PSORIASIS

Case Management Conference

Dr. Toledo

Capaya | Jadwani | Maderazo | Maloles | Neyra | Razon

GENERAL DATA
★ D.l.
★ 48/male
★ Cavite
★ Teacher
★ married, with 3 children
CHIEF COMPLAINT

“rashes”
HISTORY OF PRESENT ILLNESS
★ (+) pruritic, scaly,
erythematous patches on the
scalp
★ not significantly improved by
anti-dandruff shampoos
★ (+) consult = Seborrheic
dermatitis
2 years PTC
★ generalized erythematous
patches and plaques
★ febrile and chilly sensations
★ joint swelling on the right
ankle and left knee
1 year PTC
★ (+) 1 week hospitalization DAY OF CONSULT
due to dengue
★ rapid thickening of scalp
lesions
★ sudden eruption of
erythematous scaling papules
on the trunk and limbs
★ (+) consult with a
dermatologist and was
diagnosed with Eruptive or
Guttate psoriasis
HISTORY OF PRESENT ILLNESS
2 YEARS PTC
★ (+) pruritic, scaly, erythematous patches on the scalp
★ not significantly improved by anti-dandruff shampoos
★ (+) consult = Seborrheic dermatitis
★ topical antifungal-corticosteroid + antihistamines
★ Loratadine 10mg tablet once a day for 2 weeks
★ The patient experienced a relapsing course.
HISTORY OF PRESENT ILLNESS
1 YEAR PTC
★ (+) 1 week hospitalization due to dengue
★ rapid thickening of scalp lesions
★ sudden eruption of erythematous scaling papules on the trunk
and limbs
★ (+) consult with a dermatologist and was diagnosed with
Eruptive or Guttate psoriasis
HISTORY OF PRESENT ILLNESS
1 YEAR PTC
★ topical therapy consisting of steroid emollients, tar
preparations, and calcineurin inhibitors; Antibacterial and
antifungal; narrowband-ultraviolet B phototherapy and oral
drugs Acitretin and Cyclosporine
★ (+) joint pain and swelling on the left wrist, left knee and right
ankle → Methotrexate, NSAIDs
★ The patient was compliant for 4 weeks and was lost to follow-
up 50% improved.
★ (+) herbalists --> fruit and vegetable juice treatments
HISTORY OF PRESENT ILLNESS
DAY OF CONSULT
★ generalized erythematous patches and plaqueS
★ febrile and chilly sensations
★ joint swelling on the right ankle and left knee
PAST MEDICAL HISTORY
Metabolic syndrome: (+)dyslipidemia, (+) pre-diabetes,
(+) hypertension
Atopy: (+) allergic rhinitis, atopic dermatitis
FAMILY MEDICAL HISTORY
★ (+) Asthma (maternal)
★ No similar illness in the family
PERSONAL AND SOCIAL HISTORY
★ Graduate
★ married, with 3 children
★ Smoker
★ occasional alcoholic beverage drinker
★ lives with elderly in-laws and unemployed brother
REVIEW OF SYSTEMS
★ unremarkable
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
Primary Impression

★ Exfoliative dermatitis secondary to

psoriasis with Psoriatic arthropathy
★ Metabolic Syndrome
★ Allergic rhinitis
PSORIASIS
★ Epidemiology: Incidence of 0.4% in Asians; Male = Female
★ Onset: most likely to occur between 15-30 years old
★ Etiology and Pathogenesis: chronic inflammatory disorder
with polygenic predisposition combined with triggering
environmental factors
★ Characterized by erythematous scaly papules and plaques;
pustular and erythrodermic eruptions may occur.
★ Appears on the scalp, elbows and knees, hands, feet, trunk,
Clinical Patterns of Skin Presentation
● PSORIASIS VULGARIS, CHRONIC STATIONARY PSORIASIS,
PLAQUE-TYPE PSORIASIS
● GUTTATE (ERUPTIVE) PSORIASIS
● SMALL PLAQUE PSORIASIS
● INVERSE PSORIASIS
● ERYTHRODERMIC PSORIASIS
● PUSTULAR PSORIASIS
Clinical Patterns of Skin Presentation

Guttate
Clinical Patterns of Skin Presentation

Plaque
Clinical Patterns of Skin Presentation

Inverse
Clinical Patterns of Skin Presentation

Pustular
Related Physical Findings

● NAIL CHANGES

● GEOGRAPHIC TONGUE
PSORIATIC ARTHRITIS
● Member of the seronegative spondyloarthritis group of disorders
● 10-15% of patients with psoriasis
● Strong genetic predisposition
● Involves activation of CD8 T-cells, releasing inflammatory mediators that
affect target tissues
● Involves the distal interphalangeal joint arthritis, dactylitis, enthesis,
periosteal new bone formation, and asymmetric oligoarthritis, and
spondylitis
FEATURES SUPPORTIVE OF A DIAGNOSIS OF
PSORIASIS

Symmetry of lesions
Extensor distribution
Sharply demarcated lesions
FEATURES SUPPORTIVE OF A DIAGNOSIS OF
PSORIASIS

Auspitz Sign
Silvery scale
PATHOPHYSIOLOGY OF PSORIASIS
Antigenic stimuli activate innate immune cells in the
skin.
Innate immune cells produce proinflammatory
cytokines (IFN-alpha) to activate myeloid dendritic cells
in the skin.
Myeloid dendritic cells produce cytokines (IL-23)
to stimulate attraction and activation of T cells.
T cells produce cytokines (IL-17A) that stimulate keratinocytes to
proliferate and produce proinflammatory antimicrobial peptides and
cytokines.
Inflammatory process perpetuated via the positive feedback
loop
PATHOPHYSIOLOGY OF PSORIATIC ARTHRITIS
● Precise cause and mechanism still unknown
○ ? Genetic
○ ? Immunologic
○ ? Environmental (bacterial infection, viral infection,
trauma)
RISK FACTORS FOR PSORIASIS
● Genetics (40% of patients with psoriasis have a family
history)
● Smoking
● Obesity
● Drugs (most common: beta blockers, lithium,
antimalarial drugs, NSAIDs, tetracycline)
 Infections (most recognized: streptococcal, HIV)
● Alcohol
● Vitamin D deficiency
EXFOLIATIVE DERMATITIS
 Diffuse erythema and scaling involving > 75% of the skin
Most common cause: exacerbation of pre-existing inflammatory
dermatosis (most often psoriasis)
 Trigger: Abrupt discontinuation of corticosteroids or
immunosuppressant treatment

 Complications:
 Hemodynamic and metabolic disturbances
 Infection
MANAGEMENT
MANAGEMENT: Mild (< 10% BSA)
TOPICAL TREATMENT
First Line
❖ Emollients/Moisturizers
➢ Hydrate the skin and are used for all dry or scaling
disorders.
➢ Short-lived effects, should be applied frequently, even
after improvement occurs.
➢ Restore the natural barrier function of the skin
➢ Can be in the form of cream, ointments, or lotions
MANAGEMENT: Mild (< 10% BSA)
TOPICAL TREATMENT
First Line
❖ Glucocorticoids
➢ High-potency steroids are applied to affected areas BID x
2-4 weeks and then intermittently
➢ Effective as short-term treatment

❖ Vitamin D3 Analogs
➢ Promote keratinocyte differentiation.
➢ Efficacy increased with topical steroids
MANAGEMENT: Mild (< 10% BSA)
TOPICAL TREATMENT
Second Line
❖ Dithranol
➢ antiproliferative activity on human keratinocytes with potent
anti-inflammatory effects
➢ approved for the treatment of chronic plaque psoriasis,
particularly in resistant ones
❖ Tazarotene
➢ third-generation retinoid for topical use that reduces scaling
and plaque thickness
➢ Efficacy can be enhanced by combination with mid- to high-
potency glucocorticoids or UVB phototherapy
MANAGEMENT: Mild (< 10% BSA)
TOPICAL TREATMENT
Second Line
❖ Tar
➢ the dry distillation product of organic matter heated in the
absence of oxygen
➢ MOA is not understood well
➢ appears to exert its action through suppression of DNA
synthesis and consequent reduction of mitotic activity in
the basal layer of the epidermis, and some components in
tar appear to have anti-inflammatory activity
MANAGEMENT: Mild (< 10% BSA)
PHOTOTHERAPY
● involve selective depletion of T cells, predominantly those
that reside in the epidermis.
● involve apoptosis and is accompanied by a shift from a Th1
immune response toward a Th2 response in the lesional
skin.
MANAGEMENT: Mild (< 10% BSA)
PHOTOTHERAPY
First Line
❖ Narrowband-UV
❖ Broadband-UV
➢ Narrowband (312 nm) UVB (NBUVB) phototherapy is
superior to conventional broadband UVB (290–320 nm)
with respect to both clearing and remission times
MANAGEMENT: Mild (< 10% BSA)
PHOTOTHERAPY
Second Line
❖ Psoralen with UV A Light (PUVA)
➢ PUVA is the combined use of psoralens (P) and long-
wave ultraviolet A radiation (UVA).
➢ The combination of drug and radiation results in a
therapeutic effect, which is not achieved by the single
component alone.
➢ Remission is induced by repeated controlled phototoxic
reactions
MANAGEMENT: Mild (< 10% BSA)
PHOTOTHERAPY
Second Line
❖ Excimer Laser
➢ Supraerythemogenic fluences of UVB and PUVA
➢ known to result in faster clearing of psoriasis
➢ limiting factor lies with the intolerance of the uninvolved
surrounding skin as psoriatic lesions can often withstand
much higher UV exposures.
➢ only focally indicated for patients with stable recalcitrant
plaques particularly in the elbows and knee region
MANAGEMENT: Moderate to Severe (>10% BSA)
★ First Line: ★ Second Line: ★ Additional
○ Methotrexate ○ FAE ○ Goeckerma
○ Acretin ○ Cyclosporin A n
○ Biologicals ○ Others:
■ Hydroxyurea
■ 6-thioguanine
■ Cellcept
■ Sulfasalazine
 MANAGEMENT: Moderate to Severe (>10% BSA)
SYSTEMIC TREATMENT
Methotrexate - effective agent, especially in patients with
psoriatic arthritis
- Purine and Pyrimidine synthesis blocked by inhibition of
Dihydrofolate Reductase
Methotrexate
★ Usually given in oral form
★ Side effects: Nausea, Vomiting,
Lightheadedness, Mouth Ulcers,
Bloody Diarrhea, Hair Loss,
Sensitivity to Light
★ Methotrexate can be used with
PUVA or UVB to reduce the
amount of ultraviolet light
needed to clear the skin.
ACITRETIN
★ Acitretin - Synthetic Retinoid (Vitamin A)
★ Most applicable when immunosuppression must be avoided
★ The mechanism of action of acitretin is unknown
★ Believed to targets specific receptors (retinoid receptors
such as RXR and RAR) in the skin which help normalize
the growth cycle of skin cells.
★ Side effects: Hair Loss, Dry Mucosa, Bleeding Gums,
Depression
ACITRETIN
★ Acitretin is sometimes used with the biologic drugs Enbrel
(etanercept) and Remicade (infliximab) to achieve clearing
of psoriasis.
★ Acitretin may also be prescribed in rotation with other
systemic medications, such as cyclosporine or methotrexate.
★ Highly Teratogenic. Women who take Acitretin must wait 3
years after taking the drug before attempting pregnancy due
to high risk of severe birth defects.
Biologic Agents
★ Infliximab, Etanercept, Adalimumab,
Golimumab are all anti TNF-alpha
inhibitors.
★ Mechanism includes binding of the agents
to TNF-alpha which decreases the amount
of TNF-alpha in tissues and fluids of
patient. Increased TNF-α has direct
correlation with diseases like ankylosing
spondylitis, psoriatic arthritis, and
ulcerative colitis.
MANAGEMENT: Moderate to Severe (>10% BSA)
Fumaric Acid
 monoethylfumarate (MEF) and dimethylfumarate (DMF)
derived from Fumaric Acid
 It is thought to involve dimethyl fumarate degradation to its
active metabolite monomethyl fumarate (MMF) then MMF
up-regulates the Nuclear factor (erythroid-derived 2)-like 2
(Nrf2) pathway that is activated in response to oxidative
stress.
 NRF2 is a known cell proliferation regulator.
Cyclosporin A
★ CsA is a hydrophobic lipophilic undecapeptide extracted
from fungi.
★ Binds cyclophilin, and the resulting complex blocks
calcineurin, reducing the effect of the NF-AT in T cells,
resulting in inhibition of IL-2 and other cytokines.
Hydroxyurea
★ Hydroxyurea is converted to a free radical nitroxide.
★ In psoriasis, it is thought to work by reducing the replication
of DNA within the basal cell of the epidermis.
★ Hydroxyurea should not be taken in pregnancy as it is likely
to cause fetal abnormalities.
★ Side effects may include liver toxicity, bone marrow toxicity
(anemia and leukopenia), hair loss.
MANAGEMENT: Moderate to Severe (>10% BSA)
★ Day Treatment Centre
★ Modified Goeckerman
★ Specialized light therapy
★ Involves Coal Tar application followed by exposure to UVB
Light
GOECKERMAN THERAPY
★ Suppression of DNA
synthesis, reduction
of epidermal
hyperproliferation,
modulation of pro-
inflammatory
cytokines, depletion
of T-lymphocytes,
and inhibition of
angiogenesis.
GOECKERMAN THERAPY
 Patients are treated in daycare facilities for a minimum of 4-
8 hr/day and 5 days/week until their disease clears.
 Side effects include contact dermatitis and hypersensitivity
to Crude Coal Tar
 The rate of PASI reduction after therapy was >50% in 63.6%
of patients; 27.3% of patients achieved >75% reduction and
9.1% of patients achieved 26-50% reduction, according to a
study conducted by Gawdat in 2015 and published in the
Acta Dermatovenerologica Croatica (ADC).
 Management of EXFOLIATIVE DERMATITIS
SECONDARY TO PSORIASIS
Management of Erythrodermic Psoriasis includes the following
treatment goals:
1. Pretreatment Evaluation for the disease complications and
triggers
2. Supportive care
3. Prompt Initiation of systemic antipsoriasis therapy
Pretreatment Evaluation
1. Vital signs, Complete skin examination, and physical
examination
○ Assess for hemodynamic instability or infections
2. Complete blood count with differential count
3. Comprehensive metabolic panel
○ Assess for fluid and electrolyte status
○ Assess liver and kidney function
4. Microbiologic studies of cutaneous sites suggestive of
infection
Supportive treatment
1. Monitoring of body temperature and
hemodynamic status
2. Fluid and electrolyte replacement as needed
3. Nutritional support
4. Treatment of associated infections
 Medical management of Erythrodermic
Psoriasis

Fitzpatrick's
Dermatology in
General Medicine,
8e, 2012 > Chapter
18. Psoriasis
 Management of Psoriatic arthritis
Non Pharmacologic
1. Exercise, Physical therapy, and Occupational therapy
○ For joint protection
2. Weight Reduction
○ Obesity and metabolic syndrome may lessen treatment
response to DMARDs
○ Refer to nutritionist for further counseling
 Management of Psoriatic arthritis
★ NSAIDs.
○ relieve pain and reduce inflammation
○ ibuprofen (Advil, Motrin IB, others) and naproxen sodium
(Aleve).
○ Side effects: stomach irritation, heart problems, and liver and
kidney damage.
★ Disease-modifying antirheumatic drugs (DMARDs).
○ slow the progression of psoriatic arthritis and save the joints
and other tissues from permanent damage.
○ methotrexate (Trexall), leflunomide (Arava), and sulfasalazine
(Azulfidine).
○ Side effects: liver damage, bone marrow suppression and severe
lung infections.
 Management of Psoriatic arthritis
★ Immunosuppressants.
○ tame your immune system, which is out of control in psoriatic
arthritis
○ azathioprine (Imuran, Azasan) and cyclosporine (Gengraf,
Neoral, Sandimmune)
○ can increase susceptibility to infection
★ TNF-alpha inhibitors.
○ reduce pain, morning stiffness, and tender or swollen joints.
○ etanercept (Enbrel), infliximab (Remicade), adalimumab
(Humira), golimumab (Simponi) and certolizumab (Cimzia).
○ Side effects: nausea, diarrhea, hair loss and an increased risk
of serious infections.
THANK YOU!