Presentation on theme: "Medical Student Core Curriculum in Dermatology"— Presentation transcript:
1 Medical Student Core Curriculum in Dermatology PsoriasisMedical Student Core Curriculumin DermatologyLast updated March 28, 2011
2 Module InstructionsThe 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 ObjectivesThe 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 psoriasisDescribe associated triggers or risk factors for psoriasisDescribe the clinical features of psoriatic arthritisList the basic principles of treatment for psoriasisDiscuss the emotional and psychosocial impact of psoriasis on patientsDetermine when to refer a patient with psoriasis to a dermatologist
4 Psoriasis: The BasicsPsoriasis is a chronic multisystem disease with predominantly skin and joint manifestationsAffects approximately 2% of the U.S. populationAge of onset occurs in two peaks: ages and ages 50-60, but can be seen at any ageThere is a strong genetic componentAbout 30% of patients with psoriasis have a first-degree relative with the diseaseWaxes 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 pruriticInverse/Flexural: lesions are located in the skin foldsGuttate: presents with drop lesions, 1-10mm salmon-pink papules with a fine scaleErythrodermic: generalized erythema covering nearly the entire body surface area with varying degrees of scalingPustular: 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 solesClinical findings in patients frequently overlap in more than one categoryDifferent types of psoriasis may require different treatment
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 redAssociated with fever, chills, and malaiseLike pustular psoriasis, hospitalization is sometimes requiredSee 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 PsoriasisWell-demarcated plaques with overlying silvery scale and underlying erythemaChronic plaque psoriasis is typically symmetric and bilateralPlaques may exhibit:Auspitz sign (bleeding after removal of scale)Koebner phenomenon (lesions induced by trauma)
18 Plaque Psoriasis: The Basics Plaque psoriasis is the most common form, affecting 80-90% of patientsApproximately 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 scaleSkin proliferation is caused by cytokines released by immune cellsSystemic treatments of psoriasis target these cytokines and immune cells
21 Case One: HistoryHPI: 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 1What elements in the history are important to ask when considering the diagnosis of psoriasis?Family historyMedicationsRecent illnesses / Past medical historySocial historyAll 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 historyMedicationsRecent illnesses / Past medical historySocial historyAll of the above
24 Ask About Past Medical History Psoriasis can be triggered by infections, especially streptococcal pharyngitisPsoriasis can be more severe in patients with HIVUp to 20% of psoriasis patients have psoriatic arthritis, which can lead to joint destructionThere is a positive correlation between increased BMI and both prevalence and severity of psoriasisPatients 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 withdrawalBeta blockersLithiumAntimalarialsInterferons
26 Ask About Family History There is a strong genetic predisposition to developing psoriasis1/3 of psoriasis patients have a positive family historyHowever, 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 psoriasisAlcohol consumption is more prevalent in patients with psoriasis and it may increase the severity of psoriasisA 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 OneMr. Ronald GilsonTwenty-one year-old man with red lesion around his umbilicus
29 Case One: History Continued PMH: no major illnesses or hospitalizationsMedications: noneAllergies: noneFamily history: adopted, unknownSocial history: lives with roommates in an apartment, graduate student in physicsHealth-related behaviors: no tobacco or drug use, consumes 3-6 beers on weekendsROS: negative
30 Psoriasis: Clinical Evaluation Although you should perform a total body skin exam, plaque psoriasis tends to appear in characteristic locationsKey Areas: scalp, ears, elbows and knees (extensor surfaces), umbilicus, gluteal cleft, nails, and sites of recent traumaObservation 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 umbilicusErythematous 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 evaluationPsoriasis is typically diagnosed on clinical exam because of its characteristic location and appearanceOther conditions to be considered in the patient with chronic plaque psoriasis are:Tinea corporisNummular eczemaSeborrheic dermatitisSecondary syphilisDrug eruption
34 Case Two: HistoryHPI: 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 yearsMedications: topical clobetasol for psoriasis, hydrochlorothiazide for blood pressureAllergies: noneFamily history: mother and father both had psoriasisSocial history: lives with his wife in a house, retiredROS: negative
35 Case Two: Skin ExamLarge erythematous plaque with overlying silvery scale on anterior scalp
36 Case Two: Skin ExamErythematous plaque with overlying silvery scale at the external auditory meatus and behind the earAlso 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 jointsOnychodystrophy: nail pitting and onycholysis
38 Case Two, Question 1Mr. 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 psoriasisPresence of nail pittingUse of clobetasolAll 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 psoriasisPresence of nail pitting (up to 90% of patients with psoriatic arthritis may have nail changes)Use of clobetasolAll of the above
40 Psoriatic Onychodystrophy Nail psoriasis can occur in all psoriasis subtypesFingernails are involved in ~ 50% of all patients with psoriasis.Toenails in 35%Changes include:Pitting: punctate depressions of the nail plate surfaceOnycholysis: separation of the nail plate from the nail bedSubungual hyperkeratosis: abnormal keratinization of the distal nail bedTrachyonychia: rough nails as if scraped with sandpaper longitudinally
41 Psoriatic Arthritis (PsA) Arthritis in the presence of psoriasisA member of the seronegative spondyloarthropathiesSymptoms can range from mild to severeOccurs in percent of patients with psoriasisCan occur at any age, but for most it appears between the ages of 30 and 50 yearsIt is NOT related to the severity of psoriasisFive clinical patterns of arthritis occurMost common is oligoarthritis with swelling and tenosynovitis of one or a few hand jointsFlares 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 visitPsA may appear before the diagnosis of psoriasisIf psoriatic arthritis is diagnosed, treatment should be initiated to:Alleviate signs and symptoms of arthritisInhibit structural damageMaximize quality of lifeDiagnosis is based on clinical judgmentSpecific 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 PsADesquamation of the overlying skin as well as joint swelling and deformity (arthritis mutilans) of both feetSwelling of the PIP joints of the 2-4th digits, DIP involvement of the 2nd digit
45 Case Three: HistoryHPI: 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 hospitalizationsMedications: occasional multivitaminAllergies: noneFamily history: noncontributorySocial history: lives in the city with her parents and attends high schoolHealth-related behaviors: no tobacco, alcohol, or drug useROS: slight pruritus
46 Case Three: Skin ExamErythematous plaques with overlying silvery scale on the extensor surface of the knee.
47 Case Three, Question 1Which of the following would you recommend to start treatment for Ms. Hagerty’s psoriasis?Biologic (immunomodulators)High potency topical steroidLow potency topical steroidSystemic steroidsTopical 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 steroidLow potency topical steroidSystemic steroidsTopical antifungal
49 Psoriasis: TreatmentSince the psoriasis is localized (less than 5% body surface area), topical treatment is appropriateFirst 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 psoriasisSite and extent of psoriasis:localized = <5% of BSAgeneralized = diffuse or >30% involvementPrevious treatmentOther medical conditions
51 Psoriasis: TreatmentPatients with localized plaque psoriasis can be managed by a primary care providerPsoriasis of all other types should be evaluated by a dermatologist
52 Psoriasis: Topical Treatment MedicationUses in PsoriasisSide EffectsTopical steroidsPlaque-type psoriasisSkin atrophy, hypopigmentation, striaeCalcipotriene(Vitamin D derivative)Use in combination with topical steroids for added benefitSkin irritation, photosensitivity (but no contraindication with UVB phototherapy)Tazarotene(Topical retinoid)Plaque-type psoriasis. Best when used with topical corticosteroids.Skin irritation, photosensitivitySalicylic or Lactic acid(Keratolytic agents)Plaque-type psoriasis to reduce scaling and soften plaquesSystemic absorption can occur if applied to > 20% BSA. Decreases efficacy of UVB phototherapyCoal tarSkin irritation, odor, staining of clothesCalcineurin inhibitorsOff-label use for facial and intertriginous psoriasisSkin burning and itching
53 Clinical PearlTopical medications for psoriasis are more effective when used with occlusion which allows for better penetrationA bandage, saran-wrap, gloves, or socks placed over the medication can serve this purpose
54 Case Three, Question 2What would be an appropriate treatment if a patient had presented with this skin exam?Systemic steroidTopical steroidTopical steroid and systemic steroidTopical steroid and UV light therapyAll 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 steroidTopical steroidTopical steroid and systemic steroidTopical steroid and UV light therapyAll 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 treatmentMany patients with moderate to severe psoriasis are only given topical therapy and experience little treatment successUndertreating the patient can lead to a loss of hope regarding their diseaseOral 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, cyclosporineBiologic Agents: T- cell blocker (alefacept), TNF-α inhibitors (infliximab, etanercept, adalumimab), IL 12/23 blocker (ustekinumab)
58 Systemic TreatmentThe choice of systemic therapy depends on multiple factors:convenienceside effect risk profilepresence or absence of psoriatic arthritisco-morbiditiesSystemic 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 experienceFind out the patients’ views about their diseaseAsk the patient how psoriasis affects their daily livingAsk about symptoms such as pain, itching, burning, and dry skinAsk patients about their experience with previous treatmentsImportant to ask patients about their hopes and expectations for treatmentProvide time for patients to ask questions
60 Psoriasis and QOLPsoriasis is a lifelong disease and can affect all aspects of a patient’s quality of life (QOL), even in patients with limited skin involvementRemember to address both the physical and psychosocial aspects of psoriasisMany patients with psoriasis:Feel socially stigmatizedHave high stress levelsAre physically limited by their diseaseHave higher incidences of depression and alcoholismStruggle with their employment status
61 Take Home PointsPsoriasis is a chronic multisystem disease with predominantly skin and joint manifestationsAbout 1/3 of patients with psoriasis have a 1st-degree relative with psoriasisDifferent types of psoriasis are based on morphology: plaque, guttate, inverse, pustular, and erythrodermicPlaque psoriasis is the most common, affecting 80-90% of patientsA detailed history should be taken in patients with psoriasisPlaque psoriasis is often diagnosed clinicallyNail disease is common in patients with psoriasis
62 Take Home PointsHealth care providers are encouraged to actively seek signs and symptoms of psoriatic arthritis at each visitTopical treatment alone is used when the psoriasis is localizedPatients with moderate to severe disease often require systemic treatment in addition to topical therapySystemic treatment includes phototherapy, oral medications and biologic agentsOral steroids should never be used in psoriasisA successful treatment plan should include patient education as well as provider awareness of the patient’s experiencePsoriasis is a lifelong disease and can affect all aspects of a patient’s quality of life
63 AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup fromPrimary 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 ModuleAbdelaziz 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 ModuleJames 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.