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Medical Student Core Curriculum in Dermatology

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1 Medical Student Core Curriculum in Dermatology
Psoriasis Medical Student Core Curriculum in Dermatology Last updated March 28, 2011

2 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.

3 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 dermatologist

4 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 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

5 Classification of Psoriasis is 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

6 Classification of Psoriasis is 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

7 What Type of Psoriasis? A B C D

8 Guttate Psoriasis Acute onset of raindrop-sized lesions on the trunk and extremities Often preceded by streptococcal pharyngitis

9 Another Example of Guttate Psoriasis

10 Inverse/Flexural Psoriasis
Erythematous plaques in the axilla, groin, inframammary region, and other skin folds May lack scale due to moistness of area

11 More Examples of Inverse/Flexural Psoriasis

12 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.

13 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.

14 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

15 Question How would you describe these lesions?
What type of psoriasis does this patient have?

16 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)

17 More Examples of Plaque Psoriasis

18 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

19 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

20 Case One Mr. Ronald Gilson

21 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?”

22 Case One, Question 1 What elements in the history are important to ask when considering the diagnosis of psoriasis? Family history Medications Recent illnesses / Past medical history Social history All of the above

23 Case One, Question 1 Answer: e
What elements in the history are important to ask when considering the diagnosis of psoriasis? Family history Medications Recent illnesses / Past medical history Social history All of the above

24 Ask About Past Medical History
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

25 Ask About Medication History
Psoriasis can be triggered or exacerbated by a number of medications including: Systemic corticosteroid withdrawal Beta blockers Lithium Antimalarials Interferons

26 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

27 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

28 Twenty-one year-old man with red lesion around his umbilicus
Back to Case One Mr. Ronald Gilson Twenty-one year-old man with red lesion around his umbilicus

29 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

30 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

31 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)

32 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

33 Case Two Mr. Bruce Laney

34 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

35 Case Two: Skin Exam Large erythematous plaque with overlying silvery scale on anterior scalp

36 Case Two: Skin Exam Erythematous plaque with overlying silvery scale at the external auditory meatus and behind the ear Also with nail pitting

37 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

38 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? History of extensive psoriasis Presence of nail pitting Use of clobetasol All of the above

39 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? History of extensive psoriasis Presence of nail pitting (up to 90% of patients with psoriatic arthritis may have nail changes) Use of clobetasol All of the above

40 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

41 Psoriatic Arthritis (PsA)
Arthritis in the presence of psoriasis A member of the seronegative spondyloarthropathies Symptoms can range from mild to severe Occurs in 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

42 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

43 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

44 Case Three Ms. Sonya Hagerty

45 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

46 Case Three: Skin Exam Erythematous plaques with overlying silvery scale on the extensor surface of the knee.

47 Case Three, Question 1 Which of the following would you recommend to start treatment for Ms. Hagerty’s psoriasis? Biologic (immunomodulators) High potency topical steroid Low potency topical steroid Systemic steroids Topical antifungal

48 Case Three, Question 1 Answer: b
Which of the following would you recommend to start treatment for Ms. Hagerty’s psoriasis? Biologic (immunomodulators) High potency topical steroid Low potency topical steroid Systemic steroids Topical antifungal

49 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

50 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

51 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

52 Psoriasis: Topical Treatment
Medication Uses in Psoriasis Side Effects Topical steroids Plaque-type psoriasis Skin 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 Skin irritation, odor, staining of clothes Calcineurin inhibitors Off-label use for facial and intertriginous psoriasis Skin burning and itching

53 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

54 Case Three, Question 2 What would be an appropriate treatment if a patient had presented with this skin exam? Systemic steroid Topical steroid Topical steroid and systemic steroid Topical steroid and UV light therapy All of the above

55 Case Three, Question 2 Answer: d
What would be an appropriate treatment if a patient had presented with this skin exam? Systemic steroid Topical steroid Topical steroid and systemic steroid Topical steroid and UV light therapy All of the above

56 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

57 Systemic Treatment There are 3 choices for systemic treatment:
Phototherapy: narrow-band ultraviolet B light (nbUVB), broad-band ultraviolet B light (bbUVB), or psoralen plus ultraviolet A light (PUVA) Oral medications: methotrexate, acitretin, cyclosporine Biologic Agents: T- cell blocker (alefacept), TNF-α inhibitors (infliximab, etanercept, adalumimab), IL 12/23 blocker (ustekinumab)

58 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

59 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

60 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

61 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

62 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 life

63 Acknowledgements This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 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.

64 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; Available from: 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: 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: 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:

65 End of the Module James WD, Berger TG, Elston DM, “Chapter 13. Acne” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: , 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: Luba KM, Stulberg DL. Chronic Plaque Psoriasis. Am Fam Physician 2006;73: 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: 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: Smith CH. Clinical Review. Psoriasis and its management. BMJ 2006;333:380-4.


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