporine– Side Cyclosporine– Side EffectsEffects

Possibility of Irreversible renal damagePossibility of Irreversible renal damage HypertensionHypertension HeadacheHeadache HypertriglyceridemiaHypertriglyceridemia Hirsutism/hypertrichosisHirsutism/hypertrichosis Paresthesia/hyperesthesiaParesthesia/hyperesthesia Influenza-like symptomsInfluenza-like symptoms Nausea/vomitingNausea/vomiting DiarrheaDiarrhea ArthralgiaArthralgia

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CyclosporineCyclosporineCyclosporineCyclosporine

Multiple prescreening tests are requiredMultiple prescreening tests are required

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AcitretinAcitretinAcitretinAcitretin

Oral retinoid approved for the treatment Oral retinoid approved for the treatment of severe psoriasis in adultsof severe psoriasis in adults

Significant improvement can be Significant improvement can be achieved with 8 weeks of therapyachieved with 8 weeks of therapy

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Acitretin - Acitretin - ContraindicationsContraindicationsAcitretin - Acitretin - ContraindicationsContraindications

Patients with severely impaired liver or Patients with severely impaired liver or kidney functionkidney function

Patients with chronic abnormally Patients with chronic abnormally elevated blood lipid valueselevated blood lipid values

Patients who are taking methotrexatePatients who are taking methotrexate Ethanol use when on therapy and for 2 Ethanol use when on therapy and for 2

months following therapy in female months following therapy in female patientspatients

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AcitretinAcitretinAcitretinAcitretin

Pregnancy Category X drug product as Pregnancy Category X drug product as it is a human teratogenit is a human teratogen

Contraindicated in pregnant females or Contraindicated in pregnant females or those who intend to become pregnant those who intend to become pregnant during therapy or any time up to three during therapy or any time up to three years post therapyyears post therapy

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Acitretin– Side EffectsAcitretin– Side EffectsAcitretin– Side EffectsAcitretin– Side Effects

Those associated with retinoid therapyThose associated with retinoid therapy– CheilitisCheilitis– AlopeciaAlopecia– Skin peelingSkin peeling– Dry skinDry skin– PruritusPruritus– RhinitisRhinitis– XeropthalmiaXeropthalmia– ArthralgiaArthralgia

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Acitretin– Side EffectsAcitretin– Side EffectsAcitretin– Side EffectsAcitretin– Side Effects

Laboratory AbnormalitiesLaboratory Abnormalities– Hypertriglyceridemia (66%)Hypertriglyceridemia (66%)– Decreased HDL (40%)Decreased HDL (40%)– Hypercholesterolemia (33%)Hypercholesterolemia (33%)– Elevated liver function tests (33%)Elevated liver function tests (33%)– Elevated alkaline phosphatase (10-25%)Elevated alkaline phosphatase (10-25%)– Hyperglycemia (10-25%)Hyperglycemia (10-25%)– Elevated CPK (10-25%)Elevated CPK (10-25%)

Hepatitis and jaundice occurred in < 1% of Hepatitis and jaundice occurred in < 1% of patients in clinical trials on Soriatanepatients in clinical trials on Soriatane

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AcitretinAcitretinAcitretinAcitretin

Multiple prescreening tests must be Multiple prescreening tests must be obtainedobtained

Continued monitoring throughout Continued monitoring throughout therapy necessary with possible dosage therapy necessary with possible dosage adjustmentadjustment

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Thank you for your Thank you for your attention!attention!

Thank you for your Thank you for your attention!attention!