1 / 85

Overview of Psoriasis

Overview of Psoriasis. Adam O. Goldstein, MD, MPH Associate Professor UNC Department of Family Medicine Email: aog@med.unc.edu. Objectives. 1 . Differentiate psoriasis types 2. Form differential dx 3. Review tx guidelines 4. Review new products

zeke
Download Presentation

Overview of Psoriasis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Overview of Psoriasis Adam O. Goldstein, MD, MPH Associate Professor UNC Department of Family Medicine Email: aog@med.unc.edu

  2. Objectives 1. Differentiate psoriasis types 2. Form differential dx 3. Review tx guidelines 4. Review new products 5. Learn 2 additional patient education pearls

  3. “I am silvery, scaly. Puddles of flakes form wherever I rest my flesh.... Lusty, though we are loathsome to love. Keen-sighted, though we hate to look upon ourselves. The name of the disease, spiritually speaking, is…. Humiliation

  4. Psoriasis: Incidence • 2-3% U.S. (6.4 million) • 200,000 new cases/year • 300,000 have >20% BSA • Median age dx: 30 • Two peaks: 16-22, 57-60 • Costs: $2 billion/year • Mean per patient costs $3000 (Javitz, J Am Acad Dermatol, 2002)

  5. Psoriasis: Quality of Life • 50% seek treatment • As debilitating as other chronic illnesses • > rates depression & alcohol abuse (Sharma, J Dermatol, 2001)

  6. Case • Bob- 34 yo insurance executive • history of psoriasis for 8 years • scalp, elbows, knees and trunk • Got topical steroid (Psorcon E, 60 gms) from dermatologist 3 years ago • helped with itching • Wants a renewal and wonders if needs to see a dermatologist • You estimate 5-10% involvement of skin with plaque psoriasis

  7. Case What is your treatment plan? Do you refer him to a dermatologist?

  8. Psoriasis: Definition • Chronic, remitting and relapsing • Scaly and inflammatory • Genetically influenced

  9. Psoriasis: • Morphology: Circumscribed, thickened, plaques with secondary erythema and thick, silvery scales

  10. Psoriasis: Pathogenesis • Hyperproliferation of the epidermis • Normal skin cell matures in 28-30 days • Psoriatic skin cell matures in 3-6 days

  11. Psoriasis: Types • Plaque-typeLocalized or Generalized • PustularLocalized or Generalized

  12. Psoriasis • Arthritis associated (5-7%)

  13. Psoriasis: Distribution (From Pardasan AG, et al. Am Fam Physician 2000)

  14. Psoriasis: Distribution • Extensor

  15. Psoriasis: Distribution • Extensor

  16. Psoriasis: Distribution • Nails

  17. Psoriasis: Distribution • Genitalia

  18. Psoriasis: Distribution • Hands & feet

  19. Psoriasis: Distribution • Pustular

  20. Psoriasis: Distribution • Intertriginous/inverse- armpits, groin, under breasts(less thick “silvery”scale)

  21. Psoriasis: Distribution • Guttate-small red dots (Gutta = drops) • Appears suddenly after a strep, URI, other infection, stress, medications

  22. Psoriasis: Guttate • Appears after strep, URI, stress, medica-tions

  23. Psoriasis: Distribution • Erythrodermic • Widespread erythema, itching, pain, edema

  24. Psoriasis: Distribution • Sites of trauma (Koebner’s phenomenon)

  25. Psoriasis: Diagnosis • Early on, may look like other diseases • Bx may be necessary

  26. Psoriasis: Differential Diagnosis • Drug eruption

  27. Psoriasis: Differential Diagnosis • secondary syphilis

  28. Psoriasis: Differential Diagnosis • Seborrhea: Finer scale, central facial, scalp, central chest; Greasier; Sebopsoriasis

  29. Psoriasis: Differential Diagnosis • dermatophyte infections (Tinea) • KOH negative • scale not as thick or silvery

  30. Psoriasis: Differential Dx • intertriginous: diaper dermatitis/candidiasis • satellite pustules, beefy red, maceration; KOH positive for yeast in candidiasis; may coexist

  31. Psoriasis: Differential Diagnosis • Eczema • Neuro-dermatitis/ lichen simplex chronicus

  32. Psoriasis: Differential Dx • lichen planus

  33. Psoriasis: Differential Diagnosis • lupus erythematosus

  34. Psoriasis: Differential Diagnosis • pityriasis rosea

  35. Psoriasis: Differential Diagnosis • Cutaneous T-cell lymphoma

  36. Psoriasis: Principals of Treatment • Individualize treatment based on: • self-image, symptoms, interference with social interactions, expectations & scientific evidence • Patient education: Control, not cure • Pearl: • Combine products for better long-term control and fewer SE’s (Rees, J Am Acad Dermatol, 2003 )

  37. Psoriasis: Treatment • Flares • skin injury (including dryness, scratching) • sunburn • infections (strep, HIV) • psychological stress • medications

  38. Psoriasis: Treatment • Medications linked to psoriatic flares: • Lithium • Beta blockers • ACE inhibitors • Antimalarials • Indomethacin

  39. PsoriasisPearl • Avoid systemic corticosteroids

  40. Psoriasis: Treatment • <5% sunlight + topical tx • 5-20% sunlight + topical tx +/- systemic • >20% systemic tx +/- light therapy

  41. Psoriasis: Treatment • Sunlight

  42. Evidence-based medicine • No good evidence that non-drug tx’s work • Topical tx’s effective in short-term (few comparative RCT’s) • RCT’s show UVB and PUVA effective short/long term (long term risk PUVA-SCCa) • Cyclosporin clears short term but toxic (BMJ, Clinical Evidence 2001)

  43. Psoriasis: < 20% BSATopical Therapies 1. Emollients 2. Keratolytic agents 3. Topical steroids 4. Calcipotriene 5. Tazarotene gel 6. Topical calcineurin inhibitors 7. Anthralin 8. Coal tar ( BMJ 2001)

  44. 1. Emollient cleansers and lotions/cream • Mild cleansers • Moisturizers

  45. 2. Keratolytic Agents • WHEN THE SCALE IS REALLY THICK Scalp: P & S liquid Body: 2-10% salicylic acid qd- bid

  46. 3. Topical Corticosteroids • Never treated- • start medium potency • follow up in 2 weeks • Previously treated • start high potency • 2-4 weeks, then taper • Always use lower potencies on face and intertriginous areas

  47. 3. Topical Corticosteroids • Creams most body parts • Lotions/mousse hairy areas • Ultrapotent/potent BID 2-3 weeks to thick lesions • Taper to weekend use only or: • Taper to Class III for maintenance to avoid atrophy/striae • Educate on: • “tolerance”, signs of atrophy, tapering & relapse • If topical steroids insufficient: • Steroids + occlusion (plastic wrap QHS- if no atrophy) • Steroids + calcipotriene cream/ointment or tazarotene gel • Coal tar products and/or Anthralin (Tristani-Firouzi, Cutis, 1998)

  48. Intralesional injections • Isolated recalcitrant lesions TAC 3-10mg/cc in NS to plaques < 3 cm

  49. 4. Calcipotriene 0.005% (cream, ointment, solution) • Calcipotriene (Dovonex) • simulates differentiation • inhibits proliferation • > effective as steroids, tar, anthralin • > irritation than steroids • Use cautiously if renal or calcium-related conditions, especially (< 60 gm/week) • Use > 4 wks to determine effectiveness (BMJ 2001)

More Related