1. More than Skin Deep: Clinician Education to Improve the Diagnosis and Therapeutic Management of Psoriasis in Female Patients
Association of Reproductive Health Professionals

2. Learning Objectives
Describe the current epidemiology and the various types of psoriasis through the reproductive lifespan among women in the US
Identify knowledge gaps about the diagnosis and treatment of psoriasis and discuss medications used to treat psoriasis in women
Apply counseling and patient education techniques to facilitate discussions that support sexual and psychosocial health in women with psoriasis
Select appropriate treatment strategies to manage psoriasis in women across their reproductive lifespan
Talking Points:
Shown here are the learning objectives for this program.

3. Psoriasis Overview

4. What is Psoriasis?
Chronic, relapsing and remitting inflammatory skin disease
Variable morphology, distribution, severity, and course
Classic presentation of well circumscribed, circular red plaques with grey or silvery-white, dry scales
Multifactorial in origin
Genetic susceptibility
Immune dysfunction
Environmental triggers
Associated with considerable physical, emotional, and social burden and impaired QoL
Treatment usually lifelong and aimed at remission, symptom control
Talking Points:
Psoriasis is a chronic, relapsing and remitting inflammatory skin disease that occurs worldwide and affects men and women of all ages.
This papulosquamous disease can be highly variable in morphology, distribution, severity and course.
The lesions of psoriasis are distinct from other papulosquamous diseases, and the classic presentation is well circumscribed, circular red plaques with grey or silvery-white, dry scales. In addition, the lesions are typically distributed symmetrically on the scalp, elbows, knees, lumbosacral area, and in the body folds.
The etiology of psoriasis remains unclear, although there is evidence for genetic susceptibility and immune dysfunction, and can also be provoked by external and internal triggers, including mild trauma, sunburn, infections, systemic drugs, and stress.
Psoriasis is associated with great physical, emotional, and social burden, and general quality of life is often significantly impaired.
Unfortunately, there is still no cure for psoriasis, and treatment of this disease is still based on symptom control.
Topical and systemic therapies and phototherapy are available treatment options, and a combination of these methods is often employed.
The need for treatment is usually lifelong and aimed at remission.
World Health Organization 2016; Raychaudhuri SK, et al. Autoimmun Rev. 2014;13: ; Langley RGB, et al. Ann Rheum Dis. 2005;64(Suppl II):ii18-ii23.

5. Severity of Psoriasis MILD <3% BSA affected MODERATE
Talking Points:
This graphic illustrates the 3 categories of psoriasis severity: mild (<3% BSA affeced), moderate (3-10% BSA affected), and severe (>10% BSA affected).
The red patches denote the typical areas affected.
MILD
<3% BSA affected
MODERATE
3-10% BSA affected
SEVERE
>10% BSA affected
BSA=body surface area
Surface area of palm, including the thumb, equals approximately 1% of BSA
National Psoriasis Foundation.

6. Etiology of Psoriasis
Multifactorial disease with incompletely understood genetic, immunological, and environmental contributors
Specific genes predispose to psoriasis and impact immune system to trigger inflammatory response
Family history of psoriasis increases risk
Environmental triggers
Stress, tobacco, alcohol, obesity, infections, hormonal changes, injury to skin
Talking Points:
Psoriasis is thought to have multiple contributing factors, including genetic, immunological, and environmental.
Specific genes, believed to predispose individuals to psoriasis, impact the immune system to trigger an inflammatory response.
Results from population studies suggest a higher incidence of psoriasis in first- and second-degree relatives of patients than in the general population.
A number of environmental factors can trigger psoriasis, including stress, tobacco, alcohol, obesity, infections, hormonal changes, and injury to the skin.
Boehncke W-H, Schon MP. Psoriasis. Lancet. 2015;386(9997):983–94.
Ayala-Fontánez N, et al. Psoriasis: Targets and Therapy. 2016:6:7-32l; Boehncke W-H, Schon MP. Lancet. 2015;386:

7. Pathophysiology of Psoriasis
Normally, days required to produce new skin cells and shed old ones
In psoriasis, new skin cells generated every
3-4 days
Immunopathogenic mechanisms of psoriasis involve compleax interactions between innate
and adaptive immune systems
Innate immune cells produce key cytokines that activate dendritic cells and perpetuate inflammatory cascade
Activated dendritic cells release mediators (IL-12, IL-23), leading to differentiation of helper T cells
T cells infiltrate epidermis and secrete mediators that activate keratinocytes  abnormal proliferation and differentiation of keratinocytes
Increased interest in IL-23/Th17 axis has led to development of several novel targeted therapies
Talking Points:
Under normal circumstances, the skin rejuvenates about every days to produce new skin cells and shed old ones.
In psoriasis, new skin cells are generated about every 3-4 days, with a buildup of excess dead skin cells on the surface.
It appears that innate and adaptive immune responses contribute to the complex inflammatory process underlying psoriasis.
Initial triggers such as physical trauma or bacterial products start a cascade of events that include the formation of DNA–LL-37 complexes, activation of plasmacytoid dendritic
cells, and secretion of IFN-α.
Studies have supported the concept that interactions between dendritic cells, T cells, keratinocytes, neutrophils, and cytokines released from immune cells likely contribute to the initiation and perpetuation of the cutaneous inflammation that is characteristic of psoriasis.
Innate immune cells produce key cytokines (TNF-, IFN-, IL-6) that activate myeloid dendritic cells and perpetuate the inflammatory cascade.
These activated dendritic cells present antigens and release mediators such as IL-12 and IL-23, leading to differentiation of helper T cells (Th17 and Th1).
T cells infiltrate the epidermis and secrete mediators (eg, IL-17, IL-22) that activate keratinocytes. Abnormal proliferation and differentiation of keratinocytes contribute to the characteristic lesion thickening and scaling of psoriasis.
Increased interest in the IL-23/Th17 axis in psoriasis has resulted in the development of several novel targeted therapies.
Nestle FO, et al. N Engl J Med. 2009;361: ; Boehncke W-H, Schon MP. Lancet. 2015;386:

8. Epidemiology of Psoriasis
Approximately 7.5 million Americans have psoriasis
Affects 2-3% of US population and men and women equally
Prevalence between 1.5% and 5%; may be on the rise
Prevalence highest among Caucasians (3.6%)
Primarily seen in adults but occurs in all age groups
Mean age of onset ranges from years of age
Second peak at years of age
Significant number of women develop psoriasis during reproductive years
80% of patients have mild-to-moderate disease; 20% have moderate-to-severe disease
Substantial economic burden in US
Annual cost in 2013 approximately $112 billion
Talking Points:
Psoriasis is one of the most prevalent immune-mediated skin diseases in adults, and approximately 7.5 million people in the US have psoriasis.
This disease affects 2-3% of the US population, and men and women appear to be affected equally.
In most developed countries, prevalence is between 1.5 and 5%. There is also evidence to suggest that the prevalence of psoriasis may be increasing.
The prevalence of psoriasis is highest in Caucasians (3.6%), compared with 1.9% in Blacks and 1.6% in Hispanics.
Psoriasis occurs in all age groups, but is seen primarily in adults.
The mean age of onset ranges from years of age, with a second peak in persons years of age.
Although women may develop psoriasis at different ages, a significant number of women develop this disease during their reproductive years.
During a woman’s reproductive years, multiple physiologic changes that occur during pregnancy influence the development of psoriasis and affect its clinical expression.
Approximately 80% of patients with psoriasis have mild-to-moderate disease, whereas about 20% have moderate-to-severe disease.
The economic burden of psoriasis in the US is substantial, although the total cost is unknown.
In 2013, the annual US cost of psoriasis amounted to approximately $112 billion.
Menter A, et al. J Am Acad Dermatol. 2008;58: ; World Health Organization 2016; Brezinski EA, et al. JAMA Dermatol. 2015;151:

9. Forms of Psoriasis Plaque Guttate Inverse Pustular
Most common form of disease; well-demarcated, raised red patches with silvery-white scales. Plaques most often appear on knees, elbows, trunk, lumbosacral area, scalp, feet, hands.
Guttate
Abrupt eruption of psoriasis characterized by teardrop-shaped papules. Often starts in childhood or young adulthood and can be triggered by a strep infection.
Inverse
Painful, well-demarcted, symmetric, erythematous plaques in body folds, such as behind knee, under arm, in groin, or under breasts. May appear smooth and shiny.
Talking Points:
Forms of psoriasis are typically identified by their hallmark appearance.
Let’s take a look at the major forms of psoriasis and the major characteristics of each.
Pustular
Small, pus-filled bumps appear on preexisting plaques. Not an infection and not contagious.

10. Forms of Psoriasis (Cont’d.)
Erythrodermic
A rare and particularly severe form that leads to widespread, fiery redness over most of the body. Can cause severe itching and pain and cause skin to come off in sheets.
Sebopsoriasis
Overlap between psoriasis and seborrheic dermatitis that appears as red bumps and plaques with greasy yellow scale. Typically located on face and scalp.
Nail
Mostly occurs in persons with clinically evident psoriasis. Nails may be discolored, have ridges, grooves or pitting on nail surface, become thickened, and separate from nailbed.
Psoriatic Arthritis
An inflammatory form of psoriasis that involves joints. Variable clinical symptoms, but common ones include peripheral arthritis, spondylitis, arthritis of fingers, and dactylitis.

11. Female Genital Psoriasis
Typically affects labia majora but not mucous membranes; may also affect anus and surrounding skin
Lesions present as well-demarcated, brightly erythematous, thin plaques without scaling
Most characteristic symptom is itching
Often misdiagnosed as sexually transmitted disease or allergic reaction
Profoundly affects QoL and sexual health
Study of 487 patients with genital psoriasis
Patients with genital lesions reported significantly worse QoL than those without
Sexual distress and dysfunction particularly prominent in women when genital skin affected
Talking Points:
Since our focus is on psoriasis in females, an explanation of genital psoriasis is indicated.
Genital psoriasis is generally the inverse type of psoriasis.
In females, the outer skin of the vagina is typically affected, but not the mucous membranes. This type of psoriasis may also appear on the anus and surrounding regions.
In females, genital psoriasis lesions are well-demarcated, brightly erythematous, thin plaques that usually lack the scales associated with plaque psoriasis.
The most characteristic symptom of genital psoriasis is itching. Scratching this area may cause an infection, creating dryness and resulting in thickening of the skin and further itching.
Genital psoriasis is often misdiagnosed as a sexually transmitted disease or an allergic reaction due to the low awareness of this type of psoriasis.
While taking a patient’s history, it is relevant to ask in detail about psoriasis in the family, patient’s sexual activity, and skin lesions in other areas.
Genital psoriasis is considered an embarrassing condition and is often misjudged as a sexually transmitted disease or allergic reaction due to low social awareness of the disease
As you might imagine, genital psoriasis has a profoundly negative effect on the individual’s quality of life and overall sexual health.
A study on the quality of life and sexual health of 487 patients with genital psoriasis found that:
Patients with genital lesions report even significantly worse quality of life than patients without genital lesions
Sexual distress and dysfunction are particularly prominent in women
Sexual distress is especially high when genital skin is affected
Czuczwar P, et al. Ginekologia Polska. 2016;87: ; Ryan C, et al. J Am Acad Dermatol. 2015;72: ; Meeuwis KAP, et al. Br J Dermatol. 2011;164:

12. Common Symptoms of Psoriasis
Symptoms of psoriasis depend on type
Common symptoms:
Itching
Dry, cracked skin
Skin pain
Scaly scalp
Pitted, cracked, or crumbly nails
Joint pain

13. Common Comorbidities in Patients With Psoriasis
Cardiovascular disease
Inflammatory bowel disease (IBD)
Metabolic syndrome (obesity, hypertension, dyslipidemia, diabetes mellitus)
Cancer
Obesity
Non-alcoholic fatty liver disease (NAFLD)
Chronic obstructive pulmonary disease (COPD)
Depression
Sleep apnea
Talking Points:
Individuals with psoriasis and psoriatic arthritis are at an elevated risk of developing a number of serious conditions.
Research continues to link psoriasis and psoriatic arthritis with an increased risk for cardiovascular disease, especially in people with severe psoriasis.
In people with severe psoriasis, 58% percent are more likely to have a major cardiac event and 43% more likely to have a stroke, according to one study.
There is an apparent connection between psoriasis, psoriatic arthritis, and IBD, and individuals with psoriatic disease and Crohn’s disease share similar genetic mutations.
In a recent study of women with psoriasis, 10% developed a form of IBD (Crohn’s disease or ulcerative colitis).
A significant association has been determined between psoriatic disease and metabolic syndrome---a cluster of the 4 conditions cited on the slide.
A national sample of 6500 people found that 40% of those with psoriasis had metabolic syndrome, compared with just 23% of the general population. More women than men had metabolic syndrome.
A number of studies have found that people with psoriasis and psoriatic arthritis have an increased risk of certain types of cancer, such as lymphoma and nonmelanoma skin cancer.  No single treatment appears to significantly raise the risk of cancer, suggesting that the disease itself raises the risk.
Research has indicated for some time that individuals with psoriatic disease are more likely to be obese than the normal population, and ongoing studies continue to examine the relationship between the two.
NAFLD is found to be highly prevalent among psoriasis patients, where it is closely associated with obesity and metabolic syndrome.
A higher prevalence of COPD has been shown in patients with psoriasis.
Psoriasis and psoriatic arthritis can cause considerable emotional distress for people, including low self-esteem, and an increased chance of mood disorders, such as depression.
The prevalence of depression is thought to be as high as 60%, and depression may be severe enough that some patients will contemplate suicide.
Some studies have found that the frequency of sleep apnea is higher in patients with psoriasis than the normal population.
Gottlieb AB, et al. Am J Med. 2009;e1-9; National Psoriasis Foundation 2016; Kilic A, Cakmak S. Eur Med J Dermatol. 2013;1:78-85; Menter A, et al. J Am Acad Dermatol. 2008;58:

14. Making a Psoriasis Diagnosis
Thorough medical history and physical exam
Possible skin biopsy
Differential diagnosis
Atopic dermatitis (eczema)
Seborrheic dermatitis
Lichen planus
Ringworm (tinea corporis)
Pityriasis rosea
Talking Points:
In most cases, a dermatologist or primary care physician can diagnose psoriasis by examining the skin.
It is important to obtain a thorough medical history and determine whether there is any family history of psoriasis.
In rare instances, taking a small sample of skin for a biopsy may be indicated to determine the exact type of psoriasis and to rule out other disorders.
In some cases, psoriasis can resemble other skin diseases, such as those listed here, which makes a definitive diagnosis of psoriasis more difficult.
Atopic dermatitis (eczema) – A chronic condition of itchy, red, and dry skin caused by inflammation; tends to flare periodically and then subside.
Seborrheic dermatitis – Characterized by greasy, scaly, itchy, red skin; found on oily areas of the body such as the face, upper chest, back, and scalp.
Lichen planus – Inflammatory, itchy skin condition that appears as rows of flat-topped lesions on arms and legs.
Ringworm (tinea corporis) – A type of fungal infection that often causes as red, scaly ring or circular rash.
Pityriasis rosea – Common skin condition that usually begins as one large spot (herald patch) on the chest, abdomen, or back, and often speads. Rash of pityriasis rosea often
extends from the middle of the body and its shape resembles drooping pine tree branches.

15. Psoriasis Treatment Options

16. Treatment Categories Topical Phototherapy Systemic Talking Points:
Treatments for psoriasis fall into one of these 3 categories: topical, phototherapy, and systemic.
Let’s take a closer look at each of these treatment categories.
Systemic

17. FDA Pregnancy Categories
Category A
Adequate and well-controlled studies have failed to demonstrate a risk to the fetus
in any trimester.
Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.
Category C
Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Category D
Use of the drug in pregnant women demonstrates risk to the human fetus, but potential benefit to the mother may outweigh risk to the fetus.
Talking Points:
Since we are talking about treatment of psoriasis in women of reproductive age, it is worth noting the FDA pregnancy categories for drugs.
Category X
Studies in animals or humans have demonstrated fetal abnormalities and the potential risk to the fetus outweighs the risk to the mother.

18. Topical Therapy
Majority of patients have mild-to-moderate disease and can be treated with topical therapy
Use of topical agents intermittent and long-term
Topical corticosteroids cornerstone of psoriasis treatment
Mechanisms of action: antiinflammatory, antiproliferative, immunosuppressive, vasoconstrictive
Range in strength from low-potency OTC preparations (1% hydrocortisone) to high-potency preparations (eg, clobetasol propionate)
Considerations for potency choice and vehicle
Disease severity
Area(s) being treated
Patient preference
Patient age
Lower-potency corticosteroids – limited periods of time on face, areas with thin skin
Mid- or high-potency corticosteroids – initial therapy on other areas of body
Talking Points:
Approximately 80% of patients with psoriasis have mild-to-moderate disease and can be treated with topical agents, which generally provide a high efficacy-to-safety ratio.
Use of topical agents can be both intermittent and long-term. In general, it is recommended that more potent agents be used on a short-term basis to allow
for response, after which patients should be instructed to use these agents intermittently for long-term management.
Topical agents may also be used adjunctively for patients with more extensive psoriasis undergoing therapy with phototherapy or systemic medications.
Topical corticosteroids are considered the cornerstone of treatment for the majority of patients with psoriasis.
The mechanisms of action of corticosteroids include anti-inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects.
These effects are mediated through their binding to intracellular corticosteroid receptors and regulation of gene transcription of numerous genes, particularly those that code for proinflammatory cytokines.
These agents are available in many strengths and formulations, which allows for versatility of use.
The choice of the appropriate potency corticosteroid and its vehicle should take into consideration the disease severity, areas being treated, patient preference, as well as the age of the patient.
Lower-potency corticosteroids should generally be used for limited periods of time on the face, intertriginous areas, and areas with thin skin. In other areas, mid- or high-potency
agents are generally recommended as initial therapy. Patients with thick, chronic plaques often require treatment with the highest potency corticosteroids.
Menter A, et al. J Am Acad Dermatol. 2009;60:

19. Topical Corticosteroids: Safety and Efficacy
Use in Pregnancy
Pregnancy Category C
Women who are pregnant or actively trying to conceive should be counseled about risks/benefits of topical agents.
Local AEs
Skin atrophy, telangiectasia, striae, purpura, contact dermatitis, rosacea
Systemic AEs
Hypothalamic-pituitary-adrenal axis suppression (mid- and high-potency corticosteroids)
Class I corticosteroids
Limit to 2-4 weeks of continuous use
May be used long term as long as breaks are taken (eg, use Mon-Fri with break on weekends)
May use an alternate steroid-sparing therapy on non-steroid days (eg, Vitamin D-derived cream calcipotriene, calcipotriol)
Maximal weekly use for clobetasol and halobetasol: 50 g
Talking Points:
Some of the pertinent safety and efficacy considerations are cited here for topical corticosteroids.
Since we are focusing on the female patient with psoriasis, it is important to note that topical corticosteroids have a Category C risk.
Women who are pregnant or actively trying to conceive should be counseled about the risks/benefits of topical agents.
Local adverse events include skin atrophy, telangiectasia, striae, purpura, contact dermatitis, and rosacea.
An important systemic adverse event to be aware of is hypothalamic-pituitary-adrenal axis suppression with mid- and high-potency corticosteroids.
Regarding Class I corticosteroids, these should be limited to 2-4 weeks of continuous use.
These agents are safe to use long term as long as breaks are taken (eg, use Mon-Fri with a break on the weekends).
This dramatically reduces the incidence of side effects and allows us to make sure the patient is adequately treated.
One can use an alternate steroid-sparing therapy on non-steroid days, like a Vitamin-D derived cream (calcipotriene, calcipotriol)
Maximal weekly use for clobetasol and halobetasol is 50 g
Menter A, et al. J Am Acad Dermatol. 2009;60:643-59; Menter A, et al. J Am Acad Dermatol. 2011;65:

20. Phototherapy Recommended for moderate-to-severe psoriasis
May be used in combination with other therapies
UVB radiation, narrow-band UVB, psoralen-UVA (PUVA), excimer laser
PUVA should be avoided during pregnancy (Pregnancy Category C)
Highly effective and lacks systemic toxicities and immunosuppressive properties of systemic oral and biologic treatments; may be preferable option during pregnancy
Local immunosuppression of psoriasis in treated skin
Requires frequent office visits (2-3x/week); may require up to 30 treatments before improvement is seen
Dose-related increased risk of actinic damage and skin cancer
Talking Points:
Phototherapy is recommended for patients with moderate-to-severe psoriasis, and it may be used in combination with other therapies.
UVB phototherapy is most appropriate for patients with >10% of BSA affected who have not responded to topical treatments.
Phototherapy utilizes ultraviolet therapy in the form of ultraviolet B (UVB) radiation, narrow-band UVB, psoralen-ultraviolet A (PUVA), and excimer laser.
It is recommended that PUVA be avoided during pregnancy and has a Pregnancy Category C status.
Excimer lasers aim a high-intensity UVB light dose of 308 nanometers directly at the psoriasis plaques. Eximer lasers are considered appropriate for adults with mild, moderate, or severe psoriasis covering <10% of body.
Shown here is an example of a phototherapy system that might be used to treat a patient with psoriasis.
Phototherapy has been shown to be highly effective and lacks systemic toxicities and immunosuppressive properties of systemic and biologic treatments. As such, phototherapy may be a preferable option during pregnancy.
Local immunosuppression of psoriasis in treated skin may result.
A consideration of phototherapy is the required frequency of office visits, usually 2-3 times per week; up to 30 treatments may be required before improvement is seen.
A precaution is the dose-related increased risk of actinic damage and skin cancer.
Mehta D, Lim HW. Am J Clin Dermatol. 2016;17: ; Bangsgaard N, et al. Am J Clin Dermatol. 2015;16:

21. Features and Precautions
Systemic Therapy
Treatment
Features and Precautions
Methotrexate
Most commonly prescribed systemic therapy for psoriasis
Generally given as single weekly oral dose
Common AEs: nausea, anorexia, stomatitis, fatigue
Risk for hematologic toxicity and hepatotoxicity
Pregnancy Category X
Cyclosporine
Highly effective and rapidly active agent for treatment of psoriasis
Useful in treatment of significant flares or as bridging agent during induction of other therapies
Dosing based on ideal body weight (actual weight in obesity)
Most serious AEs: nephrotoxicity and hypertension
Pregnancy Category C
Acitretin
Generally less effective than other traditional systemic therapies
Has little cumulative toxicity and does not cause immunosuppression
Apremilast
A PDE4 inhibitor approved for moderate to severe psoriasis
Available as a pill; is not a biologic
Has demonstrated efficacy in plaque psoriasis, nail psoriasis, moderate-to-severe scalp psoriasis
Most common AEs: gastrointestinal; associated with increase in depression
Talking Points:
In the past, conventional systemic psoriasis therapies methotrexate, cyclosporine (CSA), and acitretin were used when psoriasis was too extensive for topical therapy or refractory to topical therapy and phototherapy.
Although a minimum BSA (eg, 10%) has been traditionally used as a prerequisite to initiating systemic therapy for psoriasis, a subset of patients with limited disease have debilitating symptoms, making a systemic approach to treatment appropriate.
In recent years, biologics have changed the treatment of psoriasis, giving us additional therapeutic options that are potentially less toxic to the liver, kidneys, and bone marrow and are not teratogenic. Nevertheless, traditional systemic therapies continue to play an important role in the treatment of psoriasis, with their oral route of administration and relatively low cost (compared with biologics) making them an important treatment option in the appropriate patient.
Methotrexate is the most commonly prescribed traditional systemic therapy worldwide for psoriasis.
This drug was approved by the FDA in 1972, which was prior to the acceptance of prior to the standard of randomized clinical trials as the standard for efficacy.
Methotrexate is generally given as a single weekly oral dose.
Common and generally minor toxicities include nausea, anorexia, stomatitis, and fatigue---most often occur at the time of administration.
Methotrexate is associated with hematologic toxicity and hepatotoxicity---the hepatotoxicity may warrant liver biopsy consideration.
Methotrexate is an abortifacient and a teratogen. It is FDA pregnancy category X and is absolutely contraindicated in women attempting to conceive.
Cyclosporine is a highly effective and rapidly acting systemic agent for the treatment of psoriasis.
Due to its rapid onset of action, it is useful in crisis management, as a bridge to other therapies, and in the rapid treatment of psoriasis unresponsive to other modalities.
Suggested dosing is based on ideal body weight; however, obese patients often require dosing based on actual weight.
Most serious side effects are nephrotoxicity and hypertension.
Acitretin is another systemic agent that is generally less effective than other traditional systemic therapies, but has little cumulative toxicity and does not cause immunosuppression.
The efficacy of acitretin is dose dependent
Teratogenicity is the most important safety issue, with acitretin having a Category X rating.
Apremilast is a relatively new systemic agent that is approved for the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis.
This agent is a PDE4 inhibitor and is available as a pill. It is not a biologic agent.
In addition to showing efficacy in plaque psoriasis of the trunk and extremities, apremilast has also shown efficacy for nail psoriasis and moderate-to-severe scalp psoriasis,
and has demonstrated marked and rapid reduction in pruritus associated with plaque psoriasis.
The most common AEs of apremilast are gastrointestinal in nature.
Treatment with apremilast is associated with an increase in adverse reactions of depression.
It is Pregnancy Category C.
AEs=adverse events; PDE4 = phosphodiesterase-4
Menter A, et al. J Am Acad Dermatol. 2009;61: ; Otezla (apremilast) Full Prescribing Information

22. No human data on use in pregnant women
Biologic Therapy
Typically implemented when one or more traditional systemic agents fail, are poorly tolerated, or contraindicated
Indicated for moderate-to-severe psoriasis and psoriatic arthritis
Target specific components of immune system
Given by injection or intravenous infusion
Biologic
FDA Approval*
Administration
Pregnancy Category
Etanercept
2004
Injection B
Infliximab
2006
IV infusion
Adalimumab
2008
Ustekinumab
2009
Secukinumab
2015
Ixekizumab
2016
No available data
Brodalumab
2017
No human data on use in pregnant women
Talking Points:
The introduction of biologic therapies in the last decade have changed the treatment landscape of psoriasis and provided additional therapeutic options.
The biologics are typically implemented when one or more traditional systemic agents fail, are poorly tolerated, or are contraindicated.
These agents are indicated for moderate-to-severe psoriasis and psoriatic arthritis.
They target specific components of the immune system and are given by injection or intravenous (IV) infusion.
This table shows the FDA-approved biologic agents for psoriasis, when they were approved, and their pregnancy category.
*For plaque psoriasis

23. Psoriasis Treatment Targets
Preferred assessment in clinical practice
BSA
Acceptable response after
treatment initiation
Either BSA 3% or BSA improvement 75% from baseline at 3 mos after treatment initiation
Target response after treatment initiation
BSA 1% at 3 mos after treatment initiation
Target response during maintenance therapy
BSA 1% at every 6-month assessment intervals during maintenance therapy
Talking Points:
A recent publication on the treatment targets of plaque psoriasis, based on a consensus-building study of 25 psoriasis experts by the National Psoriasis Foundation (using the Delphi method), indicated that the preferred assessment instrument in clinical practice is body surface area (BSA).
The US experts agreed that the acceptable response after treatment initiation should be either a BSA of 3% or less OR BSA improvement 75% or greater from baseline at 3 months after treatment initiation.
Target response after treatment initiation should be BSA 1% or less at 3 months after treatment initiation.
Target response at every 6-month assessment during maintenance therapy should be BSA 1% or less.
BSA=body surface area
Armstrong AW, et al. J Am Acad Dermatol. 2017;76:

24. Management of Psoriasis in Females Across the Lifespan

25. Important Considerations Related to Reproductive Status
Do oral contraceptives have an effect on psoriasis?
Do any medications adversely affect conception and fetal development?
Does genital psoriasis affect the ability to conceive or have vaginal intercourse?
What are the effects of psoriasis on pregnancy?
Which drugs can be used safely during pregnancy?
Which drugs can be used to control psoriasis while breastfeeding?
Do the hormonal changes associated with menopause influence the course of psoriasis?
Talking Points:
Here are several noteworthy questions related to female reproductive status for clinicians who treat women with psoriasis to consider, particularly those women who are thinking about becoming pregnant.
These issues will be addressed in this section.

26. Psoriasis and Conception/Contraception
Important to discuss pregnancy plans with patients of childbearing potential
For planned pregnancies, may choose to time treatments so only minimal treatment required during pregnancy
Most systemic medications require discontinuation before trying to conceive
Methotrexate
Tazarotene
Acitretin (requires 3-year washout period before conception)
Isotretinoin
Women must sign informed consent form prior to starting therapy
Pregnancy test each month of therapy before refilling prescription
Women must use 2 reliable forms of birth control simultaneously, 1 month before/during/after isotretinoin
Women must receive verbal and written warnings about pregnancy avoidance during isotretinoin therapy and for 2 months following treatment discontinuation
Limited data in medical literature supporting psoriasis skin changes with hormonal contraception
Talking Points:
It is very important for clinicians to ask their patients of childbearing potential about plans to become pregnant.
For patients with psoriasis who are planning to become pregnant, it is vital to discuss with them which medications to avoid while trying to conceive and timing treatments so that only minimal treatment is required during pregnancy.
For example, a woman who experiences remissions that average 1 year following a course of PUVA can plan to finish her most recent course before attempting to conceive.
Most systemic medications require discontinuation before trying to conceive.
Methotrexate should be discontinued at least 12 weeks before trying to conceive.
Retinoids like tazarotene, acitretin, and isotretinoin have been linked to birth defects and should also be discontinued before trying to become pregnant.
Women of childbearing age who take acitretin must use reliable methods of birth control during treatment and wait 3 years after discontinuing the medication to become pregnant.
Specific precautions surrounding the use of isotretinoin are listed here also.
There are limited data in the medical literature that support psoriasis skin changes with the use of hormonal contraception.
National Psoriasis Foundation. 2016; Robertson J, et al. Birth Defects Res A Clin Mol Teratol. 2005;73:

27. Genital Psoriasis and Conception
Genital psoriasis can cause irritation and discomfort during intercourse
Psoriasis flare may be exacerbated by sex, due to friction
Patients may avoid sexual activity
Important to treat genital psoriasis and help patients work through emotional distress
Advise patients to cleanse affected area and reapply medications or emollients after intercourse
Talking Points:
Genital psoriasis can cause irritation and discomfort during intercourse, which may affect a patient’s interest in having sex and in turn, becoming pregnant.
Unfortunately, patients with genital psoriasis may avoid sexual activity. Like any other form of psoriasis, it is important to treat genital psoriasis and also to help patients work through the emotional distress associated with this form.
Advising patients with genital psoriasis to cleanse the affected area and reapply medications or emollients after intercourse will help avoid added discomfort to the genital area.

28. Psoriasis and Pregnancy and Birth Outcomes
>100,000 births estimated to occur annually in women with psoriasis
Course of psoriasis during pregnancy unpredictable and variable
Uncontrolled inflammation and cytokine excess in psoriasis can influence pregnancy course
Approximately 50% of women experience clinical remission during pregnancy; others may have no change or worsening
Literature analysis examined psoriasis and adverse pregnancy outcomes
Outcomes included spontaneous abortion, cesarean delivery, low birth weight, macrosomia, large for gestational age, composite outcome of prematurity and low birth weight
Talking Points:
It is estimated that over 100,000 deliveries occur annually in women with psoriasis.
The course of psoriasis during pregnancy is unpredictable and variable.
The uncontrolled inflammation and excess of cytokines inherent in psoriasis can influence the course of pregnancy.
Sex hormores, especially estrogen and prolactin, have an important role in modulating the immune response.
Approximately 50% of women experience a clinical remission of their psoriasis during pregnancy, while others may have a worsening of their disease and still others may experience no change.
Hormonal changes in pregnancy may play a role in improving psoriasis by promoting a state of immune tolerance.
A systematic literature review that examined psoriasis and adverse pregnancy outcomes (included observational studies and clinical trials) determined that almost half of the included studies detected an association between psoriasis and an adverse pregnancy outcome in women with psoriasis.
Outcomes included spontaneous abortion, cesarean delivery, low birth weight, macrosomia, large for gestational age, composite outcome of prematurity, and low birth weight.
Associations were not always consistent across studies.
Future research should include large cohort studies with multivariate modelling.
Kurizky PS, et al. An Bras Dermatol. 2015;90: ; Bangsgaard N, et al. Am J Clin Dermatol. 2015;16: ; Murase JE, et al. Arch Dermatol. 2005;141: ; Bobotsis R, et al. Br J Dermatol. 2016;175:

29. Psoriasis Treatment in Pregnancy
First-line
Moisturizers and emollients
Low- to mid-potency topical steroids
High-potency topical steroids only as needed in 2nd and 3rd trimesters
Second-line
Narrowband UVB or broadband UVB
Talking Points:
This algorithm provides the suggested sequence psoriasis treatment in pregnancy, using a step-like approach.
Topical treatments, including emollients and low- to midpotency topical steroids, are considered safe in pregnancy.
Higher-potency steroids could be considered next, but should be reserved for second or third trimesters if possible.
Narrowband UVB or broadband UVB is recommended as second-line therapy for patients who fail to improve with topical treatments.
For patients who do not respond to phototherapy, systemic corticosteroids in the later trimesters can be used, but with caution given the potential for rebound flare on withdrawal.
Cyclosporine and TNF- inhibitors may be considered as alternative approaches, all with close medical monitoring.
It is always preferable to avoid systemic medications during the first trimester.
Third-line
TNF- inhibitors
Cyclosporine
Systemic steroids in impetigo herpetiformis
(2nd and 3rd trimesters only)
Bae Y-S, et al. J Am Acad Dermatol. 2012;67:

30. Psoriasis Medications According to FDA Pregnancy Category
Category B Drugs
Category D Drugs
Category X Drugs
No risks have been found in humans
Positive evidence of human fetal risk; potential benefits may warrant use of drug in pregnant women
Positive evidence of human fetal risk; risks involved in use of drug in pregnant women clearly outweigh potential benefits
TNF- inhibitors
Etanercept
Adalimumab
IL-12/IL-23 inhibitors
Ustekinumab
IL-17 inhibitors*
Sekukinumab
Mycophonolate mofetil
Topical/systemic retinoids
Tazarotene
Acitretin
Etretinate
Methotrexate
PUVA photochemotherapy
Talking Points:
This table lists specific psoriasis therapies and their assigned Pregnancy Category.
Of note, in 2015, the FDA replaced the former pregnancy risk letter categories on prescription and biological drug labeling with new information to make them more meaningful to patients and healthcare providers.
Prescription drugs submitted for FDA approval after June 30, 2015 use the new format, while labeling for prescription drugs approved on or after June 30, 2001 will be phased in gradually. Medications approved prior to June 29, 2001 are not subject to the new rule; however, the pregnancy letter category must be removed by June 29, 2018.
*No available data yet for ixekizumab and brodolumab; Kurizky PS, et al. An Bras Dermatol. 2015;90: ; Murase JE, et al. Arch Dermatol. 2005;141:

31. Safety of Psoriasis Medications in Lactation
Drug
Safety in Lactation
Acitretin
Excreted in breast milk in trace amounts
Topical tretinoin
No data on amounts excreted in breast milk
Alitretinoin
Contraindicated
Isotretinoin
Tazarotene
Trace amounts excreted in breast milk
Methotrexate
Excreted in breast milk in low concentrations;
retained in human tissue for months
Cyclosporine
Azathioprine
Risks of breastfeeding outweigh benefits
Infliximab
Little of no detectable amounts in breast milk
Adalimumab
Excreted in breast milk in low concentration
Ustekinumab
No reports of breastfeeding in humans
Talking Points:
Clinicians who treat psoriasis are frequently faced with questions from women who are breastfeeding about the safety of commonly prescribed topical and systemic medications during lactation. Safety data in lactation for some medications used for psoriasis are somewhat limited.
This table lists some of the topical and systemic medications used for treatment of psoriasis and their safety in lactation/breastfeeding.
No known risks are associated with the use of moisturizers.
For women who are lactating, consider topical corticosteroids before systemic corticosteroids when treatment is required.
Advise women who are taking systemic corticosteroids to wait 4 hours after the medication before breastfeeding.
Brown SM, et al Available at: Butler DC, et al. J Am Acad Dermatol. 2014;70:417.e1-10; Bae YSC, et al. J Am Acad Dermatol. 2012;67:

32. Postpartum Psoriasis Flares
Significant potential for postpartum psoriasis flares
40-90% of patients experience worsening of psoriatic symptoms in postpartum period
30-40% of women relate onset of psoriatic arthritis to postpartum period
Therapy
Topical therapy indicated
Biologic therapy may be considered
Some OB/GYNs may not be informed about psoriasis treatment and potential postpartum flares
Physician managing patient's psoriasis must discuss treatment plan with patient and her OB/GYN prior to delivery
Talking Points:
It has been observed that a worsening of psoriatic symptoms occurs when estrogen and progesterone levels drop postpartum.
40-90% of patients with psoriasis experience a worsening of psoriatic symptoms during the postpartum period.
30-40% of women relate the onset of psoriatic arthritis to the postpartum period; pregnancy may act as a triggering factor for the articular disease.
Topical therapy is indicated for this type of flare, although biologic therapy may be considered in the case of extremely flammatory flares.
Since some OB/Gyns may not be as informed about psoriasis treatment and the possibility of postpartum psoriasis flares, it is very important for the physician managing the patient’s psoriasis to discuss the treatment plan with the patient and her OB/GYN prior to the patient’s delivery.
Ceovic R,et al. Biomed Res Int. 2013;2013:

33. Psoriasis Pregnancy Registries
Pregnancy registries track women taking drug therapy during pregnancy
Acitretin
Cyclosporine
Etanercept
Consider enrolling pregnant psoriasis patients or those considering pregnancy in a registry

34. Psoriasis and Perimenopause/Menopause
Natural course of psoriasis modulated by hormonal shifts of menopause
Decreased estrogen concentration in postmenopausal women primary factor in exacerbation of psoriasis flares
High estrogen levels  inhibitory effect on immune system
Low estrogen levels  stimulatory effect on immune system
Reduced estrogen levels lead to insufficient Th1 cell-mediated response inhibition
Study of menopausal women showed psoriasis exacerbation in 48% vs improvement in 2%
Talking Points:
Menopause, like pregnancy or menstruation, modulates the nature course of psoriasis.
A decrease in estrogen during menopause is believed to be a major factor in the occurrence or exacerbation of psoriasis flares in patients already suffering from psoriasis.
Furthermore, reduced estrogen levels are thought to lead to insufficient Th1 cell-mediated response inhibition, playing a major role in the pathogenesis of psoriasis.
In a study conducted by Mowad et al, menopausal women had an exacerbation of psoriasis in 48% of cases, while only 2% showed improvement; 27% of those observed noticed a link between psoriasis and hormonal changes.
Ceovic R,et al. Biomed Res Int. 2013;2013:571912; Mowad CM, et al. Cutis. 1998;61:

35. Psoriasis and Perimenopause/Menopause (Cont’d.)
Caring for menopausal women with psoriasis allows for focused intervention to improve overall health and well-being
Psoriasis severity associated with diabetes, insulin resistance, smoking and higher cardiovascular profile
Metabolic syndrome related to age and menopause, but not psoriasis severity
Higher waist circumference observed among women with psoriasis
Clinicians should openly engage patients in conversations about:
Skin (psoriasis, night sweats, atrophic vaginitis)
Heart (CVD, MI)
Head (CVA, hot flashes sexual pleasure, confidence)
Talking Points:
Given the known increased risk of cardiovascular disease (CVD) with psoriasis and that the leading cause of death among women is CVD, caring for women with psoriasis allows for focused interventions to improve overall health and well-being.
Psoriasis severity is associated with diabetes, insulin resistance, smoking habit, and higher cardiovascular profile.
Metabolic syndrome is related to age and menopause, but not to psoriasis severity.
A higher waist circumference has been observed among women with psoriasis.
It is encumbent on clinicians who care for patients with psoriasis to openly engage patients in conversations about:
Their skin (psoriasis, night sweats, and atrophic vaginitis)
Their heart (CVD, MI)
Their head (CVA, hot flashes, sexual pleasure, confidence)
CVD=cardiovascular disease; MI=myocardial infarction; CVA=cerebrovascular accident; Curcó N, et al. Australas J Dermatol Feb 27. [Epub ahead of print]

36. Additional Considerations for Managing Psoriasis in Women

37. Psychological/Mental Health Impairment
Psoriasis associated with significant psychiatric comorbidity
Prevalence of depression and anxiety markedly higher than general population
High rate of suicidal ideations
Pathological worry and anxiety occur in at least 1/3 of psoriasis patients
Feelings of embarrassment and unattractiveness; altered body image
Frequent mental distress associated with psoriasis more common among women
Induction of inflammatory state can precipitate mood changes, including depressive symptoms
Talking Points:
Psoriasis is associated with a high rate of psychiatric comorbidity, which often goes unrecognized.
The prevalence of depression and anxiety in patients with psoriasis is significantly higher than that observed in the general population.
Patients with psoriasis disclose a higher rate of suicidal ideations than other patients.
Recent work has identified that pathological worry and anxiety occur in at least a third of patients with psoriasis and that psychological interpersonal difficulties impact all aspects of a patient’s daily life.
Moreover, feelings of embarrassment and unattractiveness, as well as altered body image, contribute to the psychological distress that patients with this disease suffer from.
In a study that examined health-related quality-of-life issues in patients with psoriasis, women with psoriasis reported nearly twice the mean number of mentally unhealthy days compared with men with psoriasis.
There is a growing body of literature that supports some link between major depressive disorder and inflammation.
Elevations in proinflammatory cytokines like prostaglandin E2 (PGE2), C-reactive protein (CRP), TNF-𝛼, IL-1𝛽, IL-2, and IL-6 have been reported in major depressive disorder
and, at times, have shown a dose-response with severity of depression. However, it is unclear whether the depression is causing the inflammation or vice versa.
Connor CJ, et al. Dermatol Res Pract. 2015;2015:409637; Langley RGB, et al. Ann Rheum Dis. 2005;64(Suppl 2):18-23; World Health Organization 2016; Helmick CG, et al. Am J Prev Med. 2014;47:37-45.

38. Psoriasis and Quality of Life (QoL)
Physical and mental disability comparable to or worse than other chronic diseases (cancer, arthritis, heart disease, diabetes, depression)
Severely affects self-esteem and ability to develop relationships
Contributors to diminished QoL
Chronic nature of disease
Lack of control over unexpected outbreaks
Feelings of shame, embarrassment with skin exposure
Discussing skin condition
Social avoidance behavior
Limitations in daily activities, occupational functioning, sexual functioning
Talking Points:
Psoriasis has been shown to have a major negative impact on patients’ QoL.
Research has shown that patients with psoriasis have a reduction in their QoL comparable to or worse than that of patients with other chronic diseases such as cancer, arthritis, ischemic heart disease, diabetes, and depression.
It is well established that patients with psoriasis feel extremely stigmatized by their disease---this contributes to low self-esteem and the ability to develop relationships.
A number of factors contribute to a diminished QoL among patients with psoriasis, including:
the chronic nature of the disease
lack of control over unexpected outbreaks
discussing skin condition
feelings of shame and embarrassment with skin exposure
social avoidance behavior
limitations in daily activities, occupational functioning, and sexual functioning.

39. Psoriasis and QoL: Patient-reported Experiences
U.S. study evaluated 101 patients’ experiences of living with psoriasis (symptoms, treatment, impact on daily life)
Narrative interviews conducted at baseline and within 16 weeks
Evaluated 7 impact areas (emotional, social, family, professional, physical, educational, sexual)
Most bothersome symptoms were itching/scratching, flaking/scaling (non-scalp areas), and skin pain
Impact areas most frequently reported: emotional and social
Talking Points:
A recent US non-interventional study evaluated 101 patients' experiences of living with psoriasis (symptoms, treatments, impact on daily lives).
The study design consisted of narrative interviews conducted at baseline and within 16 weeks.
The 7 impact areas evaluated were: emotional, social, family, professional, physical, educational, and sexual.
In interviews, patients with moderate or severe psoriasis indicated symptoms, ranked symptoms according to level of bother, and indicated areas of their lives affected by
psoriasis.
The most bothersome symptoms were itching/scratching, flaking/scaling (non-scalp areas), and skin pain.
Impact areas most frequently reported were emotional and social, again underscoring the tremendous toll that this disease takes on aspects of individuals’ lives in addition to just the physical component.
Pariser D, et al. J Dermatolog Treat. 2016; 27:19-26.

40. Psoriasis and QoL: Patient-reported Experiences (Cont’d.)
“I am very ashamed of the way I look, you know, like just people looking at me.”
“The flaking causes a lot of the embarrassment. And a lot of times it’s just easier to stay home than to go out.”
“You feel like you’re a leper. No one wants to get next to you. No one wants to touch you.”
“That’s all I’ve ever felt since I got psoriasis, was frustrated. Frustrated that there wasn’t an answer, there wasn’t a solution, that no one I knew had it. No one my age had it.”
“I guess the things that go hand-in-hand is ugliness, the confidence killer of it, the stares, and other people’s questions.”
Talking Points:
This slide shows selected verbatim statements from patients who participated in the study just described.
“I think it kind of molded me into this really insecure person.”
“The depression affects my whole family, not just me. I cry a lot and my daughter sees that, I don’t like her seeing that.”
Pariser D, et al. J Dermatolog Treat. 2016; 27:19-26.

41. Psoriasis and Sexual Function
Patients with psoriasis have higher risk of sexual dysfunction compared with general population
Risk factors
Disease severity
Female gender
Age
Psoriatic arthritis
Genital involvement has profound effect on sexual function and relationships
Important to obtain sexual history
Provide support for patient to discuss health and skin care with partner
Talking Points:
It has been recognized for some time that psoriasis can have a negative impact on sexuality and relationships in a substantial number of patients.
Scientific evidence shows that patients with psoriasis have a higher risk of sexual dysfunction compared with the general population.
The risk factors associated with sexual dysfunction in psoriasis patients are disease severity, female gender, age, and psoriatic arthritis.
Genital involvement also significantly affects sexual function.
In an observational, multicenter study of 354 psoriasis patients, 38% had current genital involvement and 63% had current and/or prior history of genital involvement.
42% reported dyspareunia, 32% had a worsening of genital psoriasis after intercourse, and 43% had a decreased frequency of intercourse.
When evaluating patients for psoriasis, obtaining a thorough sexual history is very important.
Providing support to patients to find best approaches to discuss health and skin care with their partner is also essential.
Molina-Leyva A, et al. J Eur Acad Dermatol Venereol ;29: ; Ryan C, et al. J Am Acad Dermatol. 2015;72:

42. Psoriasis and Sexual Function: Patient Education and Counseling Tips
Recommendations to patients:
Condom use during intercourse reduces potential skin discomfort and helps avoid skin-to-skin contact
Cleanse the affected area before sex and reapply medications after sex
Psoriasis in any form (including genital) is not contagious
Encourage to bring partner to office visits for enhanced education, counseling, and reassurance
Consider complimentary therapies (eg, referrals to trusted sexuality educators, counselors, and therapists) based on patient’s/partner’s needs and priorities
Talking Points:
Shown here are some practical recommendations for patients with psoriasis pertaining to sex and sexual function.

43. Dietary and Nutritional Considerations
Modifications
Gluten-free diet
Low-calorie diet
Nutritional supplements
Vitamin A
Vitamin D
Selenium + coenzyme Q10 + Vitamin E
Omega 3 fatty acids
Negative impact of alcohol
Talking Points:
While many options exist for the treatment of psoriasis, nutrition is a therapeutic component that should not be overlooked.
Dietary modifications, including a gluten-free diet and low-calorie diet, have been shown to induce a statistically significant improvement in clinical psoriasis.
Gluten-free diet: In several studies, including a large-scale study of over 12,000 patients, a correlation between psoriasis and celiac disease has been established. Based on this association, a reasonable hypothesis is that a gluten-free diet, which should improve celiac disease, will lead to improvement in psoriasis.
Low-calorie diet: Several studies have indicated that implementation of a low-calorie diet vs a free diet is associated with trends in improvement of psoriasis.
In addition to various diets, multiple oral and topical nutritional supplements have been studied in the treatment of psoriasis.
Vitamin A therapy is best utilized when complemented by additional treatments---both oral and topical preparations have proven effective in treating psoriasis.
Low serum levels of Vitamin D correlate with more severe psoriasis. As with Vitamin A, oral and topical formulations of Vitamin D are known to be beneficial in treating psoriasis---most commonly, Vitamin D is used topically, and particularly in combination with topical corticosteroids, topical Vitamin D analogues are a mainstay of psoriasis therapy.
Another potentially useful dietary addition is the combination of supplemental selenium, coenzyme Q10, and Vitamin E, which has been shown to improve severe forms of psoriasis.
There is some support for the use of omega 3 fatty acids in the improvement of psoriasis.
The dietary factor that impacts psoriasis most negatively is alcohol. A meta-analysis of 15 case-controlled studies showed a statistically significant association between psoriasis and alcohol consumption across a number of stratified analyses.
de Golia E, et al. In: Psoriasis: Types, Triggers, and Treatment Strategies. Nova Science Publishers, Inc. New York pp

44. Skin Care Recommendations
Moisturize! Moisturize! Moisturize!
At least twice daily all over, AFTER topical medications to improve penetration and efficacy
Ceramide-based moisturizers are excellent:
CeraVe, Cetaphil, RestoraDerm line, Aveeno Eczema line, Eucerin Eczema Relief line
Vaseline and Aquaphor (may be most helpful at bedtime if too greasy for daytime use)
Efficacy: ointments > creams > lotions
Use gentle skin cleansers; avoid anti- bacterials, excessive cleansing, fragranced products
Sunlight may help improve psoriasis plaques, ONLY IF patient does not get burned
Talking Points:
Frequent moisturizing is a cornerstone of skin care for patients with psoriasis.
Patients should moisturize at least twice daily all over AFTER applying any topical medications to help improve penetration and efficacy.
Moisturizing more often may be helpful to thicker psoriasis plaques; moisturize immediately after bathing (within 1-2 minutes) to trap in moisture.
Ceramide-based moisturizers are excellent, and OTC options include:
CeraVe (every product they make has a ceramide, including ointments, creams, lotions, sunscreens, and cleansers; they also have an anti-itch lotion that can be very helpful for patients with itchy skin symptoms), Cetaphil RestoraDerm line, Aveeno Eczema line, and Eucerin Eczema Relief line
Vaseline (thick ointment, may be most helpful at bedtime if too greasy for daytime)
Aquaphor (thick ointment, may be most helpful at bedtime if too greasy for daytime)
In general in terms of efficacy: ointments > creams > lotions
Patients should be advised to use gentle skin cleansers: avoid anti-bacterials, excessive cleansing, fragranced products
(CeraVe, Cetaphil RestoraDerm, Aveeno, Dove bar soap, etc.)
Sunlight may help improve psoriasis plaques, so sun exposure may be useful ONLY IF the patient does not get burned.
Caution is advised, as sunburns can flare psoriasis since this disease commonly flares in sites of trauma (this is known as koebnerization, or the Koebner phenomenon).
Caution: Sunburns can flare psoriasis (Koebner phenomenon)

45. Makeup Considerations for Patients With Psoriasis
Start with cleanser formulated for sensitive skin
Counsel patients to:
Use fragrance-free primer
Choose correct foundation formula (includes sunscreen) and avoid powders
Do a patch test first to check for sensitivity and effectiveness
Apply makeup with gentle dabbing motion and keep coverage simple
Consider consultation with professional makeup artist for application tips and tricks (eg, concealer use)
Choosing and applying foundation:
Talking Points:
Treating women with psoriasis involves more than just managing their type of psoriasis.
Consideration of cosmetic and aesthetic aspects is a vital part of helping female patients cope with their disease and be able to look their best.
While many clinicians may not feel comfortable or have the time to get into a conversation with their patients about cosmetics, having a fundamental knowledge about what might work for patients regarding makeup is recommended.
Patients should start with a cleanser formulated for sensitive skin.
Additional tips to counsel patients on include:
Use fragrance-free primer
Choose the correct foundation formula (foundation should include sunscreen) and avoid powders
Do a patch test first to check for sensitivity and effectiveness
Apply makeup with gentle dabbing motion and keep coverage simple
Consider consultation with professional makeup artist for application tips and tricks (eg, concealer use)
The weblink shown here refers to additional information for patients on choosing and applying foundation.

46. Scalp Psoriasis and Hair Care
Presentation ranges from slight scaling to thick, crusted plaques covering scalp
Symptoms include dry or brittle hair, intense itching, dandruff-like flakes
Special shampoos contain key ingredients to reduce inflammation/reduce scales
Topical steroids (prescription)
Salicylic acid
Coal tar
Discuss hair washing frequency and hair styling practices
Implications for hair dye, perms
Use of extensions, braids
Talking Points:
Between 50% and 80% of patients with psoriasis develop lesions on their scalp.
This presentation can range from slight scaling to thick, crusted plaques that cover the entire scalp.
Because of the visible nature of scalp psoriasis, this can be an especially frustrating manifestation of the disease and result in significant emotional distress.
Symptoms of scalp psoriasis include dry or brittle hair, intense itching, and dandruff-like flakes, which can be particularly disturbing to patients.
Special shampoos available for patients with scalp psoriasis contain ingredients designed to reduce inflammation and soften/loosen scales on the scalp so they can be washed away.
Psoriasis shampoo contains special ingredients designed to soften and loosen the scales of psoriasis on your scalp so that they can be washed away.
Two main types of psoriasis shampoo are coal tar shampoo and medicated shampoo---the active ingredient in the latter may be a corticosteroid or salicylic acid.
It is important to discuss hair washing frequency and hair styling practices with your patients with scalp psoriasis.
Patients need to be educated about the implications for hair dyes and perms, since the chemicals in hair dyes can sometimes irritate and worsen scalp psoriasis or even cause
an allergic reaction on top of the psoriasis.
Patients with this type of psoriasis may want to learn more about various hair styling techniques to help camouflage their psoriasis, such as extensions and braids.

47. Scalp Psoriasis and Hair Care (Cont’d.)
Steroid solutions often preferred by Caucasian, Asian, Hispanic patients
Steroid oils often preferred by African American patients
Ointments (possibly creams, lotions) typically avoided in scalp psoriasis, but may be used if patient prefers
Ketoconazole may be added to regimen to treat sebopsoriasis (seborrheic dermatitis psoriasis)
Counsel patients to shampoo with gentle massage with fingertips to loosen scales
Steroid oil treatment overnight prior to washing will help soften, loosen scales, regardless of hair type

48. Racial/Ethnic Considerations
Disparities in access to dermatologist and likelihood of undiagnosed disease
Appearance may be similar to other inflammatory conditions and harder to diagnose
Clinical presentation nuances of psoriasis in skin of color
Less conspicuous erythema
Postinflammatory hypo- or hyperpigmentation
Potential increased area of involvement/BSA at initial presentation
Impact of hair texture, styling practices, washing frequency
Treatment nuances in skin of color
Possible increased pigmentation with phototherapy
Selection of topical treatment compatible with hair practices and cultural preferences (eg, oils or oil-based suspensions may be preferable for African American hair texture)
Asian healing practices (eg, cupping, coining) may be relevant to clinical presentation
Use of herbal medicines may be associated with drug-drug interactions
Talking Points:
Under-reporting and selection bias may contribute to observed differences in the prevalence of psoriasis in minority populations.
Racial/ethnic disparities in access to a dermatologist have been reported in the US, and the likelihood of having undiagnosed psoriasis was higher among African Americans in a
national study analyzing NHANES data from 2003 to 2004.
In darker skin types, psoriasis may have overlapping features with other papulosquamous disorders and have less conspicuous erythema, thus presenting diagnostic challenges.
Key nuances in the clinical presentation of psoriasis in skin of color include:
Less conspicuous erythema—may appear violaceous or hyperpigmented
Postinflammatory hypo- or hyperpigmentation
Potential increased area of involvement/BSA at initial presentation
In African Americans, the impact of hair texture, styling practices, and washing frequency
Key treatment nuances that should be considered include:
Phototherapy in darker skin types should include a brief discussion about increased pigmentation in exposed areas
Selection of a topical treatment regimen that is compatible with hair care practices and cultural preferences
Traditional Asian healing practices, such as cupping, coining, and herbal remedies are examples of factors that may be relevant to the clinical presentation of psoriasis in some patients.
The use of some herbal medicines can potentially be associated with drug-drug interactions.
Alexis AF, et al. J Clin Aesthet Dermatol. 2014;7:16-24; McMichael AJ, et al. J Drugs Dermatol. 2012;11:

49. Complementary and Alternative Medicine (CAM) for Psoriasis
Talking Points:
Complementary and alternative medicine, or CAM, is the general category of products and practices that are not part of the standard care offered by medical doctors. 
CAM use is common among patients with psoriasis.
Examples of CAM used for psoriasis are shown on this slide and include:
Dietary supplements (eg, fish oil supplements, vitamin D, vitamin B12)
Herbal therapies (eg, tea tree oil, Dead sea salts, coconut oil, turmeric, and aloe vera)
Exercise (eg, yoga)
Acupuncture
It is important for clinicians who treat patients with psoriasis to be aware of the potential benefits as well as side effects associated with these alternative therapies to allow for informed discussions with their patients.

50. Helpful Resources National Psoriasis Foundation www.psoriasis.org
American Academy of Dermatology
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

51. Case Study 1 42-year-old Caucasian female
Presents with >1-year history of worsening thick pink scaly plaques on back, abdomen, thighs, and arms
Additional moist red plaques under breasts, axillae, and in intertriginous folds
Complains of pruritic lesions and is distressed by worsening/spreading
Clinical diagnosis of moderate-to-severe psoriasis confirmed by 4mm punch biopsies from inframammary moist plaque and pink scaly plaque from back

52. Case Study 1: Treatment Day 1 of presentation
Topical clobetasol M-F for all areas other than body folds
Use limited to M-W in body folds to limit adverse events
After biopsy results confirmed diagnosis
Methotrexate with folic acid supplementation and nbUVB light therapy
After 3-6 months
Plan to transition patient to a biologic medication (eg, ustekinumab or sekukinumab) if clearance not adequate
Patient’s insurance requires failure of alternative methods prior to approval for biologic therapy

53. Case Study 2
32-year-old black female (US-born) who plans to become pregnant within next year
Presents with 4-year history of worsening itching all over head and white flakes shedding from scalp increasing in size
Hair is thick, coily and worn in long, unrelaxed state (no current use of chemicals to straighten hair)
Pertinent history
Appearance of scaly, itchy patches on inner thigh during adolescence, which was never treated by a physician and resolved after 4 months
Regular salon application of hair-straightening chemicals during adolescence that caused burns and sores
Clinical exam reveals erythematous raised plaques with silver scales on scalp; some areas of thick, hyperkeratotic plaques extending beyond hairline, creating asymmetric plaques on forehead and glabella
Diagnosis of scalp psoriasis and plaque psoriasis

54. Case Study 2: Treatment
Clobetasol ointment to affected areas Q12 hrs for up to 2 weeks
Adalimumab
Day 1: Treatment initiation with an 80-mg dose (two 40-mg pens)
Day 8: Begin every other week dosing with one 40-mg pen
Day 22: Continue every-other-week dosing with one 40-mg pen
Collaboration with patient’s obstetrician
Discussion with patient on what to expect during pregnancy and postpartum
Strategies to reduce/eliminate potential trigger factors
Safe and effective medications for pregnancy and breastfeeding
Hair care guidance

55. Key Takeaways
Chronic, relapsing, and remitting inflammatory skin disease that is multifactorial in origin and associated with considerable physical and emotional distress and impaired QoL
Affects approximately 7.5 million Americans, including significant number of women during reproductive years
Numerous comorbidities associate with psoriasis, including cardiovascular disease, metabolic syndrome, IBD, cancer, obesity, liver disease, and depression
Approximately 80% of patients with psoriasis have mild-to-moderate disease and can be treated with topical agents
Phototherapy recommended for patients with moderate-to-severe psoriasis and may be used in combination with other therapies
Systemic therapies play important role in treatment of psoriasis and require consideration of pregnancy category in women of childbearing potential
Essential to discuss medications to avoid with psoriasis patients who plan to become pregnant

56. Key Takeaways (Cont’d.)
In pregnancy, topical steroids are considered first-line therapy, UVB is recommended as second-line therapy, and cyclosporine and TNF- inhibitors may be used as third-line agents
Whereas about 50% of women experience clinical remission of disease during pregnancy, there is a significant potential for psoriasis flares postpartum
Decreased estrogen during menopause may contribute to exacerbation of psoriasis flares
Self-esteem, the ability to develop relationships, and sexual function are all adversely affected by psoriasis
Dietary modifications, including a gluten-free diet and low-calorie diet, have demonstrated significant improvements in clinical psoriasis
Frequent moisturizing considered the cornerstone of skin care in psoriasis
Considerations of skin care, makeup, and hair care are critical to the treatment of females with psoriasis
Disparities in undiagnosed psoriasis and access to treatment prevalent among ethnic/minority populations

57. ARHP Resources
Additional ARHP webinars and Clinical Minutes available on-demand on
Educational slide decks on