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Psoriasis

Name: Nicki Ball Title: Dermatology Nurse Specialist Galderma UK Ltd and Honorary contract at Bristol Royal Infirmary

Learning Outcomes

• Overview of pathophysiology and aetiology of psoriasis including trigger factors

• Discuss assessment of disease severity

• Discuss identifying co-morbidities

• Describe 1st line management options in line with NICE guidance

• Describe impact on functional, psychological and social wellbeing

Overview

Psoriasis is a complicated, chronic inflammatory, multi- aetiological auto-immune condition

– Non-contagious and re-occurring

– Predominantly affects skin and joints

Epidemiology • Affects between 1% and 3% of the UK population- up to 1.8

million people • Affects males and females equally • Can occur at any age; two peaks – late teens to early 30’s &

around 50 to 60 • Most common in white people, highest prevalence in Northern

Europe/Scandinavian countries • Several clinical variants exist but plaque psoriasis most common

form

Normal skin cell matures in 21 to 28 days In psoriasis, the turnover of skin cells is much faster - 4 to 7 days Live cells can reach the surface and accumulate with dead cells Inflammatory cells accumulate in the dermis and infiltrate the epidermis, causing erythema Increased vascularisation and blood-vessel engorgement in the dermis

Pathophysiology

Why does psoriasis occur?

• Changes begin in the immune system when T cells lymphocytes are triggered and become overactive

• The T cells produce inflammatory chemicals leading to the rapid growth of skin cells causing psoriatic plaques to form

• Not yet clear what initially triggers the immune system to act in this way

• 10% of the population inherits one or more of the genes that create a predisposition to psoriasis.

• Only 2 to 3% of the population develops the disease • For a person to develop psoriasis, the individual must have

a combination of the genes that cause psoriasis and be exposed to a trigger factor

Trigger factors

• Stress and other lifestyle factors - such as smoking and alcohol • Injury to skin – psoriasis can occur in skin that has been traumatized or

injured (Koebner phenomenon)

• Medications: lithium

rapid cessation of topical or systemic corticosteroids ACE Inhibitors beta-blockers anti-malarials non-steroidal anti-inflammatories

• Infection – particularly the streptococcal B throat infection associated with guttate psoriasis

• Endocrine - disease state may fluctuate with hormonal changes (puberty, pregnancy and menopause)

Diagnosis

Most cases of psoriasis can be reliably diagnosed by simple physical examination

• skin, scalp, nails, joints • Ruby-red, well defined plaques • Silvery surface scale • Often symmetrical • Extensor surfaces or can be widespread • Examine joints for psoriatic arthritis • Punctuate bleeding points (Auspitz’s sign) • Lesions on lower legs may be less typical

Assessment

For people with any type of psoriasis assess: • Presenting condition • Medical history • Family history • Previous treatments and responses • Disease severity – patients global assessment, physicians

global assessment, PASI score • Impact of disease on physical, psychological and social

wellbeing – DLQI • Presence of psoriatic arthritis - PEST • Presence of comorbidities

PASI Score

Dermatology Life Quality Index score

Psoriatic Arthritis - PEST

As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care

When to assess

Assess the severity and impact of any type of psoriasis:

• at first presentation

• before referral for specialist advice and at each referral point in the treatment pathway

• to evaluate the efficacy of interventions

Physical Co-morbidities

Disease Impact

Psoriatic arthritis Up to 35% of people living with psoriasis

Crohns disease 2.5X higher risk

Metabolic syndrome (combination of diabetes, hypertension & obesity)

2X higher risk if have severe psoriasis

Atrial Fibrillation 3X higher risk if aged <50 with severe psoriasis

Stroke 3X higher risk if aged <50 with severe psoriasis

Heart attack 3X risk if aged 30 with severe psoriasis

Non-alcoholic fatty liver disease Can affect 17-60%

Squamous cell carcinoma 5X higher risk

Basal cell carcinoma 2X higher risk

Uveitis Can affect 7–20%

Co-morbidities

Discuss risk factors for cardiovascular comorbidities:

• Lipid modification

• Obesity

• Preventing type 2 diabetes

• Prevention of cardiovascular disease

• Alcohol use

• Smoking cessation

Assess cardiovascular risks at diagnosis and at 5 yearly intervals or more frequently if intervention required

Offer preventative advice, healthy lifestyle information & support for behavioural change

Disease Impact

Encompasses functional, psychological and social dimensions: • Symptoms related to skin – chronic itch, bleeding,

scaling, nail involvement • Problems related to treatments – mess, odour,

inconvenience and time • Effect of living with highly visible, disfiguring skin

disease – difficulties with relationships, securing employment and poor self esteem

• About 1/3rd of people with psoriasis experience major psychological distress (1)

Psychological Co-morbidities with psoriasis

• At least as severe as those seen with heart disease, kidney failure, cancer and liver disease (1)

• Compared with people with other skin conditions, more likely to suffer from psychological problems that may in themselves trigger or worsen psoriasis symptoms(2)

• Regardless of location or extent of disease, anxiety and depression are common. One study reported 60% of people with psoriasis had symptoms of depression (3)

• It is estimated that more than 10,400 diagnoses of depression, 7,100 of anxiety and 350 of suicidal thoughts and behaviour are attributable to psoriasis each year in the UK (4)

Impact of psoriasis

Assess the impact of any type of psoriasis on physical, psychological and social wellbeing by asking: • what aspects of their daily living are affected by the

person's psoriasis • how the person is coping with their skin condition and any

treatments they are using • if they need further advice or support • if their psoriasis has an impact on their mood • if their psoriasis causes them distress (be aware the patient

may have levels of distress and not be clinically depressed) • if their condition has any impact on their family or carers

Treatment Systemic biological therapy

For severe and very severe psoriasis • Etanercept * • Adalimumab * • Infliximab * • Ustekinumab

*recommended for the treatment of adults with active and progressive psoriatic arthritis

• Methotrexate • Ciclosporin • Acitretin

• Narrowband UVB for plaque or guttate

• Psoralen (oral or topical) with local ultraviolet A (PUVA) for palmoplantar pustulosis

• Risk of skin cancer!

• Emollients • Corticosteroids • Vitamin D/Vitamin D analogues • Vit D analogue/potent steroid combination • Dithranol • Tar preparations

Topical therapy

Phototherapy

Systemic therapy

Increasing toxicity

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Topical Treatments -Emollients

• NICE CG153 2012 starts the treatment pathway

with the assumption that, when appropriate,

emollients have been prescribed

• Emollients reduce dryness, cracking, scaling of the skin, including itch

• May be the only treatment necessary for mild psoriasis

• Consider using humectants

Plaque Psoriasis

Topical Treatment – Trunk & Limbs

Ist Line

• Potent topical steroid OD and a Vitamin D or Vitamin D analogue OD for up to 8 weeks

2nd Line • Vitamin D or Vitamin D analogue alone BD for 8 – 12 weeks

3rd line • Potent topical corticosteroid BD or a coal tar preparation OD/BD for up to 4 weeks

4th line

• if above cannot be used or a OD preparation would improve adherence offer a combination product of Calcipotriol and Betamethasone Dipropionate OD for up to 4 weeks

Scalp Psoriasis

Topical Scalp Treatments

1st line • Potent topical corticosteroid OD for up to 4 weeks

2nd line

• A different formulation of the potent corticosteroid for up to 4 weeks and/or • Topical agents to remove adherent scale before application of the steroid for up to 4 weeks

3rd line

• A combination product containing calcipotriol monohydrate and betamethasone dipropionate OD or • Vitamin D or vitamin D analogue OD up to 8 weeks

4th line

• Very potent topical corticosteroid up to BD for 2 weeks or • Coal tar applied OD or BD or • Referral to specialist for additional support with topical applications and/or advice on other treatment

options

Face, Flexural and Genital Psoriasis

Topical treatment Face, Flexures & Genitals

1st Line

• First line – short-term mild to moderate potency corticosteroid applied OD or BD for up to max 2 weeks

2nd Line

• Second line – calcineurin inhibitor applied BD for up to 4 weeks

Guttate Psoriasis

Guttate

• Multiple small ‘tear drop’ scaly lesions

• Can affect most of the body

• Comes on quickly

• May follow 7 – 10 days after an URTI

• Tends to affect children & young adults

• Can spontaneously clear within 2-3 months

• May progress into chronic plaque psoriasis

Differential Diagnosis:

Pityriasis rosea, viral exanthems, drug eruptions

Treatment

• Treat with emollients first

• Also tar preparations, Vitamin D/Vitamin D analogues

• Refer for narrow band UVB if unresponsive

Referral

Following assessment in a non-specialist setting refer if:

• There is diagnostic uncertainty

• Any type of psoriasis is severe or extensive e.g. more than 10% of the BSA affected

• Any type of psoriasis cannot be controlled with topical therapy

• Acute guttate psoriasis requires phototherapy

• Nail disease has a major functional or cosmetic impact

• Any type of psoriasis is having a major impact on a person’s physical, psychological or social wellbeing

In summary

• Psoriasis is a complex auto-immune disease which require accurate assessment for impact on physical, psychological and social well being

• Risk factors for co-morbidities should be assessed

• Topical treatments are first line therapy and patients should be involved in treatment choices to aid concordance

Resources

• www.psoriasis-association.org.uk • www.papaa.org • www.pcds.org.uk • www.bad.org.uk • NICE Clinical Guidelines 153 October 2012 (updated November 2014) • www.nice.org.uk/guidance/cg153/chapter/1-Guidance#assessment-and-referral • Moller et al 2015. A systematic literature review to compare quality of life in

psoriasis with other chronic diseases uisng EQ-5D derived utility values. Patient related outcome measures 2015;6:166-77

• Ferreira et al 2016 .Psoriasis and associated psychiatric disorders: a systematic review on etiopathogenesis and clincial correlation. J Clin Aesthet Dermatol. 2015; 9: 36-43

• Esposito et al 2006 .An Italian study on psoriasis and depression. Dermatol. 2006;9(36-43)

• Kurd et al 2017 The risk of depression, anxiety and suicidality in patients with psoriasis; a population based cohort study. Ann Dermatol. 2017;146:891-5