Psoriasis Module

7/30/2019 Psoriasis Module

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Psoriasis

Medical Student Core Curriculum

in Dermatology

Last updated March 28, 2011 1



Module Instructions

The following module contains a number of blue, underlined terms which are

hyperlinked to the dermatology glossary,

an illustrated interactive guide to clinicaldermatology and dermatopathology.

We encourage the learner to read all the

hyperlinked information.

2

http://missinglink.ucsf.edu/lm/DermatologyGlossary/index.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/index.html



Goals and Objectives

The purpose of this module is to help medical studentsdevelop 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 withpredominantly 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 oftenmodified by treatment initiation and cessation and has few

spontaneous remissions4



Classification of Psoriasisis based on morphology

Plaque: scaly, erythematous patches, papules, andplaques that are sometimes pruritic

Inverse/Flexural: lesions are located in the skin folds

Guttate: presents with drop lesions, 1-10mmsalmon-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 GuttatePsoriasis

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 ofInverse/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 thepalms and soles and are indistinguishable from this form

of psoriasis.13



Psoriatic Erythroderma

Involves almost the entireskin 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 silveryscale 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

M E l f Pl



More Examples of PlaquePsoriasis

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 crucialbody areas such as the hands, feet, face, or

genitals18

http://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.html



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 OneMr. 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 importantto ask when considering the diagnosis of

psoriasis?

a. Family historyb. Medications

c. Recent illnesses / Past medical history

d. Social historye. 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, especiallystreptococcal 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 exacerbatedby a number of medications including:

• Systemic corticosteroid withdrawal

• Beta blockers• Lithium

• Antimalarials

• Interferons

25



Ask About Family History

There is a strong genetic predisposition todeveloping 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 historydoes not rule it out

26

Ask About Health Related



Ask About Health-RelatedBehaviors

Studies have revealed smoking as a riskfactor for psoriasis

Alcohol consumption is more prevalent in

patients with psoriasis and it may increasethe 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: negative29



Psoriasis: Clinical Evaluation

Although you should perform a total bodyskin 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 fromother papulosquamous (scaly) skin disorders

30

http://missinglink.ucsf.edu/lm/DermatologyGlossary/papulosquamous.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/papulosquamous.html



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 (glutealpinking)

31

Differential Diagnosis of



Differential Diagnosis ofPsoriasis

Mr. Gilson is given a diagnosis of psoriasis based onthe 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

http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea_corporis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/eczema.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/syphilis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/drugeruption.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/drugeruption.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/syphilis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/seborrheic_dermatitis.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/eczema.html

http://missinglink.ucsf.edu/lm/DermatologyGlossary/tinea_corporis.html



Case TwoMr. 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: negative34



Case Two: Skin Exam

Large erythematous

plaque with overlying

silvery scale onanterior scalp

35



Case Two: Skin Exam

Erythematous plaque withoverlying 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 bypsoriatic 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 clobetasold. 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 clobetasold. 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: abnormalkeratinization of the distal nail bed

• Trachyonychia: rough nails as if scraped

with sandpaper longitudinally40



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 arthritis41



Psoriatic Arthritis Continued

Health care providers are encouraged to actively seeksigns 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 PsA42



More Examples of PsA

Desquamation of the overlying

skin as well as joint swelling anddeformity (arthritis mutilans) of

both feet

Swelling of the PIP joints of

the 2-4th digits, DIP

involvement of the 2nd digit

43



Case ThreeMs. Sonya Hagerty

44



Case Three: History

HPI: Ms. Hagerty is an 18-year-old healthy woman with a newdiagnosis 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 pruritus45



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 tostart treatment for Ms. Hagerty’s psoriasis?

a. Biologic (immunomodulators)

b. High potency topical steroidc. Low potency topical steroid

d. Systemic steroids

e. Topical antifungal

47

C Th Q i




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 steroidse. Topical antifungal

48

P i i T



Psoriasis: Treatment

Since the psoriasis is localized (less than5% body surface area), topical treatment

is appropriate

First line agents: high potency topicalsteroid in combination with calcipotriene

(vitamin D analog)

Other topical options: tazarotene, salicylicor lactic acid, tar, calcineurin inhibitors

49

P i i T




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 conditions50

P i i T




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

P i i T i l T t t



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

Cli i l P l



Clinical Pearl

Topical medications for psoriasis are more

effective when used with occlusion which

allows for better penetration

A bandage, saran-wrap, gloves, or socksplaced over the medication can serve this

purpose

53

C Th Q ti 2




What would be an appropriatetreatment 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

54

C Th Q ti 2




Answer: d What would be an appropriate

treatment if a patient had

presented with this skin exam?

a. Systemic steroidb. Topical steroid

c. Topical steroid and systemic

steroid

d. Topical steroid and UV lighttherapy

e. All of the above

55

P i i S t i T t t



Psoriasis: Systemic Treatment

In patients with moderate to severe disease, systemictreatment can be considered and should be

supplemented with topical treatment

Many patients with moderate to severe psoriasis are

only given topical therapy and experience littletreatment success

• Undertreating the patient can lead to a loss of hope

regarding their disease

Oral steroids should never be used in psoriasis as theycan severely flare psoriasis upon discontinuation

56

S t i T t t



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), IL12/23 blocker (ustekinumab)

57

S t i T t t



Systemic Treatment

The choice of systemic therapy depends onmultiple 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

dermatologist58

Th P ti t’ E i



The Patient’s Experience

A successful treatment regimen should include patienteducation 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 andexpectations for treatment

• Provide time for patients to ask questions59

Psoriasis and QOL



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 status60

Take Home Points



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 psoriasis61

Take Home Points



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 medicationsand 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 life 62

Acknowledgements



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



End of the Module

Abdelaziz A, Burge S. What should undergraduate medical students know about

psoriasis? Involving patients in curriculum development: modified Delphi technique.

BMJ 2005;330:633-6.

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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James WD, Berger TG, Elston DM, “Chapter 13. Acne” (chapter). Andrews’

Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders

Elsevier; 2006: 231-239, 245-248.

Jobling R. A Patient’s Journey. Psoriasis. BMJ 2007;334:953-4.

Kimball AB et al. The Psychosocial Burden of Psoriasis. Am J Clin Dermatol

2005;6:383-392.

Luba KM, Stulberg DL. Chronic Plaque Psoriasis. Am Fam Physician2006;73:636-44.

Menter A et al. Guidelines of care for the management of psoriasis and psoriatic

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 psoriaticarthritis. Section 3. Guidelines of care for the management and treatment of

psoriasis with topical therapies. J Am Acad Dermatol 2009;60:643-659.

Smith CH. Clinical Review. Psoriasis and its management. BMJ 2006;333:380-4.65

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