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PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
1
PSORIASISCollaboration for Optimal Management
in the Primary Care Setting
Michael Rosenblum, MD, PhDAssistant Professor of Dermatology
University of California, San Francisco
San Francisco, CA
Daniel Miller, MD, FAADBoston 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, PhDAssistant Professor of Dermatology
University of California, San FranciscoSan Francisco, CA
Best Practices PearlsThere 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
Psoriasis
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;58:826-50.
Psoriasis - Clinical
Scaly, erythematous plaquesPainful or often severely itchyDisfiguringMay cause significant compromise in QOLUsually follows a chronic relapsing and remitting courseMultiple subtypesSYMMETRIC
Menter et al. J Am Acad Dermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
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;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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Inverse Psoriasis
Lesions in the skin folds
Axillary, genital, perineal, intergluteal, and inframammaryareas
Not scaly (due to increased moisture)
Presents as erythematous plaques with minimal scale
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
Erythrodermic Psoriasis
Generalized erythema covering nearly the entire BSA with varying degrees of scalingCan develop gradually from chronic plaque disease or acutely with little preceding psoriasisErythrodermic skin may lead to chills and hypothermiaFluid loss may lead to dehydrationFever and malaise are common
Menter et al. J Am Acad Dermatol 2008;58:826-50. Weigle et al. Am Fam Physician. 2013;87(9):626-633. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
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 plaque-type disease
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
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
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
Unpredictable clinical course – may spontaneously resolve or be the first stage in the development of chronic plaque PSO
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, subungualhyperkeratosis, and “oil-drop” spots
90% of patients with psoriatic arthritis may have nail changes
ONYCHOLYSIS
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am AcadDermatol 2008;58:826-50. Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
PITTING
Making a Diagnosis of Psoriasis
1) Clinical ExamSymmetric skin plaques with thick silvery scale
Nail involvement and involvement of the navel and gluteal cleft
Associated joint complaints
2) Skin BiopsyAvoid elbow and knees
Multiple biopsies if multiple skin morphologies
3) Labs and ImagingJoint complaints => plain films and bone scans
Guttate lesions => bacterial culture of throat and perianal area, ASO
Pustular lesions => bacterial and fungal culture from pustule
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
3
Differential Diagnosis of Psoriasis
MalignancyCTCL (Mycosis Fungoides)
AutoimmuneCutaneous Lupus
InfectiousSecondary Syphilis
Skin RelatedLichen PlanusChronic Atopic DermatitisContact DermatitisSeborrheic DermatitisTinea Corporis
CTCL (Mycosis Fungoides)Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.
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
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.
Psoriasis and Psoriatic Arthritis
Classification Criteria for Psoriatic Arthritis
Established Inflammatory Articular DiseasePlus 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)
A member of the seronegativespondyloarthropathies
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
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.
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;68:654-662.
Psoriasis and the Metabolic Syndrome
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
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.
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;31:1000-1006.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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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
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Bernstein CN, et al. Gastroenterology. 2005 Sep;129(3):827-36.
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):626-633. Smedby KE et al. Cancer Epidemiol Biomarkers Prev November 2006 15; 2069-2077; Kim M, et al. Semin Cutan Med Surg 29:10-15.
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 29:10-15.
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. 2005 Dec;141(12):1527-34.
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
Higham R, et al. In Advance Healthcare Network 2010 http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Advocacy-for-Psoriasis-Patients.aspx
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
Krueger G, et al. Arch Dermatol. 2001;137(3):280-284. Higham R, et al. In Advance Healthcare Network 2010 http://nurse-practitioners-and-physician-assistants.advanceweb.com/Archives/Article-Archives/Advocacy-for-Psoriasis-Patients.aspx
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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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
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.
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
Weigle et al. Am Fam Physician. 2013;87(9):626-633. Menter et al. J Am Acad Dermatol 2008;58:826-50.
Collaborative Approach for Optimal Management
Daniel Miller, MD, FAADBoston University Medical Center
Assistant Professor of Dermatology and DermatopathologyDirector, Inpatient Dermatology Consultation Service
Boston, MA
Case Presentation
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
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
Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145:617-623.
Key Point
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;145:617-623.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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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
Renzi C, Abeni D, Picardi A et al. Br J Dermatol. 2001;145:617-623. Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12.
Patient Perspectives
Psoriasis patients view their disease as:IncomprehensibleIncurableUncontrollable
Patients are seeking:Explanations with simple, everyday languageEmpathy and careful listening to emotional concernsReassurance when discouragedHope regarding disease prognosis
Linder D, Dall'olio E, Gisondi P et al. Am J Clin Dermatol. 2009;10:325-330.
Quality of Life Concerns
Common patient complaintsFrustration 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 concernsPts think lifestyle choices may have caused psoriasisCancer risk, communicability
Uhlenhake EE, Kurkowski D, Feldman SR. J Dermatol Treat. 2010;21:6-12.
Psoriasis Patient Perspectives
Patient wish listMore information on the disease
Etiology and causes
Triggers for disease flares
Treatment options, prognosis, and curability
Clear expectations at the onset of therapyWritten 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.
Strategies for Successful Visits
Express empathy, address quality of life issues
Elicit hidden fears, alleviate anxietyScreen for depression, alcohol abuse (both increased)
Communicate the basics about psoriasisPathophysiology, disease course, and treatmentUse simple, easy-to-understand languageVerbal education during the visit = gold standard
Offer adjunctive teaching aidesHandouts, visual aidesRecommend reliable internet resources
Hong J, Nguyen TV, Prose NS. J Am Acad Dermatol. 2013;68:364.e1-10.
Patient Resources
Encourage patients to join National Psoriasis Foundation (NPF)Helpful websites:
Psoriasis.org (NPF site)AAD.orgnlm.nih.gov (US National Library of Medicine)
Patient advocacy groupRedpatch.org
Hong J, Nguyen TV, Prose NS. J Am Acad Dermatol. 2013;68:364.e1-10.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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Natural History of Psoriasis
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 diseaseDisease defined by a waxing-waning course
Typical onset between ages 20-30
Disease course can be modified by therapy initiation
Many new therapy options in the past 10 years
Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58:826-850.
Help Set Patient Expectations
Patients who expect lifetime clearance with no flares will inevitably be disappointed
Psoriasis is managed, not cured
Ascertain patient’s goals, develop a strategySome 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, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60:643-659.
Psoriasis Treatment Algorithm
Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58:826-850.
Treatment of LimitedPlaque 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;58:826-850.
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
Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60:643-659.
Topical Steroids: General Principles
The best vehicle (ointment, cream, lotion, etc) is the one the patient will actually use
Elicit patient preferencesGive enough medication for sustained usage
Takes 400 grams to cover entire body for bid x 1 week
High potency steroids for thick, chronic plaquesUse intermittently to maximize safetyLimit 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;60:643-659.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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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 sitesTwice daily usage for 2-4 weeks then treatment holiday
Mid-potency steroidsTriamcinolone 0.1% ointment or cream (classes III and IV)Maintenance therapyAlso for short periods (1-2 weeks only) on sensitive sites
Lower potency steroidsDesonide (class VI) and hydrocortisone 2.5% (class VII)Long term-use on sensitive sites such as face and groin
Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60:643-659.
Other Topical Agents to Consider
Vitamin D analogues such as calcipotrieneAdjunctive therapy to topical steroidsExcellent safety profile
Topical retinoids (tazarotene)Useful in combination with topical steroidsMay cause skin irritation, rednessPregnancy category X
Coal tarMore than 100 years of use in treatment of psoriasisMany OTC preparations availableCosmetic concerns (smell, stains clothes) limit use for some
Nonmedicated emollients (moisturizers)
Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2009;60:643-659.
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
Menter A, Korman NJ, Elmets CA et al. J Am Acad Dermatol. 2010;62:114-135.
Phototherapy
Typical regimensnbUVB (narrow-band UVB) 2-3 times weekly
Response observed at 8-10 treatments
Single course is 15-20 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;62:114-135.
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 outcomesOnly a minority were screening appropriately based on current AHA guidelines for psoriasis:
43% were appropriately screening for HTNOnly 11% for dyslipidemia30% for obesity27% for type II diabetes
Parsi KK, Brezinski EA, Lin T-C et al. J Am Acad Dermatol. 2012;67:357-362.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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Cardiovascular Screening: Starting at Age 20 in Psoriasis Patients
Factor Baseline Frequency Targets
HypertensionBlood pressureFamily history
At each visitSBP < 130DBP < 85
DiabetesFasting glucoseFamily history
At least once every 3 years
<100 mm/dL
Dyslipidemia Fasting lipids AnnuallyTotal chol < 200LDL < 100 mg/dLHDL > 50 mg/dL
Obesity BMI measurement At each visit BMI < 25
Parsi KK, Brezinski EA, Lin T-C et al. J Am Acad Dermatol. 2012;67:357-362. Kimball AB, Gladman D, Gelfand JM et al. J Am Acad Dermatol. 2008;58:1031-1042.
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
Rahier JF, Moutschen M, Van Gompel A et al. Rheumatol. 2010;49:1815-1827.
Vaccines in Immunosuppressed Patients
Live vaccines contraindicatedduring therapy:
Measles-mumps-rubella
Poliomyelitis (live version)
Varicella/zoster
Typhoid fever
Yellow fever
Cholera
Rahier JF, Moutschen M, Van Gompel A et al. Rheumatol. 2010;49:1815-1827.
Vaccines in Immunosuppressed Patients
Non-live vaccines can safely be given:Diptheria-tetanus-pertussisPoliomyelitis (non-live version)PneumococcalInfluenzaHuman papillomavirusHepatitis A and B
Humoral response is diminished with certain drugs (MTX, TNF-inhibitors), but is usually adequateNo clear evidence that these vaccines cause dz flares
Rahier JF, Moutschen M, Van Gompel A et al. Rheumatol. 2010;49:1815-1827.
Best Practices Pearls
Vaccines in Psoriasis Patients on Immunotherapy
Best to vaccinate prior to starting immunotherapyLive vaccines safe: give 3-4 weeks before starting
MMR in high risk patients over 50VZV in patients over 60 or high risk
Best humoral response to inactivated vaccines
During therapyAnnual influenza vaccineDTP with booster every 10 yearsPoliomyelitis (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;58:94-105.
PSORIASIS: Collaboration for Optimal Management in the Primary Care Setting
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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 dermatitisPityriasis rubra pilarisSeborrheic dermatitisSecondary syphilisNutritional deficiencies
Mycosis fungoides
Craft N, Fox LP, Goldsmith LA, et al. VisualDx: Essential Adult Dermatology. Goldsmith LA, Papier A (eds). Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
When to Refer?
Menter A, Gottlieb A, Feldman SR et al. J Am Acad Dermatol. 2008;58:826-850.
When to Refer to Dermatology
Moderate-to-severe psoriasis:>5%-10% total body surface area (TBSA) affectedSkin sites with functional or cosmetic concerns:
FaceGenital skinPalms and soles
Failure to respond to topical therapiesPsoriatic arthritis
Kimball AB, Gladman D, Gelfand JM et al. J Am Acad Dermatol. 2008;58:1031-1042.
Conclusions
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 diseaseHave a set of topicals you can prescribe confidently
Know when to refer to your specialists