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Psoriasis
Medical Student Core Curriculum
in Dermatology
Last updated March 28, 20111
Module Instructions
The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.
We encourage the learner to read all the hyperlinked information.
2
Goals and Objectives
The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with psoriasis.
By completing this module, the learner will be able to:• Identify and describe the morphology of psoriasis • Describe associated triggers or risk factors for psoriasis• Describe the clinical features of psoriatic arthritis• List the basic principles of treatment for psoriasis • Discuss the emotional and psychosocial impact of psoriasis
on patients• Determine when to refer a patient with psoriasis to a
dermatologist3
Psoriasis: The Basics
Psoriasis is a chronic multisystem disease with predominantly skin and joint manifestations
Affects approximately 2% of the U.S. population Age of onset occurs in two peaks: ages 20-30 and ages
50-60, but can be seen at any age There is a strong genetic component
• About 30% of patients with psoriasis have a first-degree relative with the disease
Waxes and wanes during a patient’s lifetime, is often modified by treatment initiation and cessation and has few spontaneous remissions 4
Classification of Psoriasisis based on morphology
Plaque: scaly, erythematous patches, papules, and plaques that are sometimes pruritic
Inverse/Flexural: lesions are located in the skin folds
Guttate: presents with drop lesions, 1-10mm salmon-pink papules with a fine scale
Erythrodermic: generalized erythema covering nearly the entire body surface area with varying degrees of scaling
Pustular: clinically apparent pustules 5
Classification of Psoriasisis based on morphology (cont.)
Pustular psoriasis includes:• Rare, acute generalized variety called “von
Zumbusch variant”• Palmoplantar – localized involving palms and soles
Clinical findings in patients frequently overlap in more than one category
Different types of psoriasis may require different treatment
6
What Type of Psoriasis?
A B
C D
7
Guttate Psoriasis
Acute onset of raindrop-sized lesions on the trunk and extremities
Often preceded by streptococcal pharyngitis
8
Another Example of Guttate Psoriasis
9
Inverse/Flexural Psoriasis
Erythematous plaques in the axilla, groin, inframammary region, and other skin folds
May lack scale due to moistness of area
10
More Examples of Inverse/Flexural Psoriasis
11
Pustular Psoriasis
Characterized by psoriatic lesions with pustules. Often triggered by corticosteroid withdrawal. When generalized, pustular psoriasis can be life-threatening. These patients should be hospitalized and a dermatologist
consulted.12
Palmoplantar Psoriasis
May occur as either plaque type or pustular type. Often very functionally disabling for the patient. The skin lesions of reactive arthritis typically occur on the
palms and soles and are indistinguishable from this form of psoriasis.
13
Psoriatic Erythroderma
Involves almost the entire skin surface; skin is bright red
Associated with fever, chills, and malaise
Like pustular psoriasis, hospitalization is sometimes required
See the module on Erythroderma for more information
14
Question
How would you describe these lesions? What type of psoriasis does this patient have?
15
Plaque Psoriasis
Well-demarcated plaques with overlying silvery scale and underlying erythema
Chronic plaque psoriasis is typically symmetric and bilateral
Plaques may exhibit:• Auspitz sign (bleeding
after removal of scale)• Koebner phenomenon
(lesions induced by trauma)
16
More Examples of Plaque Psoriasis
17
Plaque Psoriasis: The Basics
Plaque psoriasis is the most common form, affecting 80-90% of patients
Approximately 80% of patients with plaque psoriasis have mild to moderate disease – localized or scattered lesions covering less than 5% of the body surface area (BSA)
20% have moderate to severe disease affecting more than 5% of the BSA or affecting crucial body areas such as the hands, feet, face, or genitals
18
Psoriasis: Pathogenesis
Psoriasis is a hyperproliferative state resulting in thick skin and excess scale
Skin proliferation is caused by cytokines released by immune cells
Systemic treatments of psoriasis target these cytokines and immune cells
19
Case One
Mr. Ronald Gilson
20
Case One: History
HPI: Mr. Gilson is a 24-year-old man who presents with a red lesion around his belly button that has been present for one month with occasional itching.
He has been reading on the internet and asks: “Do I have psoriasis?”
21
Case One, Question 1
What elements in the history are important to ask when considering the diagnosis of psoriasis?
a. Family history
b. Medications
c. Recent illnesses / Past medical history
d. Social history
e. All of the above
22
Case One, Question 1
Answer: e What elements in the history are important to
ask when considering the diagnosis of psoriasis?
a. Family history
b. Medications
c. Recent illnesses / Past medical history
d. Social history
e. All of the above23
Ask About Past Medical History
24
Psoriasis can be triggered by infections, especially streptococcal pharyngitis
Psoriasis can be more severe in patients with HIV Up to 20% of psoriasis patients have psoriatic arthritis,
which can lead to joint destruction There is a positive correlation between increased BMI
and both prevalence and severity of psoriasis Patients with psoriasis may have an increased risk for
cardiovascular disease and should be encouraged to address their modifiable cardiovascular risk factors
Ask About Medication History
Psoriasis can be triggered or exacerbated by a number of medications including:
• Systemic corticosteroid withdrawal • Beta blockers• Lithium • Antimalarials• Interferons
25
Ask About Family History
There is a strong genetic predisposition to developing psoriasis
1/3 of psoriasis patients have a positive family history• However, this means up to 2/3 of patients
with psoriasis do not have a family history of psoriasis, so a negative family history does not rule it out
26
Ask About Health-Related Behaviors
Studies have revealed smoking as a risk factor for psoriasis
Alcohol consumption is more prevalent in patients with psoriasis and it may increase the severity of psoriasis
A higher BMI is associated with an increased prevalence and severity of psoriasis
27
Back to Case One
Mr. Ronald Gilson
Twenty-one year-old man with red lesion around his umbilicus
28
Case One: History Continued
PMH: no major illnesses or hospitalizations Medications: none Allergies: none Family history: adopted, unknown Social history: lives with roommates in an
apartment, graduate student in physics Health-related behaviors: no tobacco or drug use,
consumes 3-6 beers on weekends ROS: negative
29
Psoriasis: Clinical Evaluation
Although you should perform a total body skin exam, plaque psoriasis tends to appear in characteristic locations • Key Areas: scalp, ears, elbows and knees
(extensor surfaces), umbilicus, gluteal cleft, nails, and sites of recent trauma
• Observation of psoriatic lesions in these locations helps distinguish psoriasis from other papulosquamous (scaly) skin disorders
30
Back to Case One: Skin Exam
Erythematous plaque around and in the umbilicus
Erythematous plaque with overlying silvery scale is present in the gluteal cleft (gluteal pinking)
31
Differential Diagnosis of Psoriasis
Mr. Gilson is given a diagnosis of psoriasis based on the clinical evaluation
Psoriasis is typically diagnosed on clinical exam because of its characteristic location and appearance
Other conditions to be considered in the patient with chronic plaque psoriasis are:• Tinea corporis• Nummular eczema• Seborrheic dermatitis
• Secondary syphilis• Drug eruption
32
Case Two
Mr. Bruce Laney
33
Case Two: History
HPI: Mr. Laney is a 68-year-old man with a history of psoriasis who presents with increased joint pain and joint changes. He currently uses a topical steroid to treat his psoriasis.
PMH: psoriasis x 40 years, hypertension x 20 years Medications: topical clobetasol for psoriasis,
hydrochlorothiazide for blood pressure Allergies: none Family history: mother and father both had psoriasis Social history: lives with his wife in a house, retired ROS: negative
34
Case Two: Skin Exam
Large erythematous plaque with overlying silvery scale on anterior scalp
35
Case Two: Skin Exam
Erythematous plaque with overlying silvery scale at the external auditory meatus and behind the ear
36
Also with nail pitting
Case Two: Exam Continued
Erythematous and edematous foot, with dactylitis (sausage digit) of the 2nd digit, and destruction of the DIP joints
Onychodystrophy: nail pitting and onycholysis
37
Case Two, Question 1
Mr. Laney has psoriasis complicated by psoriatic arthritis. What part(s) of his history/exam are most characteristic of a patient with psoriatic arthritis?
a. History of extensive psoriasis
b. Presence of nail pitting
c. Use of clobetasol
d. All of the above
38
Case Two, Question 1
Answer: b Mr. Laney has psoriasis complicated by psoriatic
arthritis. What part(s) of his history/exam is most consistent with this diagnosis?
a. History of extensive psoriasis
b. Presence of nail pitting (up to 90% of patients with psoriatic arthritis may have nail changes)
c. Use of clobetasol
d. All of the above
39
Psoriatic Onychodystrophy
Nail psoriasis can occur in all psoriasis subtypes Fingernails are involved in ~ 50% of all patients with
psoriasis. Toenails in 35% Changes include:
• Pitting: punctate depressions of the nail plate surface
• Onycholysis: separation of the nail plate from the nail bed
• Subungual hyperkeratosis: abnormal keratinization of the distal nail bed
• Trachyonychia: rough nails as if scraped with sandpaper longitudinally
40
Psoriatic Arthritis (PsA)
Arthritis in the presence of psoriasis • A member of the seronegative spondyloarthropathies
Symptoms can range from mild to severe Occurs in 10-25 percent of patients with psoriasis
• Can occur at any age, but for most it appears between the ages of 30 and 50 years
• It is NOT related to the severity of psoriasis
Five clinical patterns of arthritis occur• Most common is oligoarthritis with swelling and tenosynovitis of
one or a few hand joints
Flares and remissions usually characterize the course of psoriatic arthritis
41
Psoriatic Arthritis Continued
Health care providers are encouraged to actively seek signs and symptoms of PsA at each visit
PsA may appear before the diagnosis of psoriasis If psoriatic arthritis is diagnosed, treatment should be
initiated to:• Alleviate signs and symptoms of arthritis• Inhibit structural damage • Maximize quality of life
Diagnosis is based on clinical judgment • Specific patterns of joint inflammation, absence of rheumatoid
factor, and the presence of skin and nail lesions of psoriasis aid clinicians in making the diagnosis of PsA
42
More Examples of PsA
Desquamation of the overlying skin as well as joint swelling and deformity (arthritis mutilans) of both feet
Swelling of the PIP joints of the 2-4th digits, DIP involvement of the 2nd digit
43
Case Three
Ms. Sonya Hagerty
44
Case Three: History
HPI: Ms. Hagerty is an 18-year-old healthy woman with a new diagnosis of psoriasis. She reports lesions localized to her knees with no other affected areas. She has not tried any therapy.
PMH: no major illnesses or hospitalizations Medications: occasional multivitamin Allergies: none Family history: noncontributory Social history: lives in the city with her parents and attends
high school Health-related behaviors: no tobacco, alcohol, or drug use ROS: slight pruritus
45
Case Three: Skin Exam
Erythematous plaques with overlying silvery scale on the extensor surface of the knee.
46
Case Three, Question 1
Which of the following would you recommend to start treatment for Ms. Hagerty’s psoriasis?
a. Biologic (immunomodulators)
b. High potency topical steroid
c. Low potency topical steroid
d. Systemic steroids
e. Topical antifungal
47
Case Three, Question 1
Answer: b Which of the following would you recommend
to start treatment for Ms. Hagerty’s psoriasis?a. Biologic (immunomodulators)
b. High potency topical steroid
c. Low potency topical steroid
d. Systemic steroids
e. Topical antifungal
48
Psoriasis: Treatment
Since the psoriasis is localized (less than 5% body surface area), topical treatment is appropriate
First line agents: high potency topical steroid in combination with calcipotriene (vitamin D analog)
Other topical options: tazarotene, salicylic or lactic acid, tar, calcineurin inhibitors
49
Psoriasis: Treatment
Factors that influence type of treatment:• Age• Type of psoriasis:
– plaque, guttate, pustular, erythrodermic psoriasis
• Site and extent of psoriasis: – localized = <5% of BSA– generalized = diffuse or >30% involvement
• Previous treatment• Other medical conditions
50
Psoriasis: Treatment
Patients with localized plaque psoriasis can be managed by a primary care provider
Psoriasis of all other types should be evaluated by a dermatologist
51
Psoriasis: Topical Treatment
Medication Uses in Psoriasis Side Effects
Topical steroids Plaque-type psoriasisSkin atrophy, hypopigmentation, striae
Calcipotriene(Vitamin D derivative)
Use in combination with topical steroids for added benefit
Skin irritation, photosensitivity (but no contraindication with UVB phototherapy)
Tazarotene (Topical retinoid)
Plaque-type psoriasis. Best when used with topical corticosteroids.
Skin irritation, photosensitivity
Salicylic or Lactic acid(Keratolytic agents)
Plaque-type psoriasis to reduce scaling and soften plaques
Systemic absorption can occur if applied to > 20% BSA. Decreases efficacy of UVB phototherapy
Coal tar Plaque-type psoriasisSkin irritation, odor, staining of clothes
Calcineurin inhibitorsOff-label use for facial and intertriginous psoriasis
Skin burning and itching
Clinical Pearl
Topical medications for psoriasis are more effective when used with occlusion which allows for better penetration
A bandage, saran-wrap, gloves, or socks placed over the medication can serve this purpose
53
Case Three, Question 2
What would be an appropriate treatment if a patient had presented with this skin exam?
a. Systemic steroid
b. Topical steroid
c. Topical steroid and systemic steroid
d. Topical steroid and UV light therapy
e. All of the above54
Case Three, Question 2
Answer: d What would be an appropriate
treatment if a patient had presented with this skin exam?
a. Systemic steroid
b. Topical steroid
c. Topical steroid and systemic steroid
d. Topical steroid and UV light therapy
e. All of the above
55
Psoriasis: Systemic Treatment
In patients with moderate to severe disease, systemic treatment can be considered and should be supplemented with topical treatment
Many patients with moderate to severe psoriasis are only given topical therapy and experience little treatment success• Undertreating the patient can lead to a loss of hope
regarding their disease Oral steroids should never be used in psoriasis as they
can severely flare psoriasis upon discontinuation
56
Systemic Treatment
There are 3 choices for systemic treatment:1. Phototherapy: narrow-band ultraviolet B light
(nbUVB), broad-band ultraviolet B light (bbUVB), or psoralen plus ultraviolet A light (PUVA)
2. Oral medications: methotrexate, acitretin, cyclosporine
3. Biologic Agents: T- cell blocker (alefacept), TNF-α inhibitors (infliximab, etanercept, adalumimab), IL 12/23 blocker (ustekinumab)
57
Systemic Treatment
The choice of systemic therapy depends on multiple factors:
• convenience• side effect risk profile • presence or absence of psoriatic arthritis • co-morbidities
Systemic treatment for psoriasis should be given only after consultation with a dermatologist
58
The Patient’s Experience
A successful treatment regimen should include patient education as well as provider awareness of the patient’s experience
• Find out the patients’ views about their disease• Ask the patient how psoriasis affects their daily living • Ask about symptoms such as pain, itching, burning, and
dry skin• Ask patients about their experience with previous
treatments• Important to ask patients about their hopes and
expectations for treatment• Provide time for patients to ask questions
59
Psoriasis and QOL
Psoriasis is a lifelong disease and can affect all aspects of a patient’s quality of life (QOL), even in patients with limited skin involvement
Remember to address both the physical and psychosocial aspects of psoriasis
Many patients with psoriasis:• Feel socially stigmatized • Have high stress levels• Are physically limited by their disease • Have higher incidences of depression and alcoholism • Struggle with their employment status
60
Take Home Points
Psoriasis is a chronic multisystem disease with predominantly skin and joint manifestations
About 1/3 of patients with psoriasis have a 1st-degree relative with psoriasis
Different types of psoriasis are based on morphology: plaque, guttate, inverse, pustular, and erythrodermic
Plaque psoriasis is the most common, affecting 80-90% of patients
A detailed history should be taken in patients with psoriasis Plaque psoriasis is often diagnosed clinically Nail disease is common in patients with psoriasis
61
Take Home Points
Health care providers are encouraged to actively seek signs and symptoms of psoriatic arthritis at each visit
Topical treatment alone is used when the psoriasis is localized Patients with moderate to severe disease often require
systemic treatment in addition to topical therapy Systemic treatment includes phototherapy, oral medications
and biologic agents Oral steroids should never be used in psoriasis A successful treatment plan should include patient education
as well as provider awareness of the patient’s experience Psoriasis is a lifelong disease and can affect all aspects of a
patient’s quality of life62
Acknowledgements
This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.
Primary authors: Sarah D. Cipriano, MD, MPH; Eric Meinhardt, MD; Timothy G. Berger, MD, FAAD; Wilson Liao, MD, FAAD.
Peer reviewers: Peter A. Lio, MD, FAAD; Jennifer Swearingen, MD.
Revisions and editing: Sarah D. Cipriano, MD, MPH; John Trinidad. Last revised March 2011.
63
End of the Module
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Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462.
Bremmer S et al. Obesity and psoriasis: From the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2009 article in press.
Gelfand JM, et al. Risk of Myocardial Infarction in Patients With Psoriasis. JAMA 2006;296:1735-41.
Gottlieb et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 2. Psoriatic arthritis: Overview and guidelines of care for treatment with an emphasis on biologics. J Am Acad Dermatol 2008;58:851-864.
Gudjonsson Johann E, Elder James T, "Chapter 18. Psoriasis" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2983780.
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End of the Module
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arthritis. Section 1. Overview of psoriasis and guideline of acre for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008;58:826-850.
Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol 2009;60:643-659.
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