Psoriasis and its management in primary care

1. 1
DR CHIA KOK KING
PEGAWAI PERUBATAN & KESIHATAN
GRED U44
KLINIK KESIHATAN KUAH, LANGKAWI

3.  Chronic skin disorder
 Psora = itch
 Also termed psoriasis vulgaris
 T-cell mediated inflammatory disease
 Accelerated epidermal turnover with hyperproliferation 2O
to activation of immune system
 Altered maturation of epidermal keratinocytes
 Inflammation
 Vascular changes

4. N Disorganized
O
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M
A
L
4
DERMIS
STRATUM
CORNEUM
STRATUM
GRANULOSUM
STRATUM
SPINOSUM
STRATUM
BASALE
Neutrophil
accumulation
Immaturity
Proliferation
P
S
O
R
I
A
S
I
S

5.  Psoriasis occurs in 2% of the world’s population
Highest in Caucasians (Scandinavian/European
descent)
 In Africans, African Americans and Asians between
0.4% and 0.7%
Equal frequency in males and females
May occur at any age from infancy to the 10th
decade of life
 First signs of psoriasis
 Females mean age of 27 years
 Males mean age of 29 years

6. Two Peaks of Occurrence
 One at 20-30 years
 One at 50-60 years
Psoriasis in children
 Low – between 0.5 and 1.1% in children 16
years old and younger
 Mean age of onset - between 8 and 12.5 years

7.  Two-thirds of patients have mild disease
 One-third have moderate to severe disease
 Early onset (prior to age 15)
 Associated with more severe disease
 More likely to have a positive family history
 Life-long disease
 Remitting and relapsing unpredictably
 Spontaneous remissions of up to 5 years have been
reported in approximately 5% of patients

8. If you have psoriasis, what is the risk to:
Your unrelated neighbor? About 2%
Your sibling? 15-20%
Your identical twin? 65-70%
Your child? 25%

9. Genetic Factors:
- 30% of people with psoriasis have had psoriasis
in family
- Autosomal dominant inheritance
Nongenetic Factors:
- Mechanical, ultraviolet, chemical injury
- Infections: Strep, viral, HIV
- Prescription drugs, stress, endocrine,
hormonal, obesity, alcohol, smoking

10. 1. Immune abnormalities are profound
2. Psoriasis severity is associated with
greater levels of systemic
inflammation (e.g. CRP, Th-1
cytokines)
3. Inflammation may be a common
pathway to a variety of diseases
including atherosclerosis, obesity, and
insulin resistance Krueger JG, Bowcock, A. Ann
Rheum Dis 2005;64:30-36.

11.  Koebner Phenomenon
 Elevated ESR
 Increased uric acid levels → gout
 Mild anemia
 Elevated α2-macroglobulin
 Elevated IgA levels
 Increased quantities of Immune Complexes
 Psoriatic arthropathy
 Aggravation of psoriasis by systemic factors
 Medication
 Focal infections
 Stress
 Life-threatening forms of psoriasis

12.  Although psoriatic arthritis sometimes causes an increased
erythrocyte sedimentation rate (ESR), mild anemia, and
elevated blood uric acid levels, these symptoms are also
associated with other rheumatic diseases, including gout
 ESR and CRP can be normal in psoriatic arthritis
Psoriatic arthritis, CP Rajendran, SG Ledge, Kanaka P Rani, Radha Madhavan
JAPI • VOL. 51 • NOVEMBER 2003
 Increasing PASI was linked to increasing CRP and a trend
to higher elastase and lactoferrin. CRP levels were shown
to correlate with PASI, total leucocytes, neutrophils,
elastase, lactoferrin and α1-antitrypsin.
Journal of the European Academy of Dermatology & Venereology , 24(7):789-
796

13.  Disease severity
 85% Mild, 10% Moderate, 5% severe
 Control of severe disease
 50% of patients intensively treated continue to have very
active disease (PUVA cohort)
 75% of patients with severe disease are not receiving
appropriate therapies (NPF survey)
 Pathways affected and possible outcomes
 Inflammatory atherosclerosis, thrombosis
 Angiogenesis endothelial (endothelial
progenitor cells)dysfunction
 Metabolic oxidative stress

14. TRIGGERS
THROAT
INFECTION
COLD
WEATHER MEDICINES DIET

15. Risk factors
•Genes
•Environment
Outcomes
• Cancer
• Cardiovascular
disease
• Metabolic disease
• Arthritis
• Mortality
Mediating Factors
• Pathophysiology (inflammation,
hyper-proliferation, angiogenesis)
• Treatment
• Psychosocial impact

16. • Smoking
• Obesity
• Dyslipidemia
• Hypertension
• Diabetes
Neiman AN, Porter S, and Gelfand JM. Expert Review of Derm. 2006;1:63-75

17. Psoriasis CAD MI
Smoking
HTN
DM
Obesity
Lipids

18.  Psoriasis is independently associated with carotid
atherosclerotic disease and impaired endothelial
function
Balci DD et al, Increased carotid artery intima-media thickness and
impaired endothelial function in psoriasis JEADV ISSN 1468-3083
 In patients with Psoriatic arthritis, psoriasis severity
is an independent predictor of cardiovascular disease
Gladman, DD et al. Cardiovascular morbidity in psoriatic arthritis. Ann
Rheum Dis 2008.094839

19.  Sharply demarcated ERYTHEMATOUS plaque with silvery
white scales typically on extensor surfaces
 Symmetric
 Pruritic/ Painful
 Pitting Nails
 Inflammatory arthropathy in 10-20% of patients, which in
severe cases may be the dominant cause of morbidity
 Histopathology
 Thickening of the epidermis
 Tortuous and dilated blood vessels
 Inflammatory infiltrate primarily of lymphocytes

21. Type Characteristics
Plaque psoriasis
Guttate psoriasis
Erythrodermic
psoriasis
Flexural
psoriasis
Pustular
psoriasis
Nail psoriasis
Palmar/Plantar
psoriasis
Psoriatic arthritis
Scalp psoriasis
Dry scaling patches (AKA common psoriasis) 75%
Drop-like dots, occurs after strep or viral infection 12%
Exfoliation of fine scales (total body “dandruff”),
widespread, often accompanied by severe itching and
pain 7%
Smooth, dry, red inflamed, lack of scales, appear on skin
folds (underarm, buttocks, groin, breasts)
Pus-like blisters, noninfectious, fluid contains white blood
cells 2%
Seen on toenails and fingernails, starts as numerous pits,
at times progresses to yellowing, crumbly, and thickened
nail; nails may slough
Erythema, thickening and peeling of the skin, blistering is
often present. Can lead to disability.
Inflammation, swelling, and joint destruction
Plaque-type lesion

22. AKA psoriasis vulgaris is the most common form of
psoriasis.
 It affects 80 to 90% of people with psoriasis.
 Typically appears as raised areas of inflamed skin
covered with silvery white scaly skin (plaques)

23. Plaques may be as large as 20 cm
Symmetrical disease
Sites of predilection
Elbows
Knees
 Presacrum
 Scalp
Hands and Feet

25. Pruritus
Pain
Excessive heat loss
Patient Complaints
Unsightliness of the lesions
Low self-esteem
 Feelings of being socially outcast
Excessive scale

26.  May be widespread – up to 90% BSA
 Genitalia involved in up to 30% of patients
Most patients have nail changes
 Nail pitting
 “Oil Spots”
 Involvement of the entire nail bed
Onychodystrophy
Loss of nail plate

28. 28

30. 30

31.  Characterized by numerous 0.5 to 1.5 cm small oval
(tear drop shaped) papules and plaques
Appear over large areas of the body, such as the
trunk, limbs, and scalp.
Early age of onset
Most common form in children
 Streptococcal throat infection often a trigger and
rashes develop 1-2 weeks following infection
Spontaneous remissions in children
 Often chronic in adults

32. 32
Guttate Psoriasis

33.  AKA inverse psoriasis appears as smooth
inflamed patches of skin.
 Occurs in skin folds, particularly around
the genitals (between the thigh and
groin), the armpits, under an overweight
stomach (pannus), and under the breasts
(inframammary fold).
 It is aggravated by friction and sweat, and
is vulnerable to fungal infections.

34.  appears as raised bumps that are filled with
non-infectious pus (pustules).
 skin under and surrounding pustules is red
and tender.
 can be localised, commonly to the hands and
feet , or generalised with widespread patches
occurring randomly on any part of the body.
 May cause long lasting disability include
palmoplantar chronic pustular psoriasis
(palmoplantar pustulosis), acrodermatitis
continua of Hallopeau (acropustulosis)

35.  Changes in the appearance of finger and toe nails
including discolouring under the nail plate, pitting of
the nails, lines going across the nails, thickening of
the skin under the nail, and the loosening
(onycholysis) and crumbling of the nail.

37.  Psoriatic arthritis involves joint and connective
tissue inflammation.
 Psoriatic arthritis can affect any joint but is most
common in the joints of the fingers and toes.
 This can result in a sausage-shaped swelling of
the fingers and toes known as dactylitis.
 Psoriatic arthritis can also affect the hips, knees
and spine (spondylitis).
About 10-15% of people who have psoriasis also
have psoriatic arthritis.

38. 38

39. 1. Generalized Pustular Psoriasis
2. Erythrodermic Psoriasis
 May be complicated by high-output cardiac failure,
temperature dysregulation, and septicaemia,
particularly in elderly patients.

40.  Unusual manifestation of psoriasis
 Can have a gradual or an acute onset
 Characterized by waves of pustules on
erythematous skin often after short episodes of
fever of 39˚ to 40˚C
 Weight loss
 Muscle Weakness
 Hypocalcemia
 Leukocytosis
 Elevated ESR

41. Cause is obscure
Triggering Factors
 Infection
 Pregnancy
 Lithium
 Hypocalcemia secondary to hypoalbuminemia
 Irritant contact dermatitis
Withdrawal of glucocorticosteroids, primarily
systemic

43. Classic lesion is lost
Entire skin surface becomes markedly
erythematous with desquamative scaling.
It may be accompanied by severe itching,
swelling and pain.
Often only clues to underlying psoriasis are
the nail changes and usually facial sparing

44.  Triggering Factors
 Systemic Infection
 Withdrawal of high potency topical or oral steroids
 Withdrawal of Methotrexate
 Phototoxicity
 Irritant contact dermatitis
 Often the result of an exacerbation of unstable plaque
psoriasis, particularly following the abrupt withdrawal of
systemic treatment.
 This form of psoriasis can be fatal, as the extreme
inflammation and exfoliation disrupt the body's ability to
regulate temperature and for the skin to perform barrier
functions.

46.  In 78% of psoriatic patients
 Fingernails>Toenails
 Four changes
1. Onycholysis (= separation from nail bed)
2. Pitting*
3. Subungual debris accumulation
4. Color alterations
*Pitting rules out a fungal infection

47. 47

48. In 10-20% of psoriasis patients
Often seen in patients with nail and
scalp psoriasis
Peripheral interphalangeal joints
No elevated serum levels of
rheumatoid factors (as seen in
rheumatoid arthritis, yet has all other
features)

49. Diagnosis:
1. Based on the appearance of the skin.
2. There are no special blood tests or diagnostic
procedures.
3. A skin biopsy (or scraping) may be needed to
rule out other disorders and to confirm the
diagnosis.
4. When the plaques are scraped, one can see
pinpoint bleeding from the skin below
(Auspitz's sign)
University of Jordan/Faculty of Pharmacy 27/03/2011

50.  Three Cardinal Signs of Psoriatic Lesions
 Plaque elevation
 Erythema
 Scale
 Body Surface Area

51.  The Psoriasis Area Severity Index (PASI):
- The most widely used measurement tool for psoriasis.
- Combines the assessment of the severity of lesions and
the area affected into a single score in the range 0 (no disease)
to 72 (maximal disease).
http://www.pasitraining.com/pasi_score/
http://pasi.corti.li/
 Severity:
- Mild
- Moderate
- Severe

52. 52

54.  Explanation/no cure
 Treatment options (including none)
 Patient’s expectation
1. Diagnostic difficulty
2. Education
3. Failed Topical
4. >30% skin surface
5. Increasing steroids
6. Pustular/erythrodermic
7. Systemic therapy

55.  50% of patients with moderate or worse disease
are currently untreated
 46% have topical therapy only
 Reason dermatologists do not use
more aggressive therapies
 Safety concerns
 Time consuming
 Cost
1 Leonardi, 2003; 2 Market Measures/Cozint LLP, June 2003.
Other
therapies
54%
Topicals
only
46%

56. 1. Ryan S. Br J Nurs 2010;19:822-5
Two key disease processes underlie psoriasis1
Cell
proliferation
AIM:
Reduced cell
turnover time and
reduce scale
AIM:
Prevent the
infiltration of
inflammatory cells
into the epidermis
Inflammation

57. Step 1- Topical1
• First step of treatment
for mild-to-moderate
plaque psoriasis
• Calcipotriol +
betamethasone
dipropionate
combination (Dovobet®)
is recommended first-line
therapy by the PCDS
for most patients
Step 2 – Second line1
• Patients with moderate-severe
psoriasis at onset
or patients with
inadequate response to
topicals
• Phototherapy or oral
agents i.e.
methotrexate, acitretin,
ciclosporin
Step 3 – Biologics1
• Etanercept, infliximab,
adalimumab,
ustekinumab
• If 2nd-line treatments
ineffective or not
tolerated – as per NICE
guidance
1. Adapted from Primary Care Dermatology Society (PCDS) 2010. Available from www.pcds.org.uk (Last accessed 24 January
2012)

58. Treatment type Mode of action
Treats
inflammation
Treats cell
proliferation
Emollients1 Reduce dryness, scaling and cracking  ?
Topical corticosteroids2 Dampen down inflammation  
Tar preparations1 Remove loose scales may act as an anti-inflammatory
 
Dithranol2 Suppresses production of skin cells  
Vitamin D analogues2 Reduce excessive skin cell production  
Vitamin D + steroid
combination3
Reduce excessive skin cell production +
dampen down inflammation
 
Tazarotene2 Slows production of skin cells  
1.British National Formulary (BNF) BNF 62 Section 13.5.2; September 2011: 62. Available from www.bnf.org
(Last accessed 19 January 2012)
2.Menter A et al. J Am Acad Dermatol 2009:60;643-659
3.Dovobet® Gel Summary of Product Characteristics. Available from www.medicines.org.uk (Last accessed 9 January 2012)

59. Bandwidth Characteristics
Narrowband UVB
(311nm)
• Patients receive TL01 narrowband UVB1
• UVB slows keratinocyte proliferation and differentiation2
• 3x weekly for 6-8 weeks (max. once weekly)
• Equivalent to a two week holiday in the Mediterranean
PUVA
(Psoralen + UVA)
• Penetrates skin more deeply than UVB3
• Used for those with a long history of PsO unresponsive to NBUVB3
– or considered first line for palmoplantar PsO
• Maximum 150 exposures in a lifetime
• Twice weekly for 5-10 weeks
.
1. Gambichler T et al. J Am Acad Dermatol 2005:52;660-670
2. Menter A et al. J Am Acad Dermatol 2010:62;114-135
3. Lapolla, W et al. J Am Acad Dermatol 2011:64:936-949

60. Treatment Action
Systemics
Methotrexate1
5-25mg weekly (PO or SC)
Folate antagonist with immunosuppressive, cytostatic and anti-inflammatory
effects
Acitretin1
(10-75mg OD)
Retinoid – reduces keratinocyte production/turnover. Anti-inflammatory
effects. Can combine with TLO1
Ciclosporin1
(3-5mg/kg/day)
Calcineurin inhibitor – prevents T-cell activation from translation into the
release of inflammatory cytokines
Others Fumaric acid esters, Mycophenolate mofetil, Calcitriol
Biologics
TNF-α blockers2
Etanercept, Adalimumab,
Infliximab
Block activity of TNF alpha – the master regulator (central cytokine)
involved in psoriasis2
Anti IL-12/23p40
Ustekinumab
Neutralises all Th1(IL-12) and Th17(IL-23) cell-mediated responses
1. Menter A et al. J Am Acad Dermatol 2009;61:451-485
2. Menter A et al. J Am Acad Dermatol 2008;58:826-850

61.  Medications with the least potential for adverse reactions
are preferentially employed.
 As a first step, medicated ointments or creams are applied
to the skin. If topical treatment fails to achieve the desired
goal then the next step would be to expose the skin to
ultraviolet (UV) radiation. This type of treatment is called
phototherapy.
 The third step involves the use of medications which are
taken internally by pill or injection : systemic treatment.
 Over time, psoriasis can become resistant to a specific
therapy. Treatments may be periodically changed to prevent
resistance developing (tachyphylaxis) and to reduce the
chance of adverse reactions occurring: treatment rotation.

63. GENERAL
MANAGEMENT
SUN
EXPOSURE
MOISTURISE ADEQUATE
CLOTHING
PROPER
BATHING
SUPPORT
NETWORK

64. PSYCHO-LOGICAL
IMPLICATIONS
SOCIAL
ISOLATION
AND
LONELINESS
ANXIETY
LOW
SELF-ESTEEM
DEPRESSION
EMBARRASSMENT

65.  Lubrication
 Removal of scales
 Slow down lesion proliferation
 Pruritus management
 Prevent complications
 Lessen patient stress
 Season and climate

66.  Aqueous cream
 Hydrocortisone cream 1%
 Betamethasone cream 0.025%
 Betamethasone cream 0.1%
 Clobetasol propionate cream 0.05%

67.  Moisturizes, lubricates and soothes dry and flaky skin *Recommended*
 May be the only treatment for mild psoriasis
 ?Minimises Koebner phenomenon
 Produces occlusive film to limit water evaporation from skin/by
osmotic effect increased hydration allows stratum
corneum to swell scaling decreases, skin is more pliable,
less itch, less scaling
 Adverse Effect : contact dermatitis, folliculitis (rare)
 When in control of psoriasis, regular use of emollients should
continue to be encouraged
 The only option available in our KK  AQUEOUS CREAM

69.  Reduce inflammation, itching and scaling
 Anti-inflammatory effect
 Decrease in vascular permeability, decreasing
dermal edema and leukocyte penetration into
skin
 Antiproliferative effect
 Immunosuppressive effect
69

70.  Not indicated for widespread psoriasis – careful supervision
 Can enhance effects by occlusion ONLY in suitable patients
 Reduce inflammation, itching and scaling
 Anti-inflammatory effect
 Decrease in vascular permeability, decreasing dermal edema and leukocyte
penetration into skin
 Antiproliferative effect
 Immunosuppressive effect
 Use for specific targeted flares, e.g. scalp (Dovobet® gel, Etrivex®
Shampoo)
 Consider combination products, e.g. Diprosalic® ointment for thick
scale
 Maybe hazardous for a number of reasons including:
 Rebound relapses
 Development of tolerance
 Risk of generalised pustular psoriasis
 Development of local/systemic toxicity due to impaired barrier function

71.  Ointments: helps hydrate; good for dry,
hyperkeratotic, scaly lesions
 Cream: for use on all areas, useful for infected
lesions
 Solutions: for scalp psoriasis, often contain
alcohols which can be painful with open
lesions
71

79.  Adverse Effects: (esp. with occlusion)
 Systemic absorption
 Dermal atrophy
 Telangiectasis
 Ecchymoses
 Peri-orbital acne
 Poor wound healing
 Pyogenic infections