Table Of Contentthe
psoriasis
and psoriatic
arthritis
pocket guide
Treatment algorithms and
management options
www.psoriasis.org
Authored by:
Abby Van Voorhees, M.D.
Steven R. Feldman, M.D., Ph.D.
John Y. M. Koo, M.D.
Mark G. Lebwohl, M.D.
Alan Menter, M.D.
The psoriasis and psoriaTic TABLE OF CONTENTS
arThriTis pockeT guide:
TreaTmenT opTions and paTienT
managemenT CHAPTER 1: INTRODUCTION .................1
Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
This is the third edition of the Psoriasis and
Psoriasis: A Systemic Disease . . . . . . . . . . . . . . 1
Psoriatic Arthritis Pocket Guide: Treatment
Psoriasis Negatively Affects Quality of Life . . . 2
Algorithms and Management Options. The
previous editions were well received by Comorbidities in Psoriasis . . . . . . . . . . . . . . . . . 3
dermatologists. Since the publication of Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . 4
the second edition, many new psoriasis
Systemic Therapy: Going Beyond Topicals . . . . 5
treatments—particularly biologics—have
Therapy Options . . . . . . . . . . . . . . . . . . . . . . . . . . 6
become available. The original work was
revised to provide guidance for managing How Much, How Often and at What Dose? . . . . 7
patients with moderate-to-severe psoriasis, Treating Patients in Practice . . . . . . . . . . . . . . . 7
and to put the role of new biologics into
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . 8
perspective.
Abby Van Voorhees, M.D. CHAPTER 2: ASSESSING A PSORIASIS
Assistant Professor of Dermatology PATIENT ................................................9
University of Pennsylvania School of Medicine
Philadelphia, Pa. Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . 9
Initial Work-up . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Steven R. Feldman, M.D., Ph.D.
Professor of Dermatology, Pathology & Public Determining Disease Severity . . . . . . . . . . . . . .11
Health Sciences
Wake Forest University School of Medicine Assessing a Patient . . . . . . . . . . . . . . . . . . . . . . .12
Winston-Salem, N.C.
Measuring BSA . . . . . . . . . . . . . . . . . . . . . . . . . . .12
John Y. M. Koo, M.D. Quality of Life and Severity . . . . . . . . . . . . . . . . .13
Professor and Vice Chairman
Psoriasis is as Debilitating as Other
Department of Dermatology
University of California San Francisco Major Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Medical Center
Koo-Menter Psoriasis Instrument . . . . . . . . . . .16
San Francisco, Calif.
Psoriasis Affects Social and Economic
Mark G. Lebwohl, M.D. Well-being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Chairman, Department of Dermatology
Mount Sinai School of Medicine Types of Psoriasis . . . . . . . . . . . . . . . . . . . . . . . 25
New York, N.Y.
Nail and Mucosal Manifestations of Psoriasis 28
Alan Menter, M.D. Psoriatic Arthritis . . . . . . . . . . . . . . . . . . . . . . . 30
Chairman, Division of Dermatology
PASE Questionnaire . . . . . . . . . . . . . . . . . . . . . . 30
Baylor University Medical Center
Clinical Professor of Dermatology Differential Diagnosis . . . . . . . . . . . . . . . . . . . . 37
University of Texas
Southwestern Medical School Comorbidities and Psoriasis . . . . . . . . . . . . . . 43
Dallas, Texas
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CHAPTER 3: CHOOSING A TREATMENT CHAPTER 5: THERAPEUTIC TREATMENT
STRATEGY ...........................................45 OPTIONS AND SIDE EFFECTS ..............79
Monotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Topical Therapies . . . . . . . . . . . . . . . . . . . . . . . . 79
Combination Therapy . . . . . . . . . . . . . . . . . . . . 48 Steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Rotational Therapy . . . . . . . . . . . . . . . . . . . . . . . .49 Anthralin . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Sequential Therapy . . . . . . . . . . . . . . . . . . . . . . 52 Coal Tar Preparations . . . . . . . . . . . . . . . .81
CHAPTER 4: TREATMENT ALGORITHMS Vitamin D Analogs . . . . . . . . . . . . . . . . . . . 81
FOR SPECIFIC PATIENT TYPES ............57
Combination Products . . . . . . . . . . . . . . . 83
Healthy Male Adult With Plaque Psoriasis . . . 59
Retinoids . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Healthy Children Under 18 With Psoriasis . . . 60
Phototherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Women Trying to Become Pregnant . . . . . . . . .61
UVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Guttate Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . 62
PUVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Erythrodermic Psoriasis . . . . . . . . . . . . . . . . . . 63
Broad-band UVB . . . . . . . . . . . . . . . . . . . . 88
Alcohol Intake + Psoriasis . . . . . . . . . . . . . . . . 64
Narrow-band UVB (nbUVB) . . . . . . . . . . . 91
Hepatitis C + Psoriasis . . . . . . . . . . . . . . . . . . . 65
Systemic Therapies . . . . . . . . . . . . . . . . . . . . . . 92
Palmoplantar Psoriasis . . . . . . . . . . . . . . . . . . 66
Acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
HIV + Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . .67
Cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 96
Pustular Psoriasis . . . . . . . . . . . . . . . . . . . . . . . 68
Methotrexate . . . . . . . . . . . . . . . . . . . . . . 102
Psoriatic Arthritis + Psoriasis . . . . . . . . . . . . . .69
Biologics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Hypertension + Psoriasis . . . . . . . . . . . . . . . . . 70
Adalimumab . . . . . . . . . . . . . . . . . . . . . . 108
Healthy Elderly Patient with Psoriasis . . . . . . 71
Alefacept . . . . . . . . . . . . . . . . . . . . . . . . . 109
Nail Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Etanercept . . . . . . . . . . . . . . . . . . . . . . . . . 111
Person of Color with Psoriasis . . . . . . . . . . . . . 73
Golimumab . . . . . . . . . . . . . . . . . . . . . . . .114
History of Skin Cancer + Psoriasis . . . . . . . . . .74
Infliximab . . . . . . . . . . . . . . . . . . . . . . . . . .115
Women of Childbearing Potential
with Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 Ustekinumab . . . . . . . . . . . . . . . . . . . . . . .118
Scalp Psoriasis . . . . . . . . . . . . . . . . . . . . . . . . . . 78
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Unapproved Agents . . . . . . . . . . . . . . . . . . . . . 120
Hydroxyurea . . . . . . . . . . . . . . . . . . . . . . 120
Mycophenolate Mofetil . . . . . . . . . . . . . . .121
6-Thioguanine . . . . . . . . . . . . . . . . . . . . . 122
Introduction
CHAPTER 6: TRANSITIONAL STRATEGIES
FOR SWITCHING THERAPY ................123
CHAPTER 7: MEDICAL PROFESSIONALS
AND THE NATIONAL PSORIASIS
FOUNDATION .....................................127
Who We Are . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Insurance Advocacy . . . . . . . . . . . . . . . . . . . . . 130
Medical Education . . . . . . . . . . . . . . . . . . . . . . .131
Online Physician Directory . . . . . . . . . . . . . . . 132
Join Hands With Us . . . . . . . . . . . . . . . . . . . . . 133
Benefits of Professional Membership . . . . . . 133
A Year in the Life of the
Psoriasis Foundation . . . . . . . . . . . . . . . . . . . . 134
REFERENCES ....................................135
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chapTer 1: inTroduc Tion
epidemiology
Psoriasis affects approximately 2.1% of U.S.
adults, up to 7.5 million people, of whom
about 30% will develop psoriatic arthritis.
Approximately 1.5 million U.S. adults are
considered to have moderate to severe
psoriasis and between 150,000 and 260,000
new cases of psoriasis are diagnosed each
year.1-3
Although there is evidence that psoriasis
may be more prevalent in women than
men, psoriasis affects all ages, genders,
races and ethnicities. The majority of
patients will present before the age of 35
with their first signs and symptoms of
psoriasis. From an economic standpoint,
an estimated 56 million hours of work are
lost each year by people with psoriasis.
In addition, approximately $11.25 billion
are spent annually treating the disease.4
The costs are greater for those with more
severe disease, and these financial implica-
tions are associated with a lower quality
of life.5 These costs are more than those of
other lifelong illnesses, such as emphysema
and epilepsy.6
psoriasis: a systemic disease
Psoriasis is a systemic, immunological,
genetic disease manifesting in the skin
and/or joints. Because of its systemic
nature, patients exhibit a broad spec-
trum of symptoms that vary in severity.
Although many patients, particularly those
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with the limited form of the disease, may Psoriasis Foundation, 33% of patients
be treated with topical therapy, those with with mild disease and 60% of patients
extensive (moderate to severe) psoriasis with moderate-to-severe reported that
eventually require phototherapy, systemic their disease was a significant problem
or biologic therapy to adequately suppress in their everyday life.7 Psoriasis can be as
the systemic, immunopathogenic process. debilitating as many other serious medical
or psychiatric conditions. The negative
Psoriasis may be defined based purely effect on the physical, psychological and
on body surface area (BSA) with 0-3% social dimensions of life can be greater
BSA = mild, 3-10% BSA = moderate, and than those resulting from life-threatening
greater than 10% BSA = severe. Others illnesses such as myocardial infarction.8
define it as limited, less than 3% BSA, or, (Figure 1-1).
extensive, greater than 3% BSA. In clinical
trials, severe psoriasis is defined as the
Figure 1-1: Physical and Mental Rankings
presence of lesions over more than 10%
of Psoriasis and Other Diseases, From Best
BSA. These definitions however do not
Functioning (1) to Worst Functioning (11)
take into consideration the impact on the
patient’s quality of life. Congestive heart failure 11 5
psoriasis 10 9
Type 2 diabetes 9 3
How do physicians define severity of psori-
Chronic lung disease 8 10
asis? In clinical practice, the definition of Myocardial infarction 7 4
severity is based more on the physician’s Arthritis 6 7
judgment and assessment of the extent of Hypertension 5 2
Depression 4 11
the disease, specific locations involved, and
Cancer 3 6
the effect of the disease on the patient’s
Dermatitis 2 8
life. In severe psoriasis, and in many cases Healthy 1 1
of moderate psoriasis, systemic therapies
0 5 10 15 20
are used to treat the disease effectively. Physical rank Mental rank
Involvement of localized areas such as the
hands, face and scalp (less than 3% BSA), comorbidities in psoriasis
as well as the emotional impact on the While psoriasis has traditionally been
patient, may certainly be of sufficient considered a disease of the skin and/or
magnitude to warrant systemic therapy. the joints, multiple reports attest to the
important role of systemic inflamma-
psoriasis negatively affects Quality of Life tion with ramifications for other organ
Psoriasis is a lifelong, chronic, recurrent systems, including the cardiovascular,
disease. In patient surveys conducted liver, respiratory and hematological
between 2001 and 2008 by the National systems. Thus patients, particularly
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those with more severe disease, may be mimic psoriasis. Chapter 2 includes a full
at increased risk for coronary artery differential diagnosis section relating to
disease, type II diabetes, fatty liver and this problem.
its consequences, stroke, COPD, sleep
apnea, and lymphoma.9 In addition, there is systemic therapy: going Beyond topicals
well-documented evidence for an increase It is medically appropriate to use systemic
in depression, with resulting personal therapies, alone or in combination with
behavior issues such as an increase in topicals and phototherapy, in patients who
alcohol consumption and smoking.10 do not meet the criteria for moderate-to-
severe psoriasis if:
Finally, other important autoimmune
diseases such as Crohn’s disease, diabetes • The patient is unresponsive to topicals
mellitus, and even multiple sclerosis may and other therapies;
be genetically linked to psoriasis and
hence seen in increased frequency in • Phototherapy is inconvenient or
psoriasis patients.11 impractical;
It is therefore important for all patients • The patient’s quality of life is negatively
with psoriasis to be evaluated for these affected to a degree that justifies the
comorbid conditions and for dermatolo- potential adverse effects of systemic
gists to play a central role in consultation therapy.
with primary care physicians and other
specialists in elucidating the medical The decision to use systemic therapy
consequences of this autoimmune disease. requires an important discussion between
the patient, the physician and his/her
differential diagnosis support staff. (See Figure 1-2.) For more
A number of important dermatoses, information regarding systemic therapy
including fungal infections, mycosis visit www.psoriasis.org/severe/systemics.
fungoides (MF) and drug eruptions, may
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Figure 1-2: Systemic Therapy Algorithm
immunologic disease such as psoriasis can
be difficult for both patient and physician.
1. Does the psoriasis affect > 3% body
surface area (BSA)? This handbook is designed to facilitate
2. Is the patient disabled by the psoriasis?
No to all. successful treatment. To help you choose
3. Does the psoriasis have a significant
impact on the patient’s quality of life? therapies, we have included suggested
4. Does the patient have psoriatic arthritis? patient algorithms in Chapter 4, allowing
The patient is not quick reference to a variety of patient
a candidate for
types, recommended treatments, side
Yes to any of the above. phototherapy or
systemic treatment. effects and management options. We have
also suggested treatment sequences. The
therapies reviewed in Chapter 4 vary in the
5. Does the patient have psoriatic arthritis?*
6. Was systemic treatment required in the seriousness of their side effects, which are
past? No to all. always to be weighed in the balance when
7. Is phototherapy contraindicated or
unavailable, or is the psoriasis resistant you consider using a course of therapy.
to phototherapy?
The patient is not
how Much, how often and at What dose?
a candidate for
Yes to any of the above.
phototherapy or Once you have chosen a treatment strategy,
systemic treatment.
you must consider dosing, side effects,
The patient is a candidate for length of treatment and overall patient
systemic treatment.
management, especially if the strategy
includes switching from one systemic treat-
*Phototherapy can be used for the treatment of
ment to the next, as in sequential therapy.
psoriasis skin lesions in patients with psoriatic
arthritis, but these patients also require systemic
treatment for the joint involvement. Chapters 5 and 6 discuss each of these
points relative to the therapies outlined in
the patient algorithms. These chapters also
therapy options discuss clinical pearls and transitional
Currently, many therapeutic options are issues related to the systemic therapies.
available to physicians treating psoriasis
patients, including targeted immunologic treating patients in practice
therapies (biologics). In addition, there are Patients should be fully educated about
various treatment strategies that can be all aspects of their disease, including all
used (discussed in Chapter 3) employing potential systemic-related disorders and
combination, rotation and sequential a specific, personalized treatment plan
therapies. Treating a chronic systemic developed for that patient.
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chapTer 2
objectives
After studying this handbook, you should
be able to:
• Define the severity of psoriasis and
develop an appropriate therapy plan.
Assessing
• Explain the profound emotional, social
and physical impact psoriasis has on
the patient. a psoriasis
• Understand the important comorbidi-
ties associated with psoriasis.
patient
• Differentiate psoriasis from other
diseases when you evaluate patients
who present with similar types of skin
lesions.
• Diagnose patients who have moderate
disease (3% to 10% body involvement)
and severe disease (>10% body involve-
ment or <10% involvement but resistant
to topical therapy) and identify those
who will potentially benefit from
systemic therapy.
• Discuss therapeutic options and appro-
priate doses for patients at various
stages of severity.
• Describe toxicities expected with
various therapies and ways to minimize
and manage them.
8 | The National Psoriasis Foundation
chapTer 2: assessing a psoriasis
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clinical presentation sg
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The clinical manifestations of psoriasis in p
gaT
are well-known and are usually recognized aie
easily, although presentation and the loca- pnT
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tion of the psoriasis may vary at different Ti
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stages of the disease.12 (See Table 2-1.) n
T
Table 2-1: The Most Common Locations of
Lesions in Patients With Psoriasis
Location % of Psoriasis Patients
Scalp 80
Elbows 78
Legs 74
Knees 57
Arms 54
Trunk 53
Lower part of the
47
body
Base of the back 38
Other 38
Palms and soles 12
Adapted from van de Kerkhof 13
Chronic plaque-type disease is the most
common form of psoriasis, being present
in 80% to 90% of patients. It is most often
found on the elbows, knees, scalp, legs and
sacrum.
Erythroderma, especially of recent onset,
is often associated with psoriasis but may
be difficult to differentiate from other
possible causes of erythrodermic or exfo-
liative dermatitis. Patients may present
with systemic symptoms and abnormal
laboratory values.
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