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2nd Annual Primary Care Fall Conference Tuesday, October 23, 2012

Richard Usatine, MDPapulosquamous Disorders

Papulosquamous Disorders

Richard P. Usatine, MD, FAAFPProfessor, Family and Community Medicine

Professor, Dermatology and Cutaneous SurgeryMedical Director, Skin Clinic

University of Texas Health Science Center, San Antonio

Disclosure Statement:• Co-President, Usatine Media

– medical app development company• Author, medical books

– Dermatologic and Cosmetic Procedures in Office Practice. Elsevier, Inc., Philadelphia. 2012.

– The Color Atlas of Family Medicine. McGraw-Hill, New York, 2009

• Off- label use:– Cyclosporine, Tacrolimus



Objectives

1. Identify the different types of papulosquamous disorders along with their distinguishing features.2. Collect clues for the clinical diagnosis of psoriasis and other papulosquamous disorders.3. Distinguish the different types of psoriasis.4. Compare treatment options for psoriasis.

Papulosquamous Disorders

• IN order of prevalence:

• Seborrhea• Psoriasis• Pityriasis rosea• Lichen planus

• Presentation will be in reverse order



Patient presentation

• A 38-year-old Hispanic woman presents with a rash on her forearms wrists ankle and back. She states the rash is mildly itchy and she does not like the way it looks.

All unlabeled photos are courtesy of Richard P. Usatine, MD



Koebner phenomenon



5 Ps of Lichen Planus

• Planar• Purple• Polygonal• Pruritic• Papule

Wickham’s lines

• Wickham’s striae (lacy, reticular white lines)



Skin Variants

• Hypertrophic• Follicular – scale on scalp, may lead

to cicatricial alopecia (lichen planopilaris)

• Vesicular or bullous• Actinic - typical lesions in sun-

exposed areas• Atrophic• Ulcerative



(Courtesy of Dan Stulberg, MD)

Skin Treatment

• May resolve in 8 – 18 months• Topical steroids (mid to high

potency)• Intralesional triamcinolone (3

mg/ml) may repeat every 3 to 4 weeks



Systemic Treatment

• For most severe and symptomatic cases.

• Three-week tapered course of oral prednisone (60 mg/d starting dose)

• Systemic retinoids - acitretin (Soriatane) 25 mg/day

• Mycophenolate mofetil • Cyclosporine (5 mg/kg/d)

Courtesy ofEJ Mayeaux, MDAnd the Color Atlas

CASE16 yo boy with a rash and mild itching



Pityriasis roseaRecognize and reassure



Pityriasis Rosea

• Human herpesvirus 6 (HHV-6) and HHV-7 may play a role in pathogenesis

• Comparison between the efficacy of high dose acyclovir and erythromycin for pityriasis rosea.– Indian J Dermatol. 2010 Jul-

Sep;55(3):246-8

Psoriasis Risk factors

• Family history• Obesity• Smoking• Heavy alcohol use



Age

• Plaque psoriasis first appears during 2 peak age ranges:

• 16-22 years of age• 57-60 years of age

9 categories of Psoriasis

1. Plaque (80%-90% of patients with psoriasis)2. Scalp psoriasis3. Guttate psoriasis4. Inverse psoriasis5. Palmar-plantar psoriasis. 6. Erythrodermic psoriasis.7. Pustular psoriasis—localized and generalized.8. Nail psoriasis. 9. Psoriatic arthritis

• AAD consensus statement on psoriasis therapies. JAAD. 2003;49:897-899.



Scalp psoriasis

• Seen at the hairline• Around ears



Guttate psoriasis

• small round plaques that resemble water drops (guttate means like a water drop)

• typical distribution: the trunk and extremities but may include the face and neck

• classically described as occurring after strep pharyngitis or another bacterial infection



Guttate psoriasis



Inverse psoriasis• found in the intertriginous areas of the axilla,

groin, inframammary folds, and intergluteal fold. It can also be seen below the pannus or within adipose folds in obese individuals.

• The name inverse refers to the fact that the distribution is not on extensor surfaces but in areas of body folds.

• Morphologically the lesions have little to no visible scale

• Color is generally pink to red but can be hyperpigmented in dark-skinned individuals



Palmar plantar psoriasis

• psoriasis occurs on the plantar aspects of the hands and feet (palms and soles).



(Courtesy of Jeffrey Meffert, MD)

Erythrodermic psoriasis

• Erythrodermic psoriasis is generally widespread and erythematosus.

• Morphologically it can have plaques and erythema or the erythroderma can appears with the desquamation of pustular psoriasis

• Widespread distribution can impair the important functions of the skin and this can be a dermatologic urgency requiring hospitalization and IV fluids.



Erythrodermic psoriasis with exfoliation

Courtesy of Jack Resneck, Sr, MD



Pustular psoriasis• Localized and generalized types.• Generalized type, the skin initially becomes fiery

red and tender and the patient experiences constitutional signs and symptoms, such as headache, fever, chills, arthralgia, malaise, anorexia, and nausea.

• desquamation that occurs in the generalized form can impair the important functions of the skin predisposing to dehydration and sepsis. dermatologic emergency requiring hospitalization and IV fluids

• flexural and anogenital• Less often, facial lesions occur

(Courtesy of Jack Resneck, Sr., MD)



(Courtesy of Jeffrey Meffert, MD)

Pustular psoriasis

• Within hours, clusters of nonfollicular, superficial 2- to 3-mm pustules may appear in a generalized pattern.

• These pustules coalesce within 1 day to form lakes of pus that dry and desquamate in sheets

• leaving behind a smooth erythematous surface on which new crops of pustules may appear.



(Courtesy of Meng Lu, MS3)

Nails

• nail involvement in psoriasis can lead to pitting, onycholysis, subungual keratosis, splinter hemorrhages, oil spots and nail loss.



Psoriatic Arthritis

Courtesy of Ricardo Zuniga-Montes, MD

Dactylitis

Nails involved



Disabling psoriatic arthritis

Making the diagnosis

• KOH preparation first if suspect fungal infection is possible

• Punch biopsy or scoop shave if not typical (if want to investigate for mycosis fungoides)

• Nails – KOH, culture or clipping for PAS stain

• Always inquire about psoriatic arthritis



Look for clues away from rash



Psoriatic arthritis

• History- ask about:–Morning stiffness– Joint pain

• Physical exam ––Fingers – DIP joint swelling, tenderness–Dactylitis – fat swollen fingers–Axial spine involvement–Enthesopathy – Achilles tendonitis

• X-ray – joint erosions

Non-pharmacologicalManagement

• Encourage smoking cessation to all who smoke.

• Minimize alcohol use. • Recommend weight loss if needed.• Recommend stress management

techniques.



Psoriasis Treatment Level 1 – topical or local

(may be all that is needed)

• Emollients• Topical steroids • Topical vitamin D• Topical retinoids• Topical calcineurin inhibitors • Topical tar and tar shampoo• Keratolytic agents• Intralesional steroids• Phototherapy – narrow-band UVB

Level 2 – Systemic(for more severe cases and pts with

psoriatic arthritis)

• Oral therapy - methotrexate, oral retinoids (acitretin), Cyclosporine

• New biologics – injectables• If psoriatic arthritis – start with

methotrexate and consider biologics

• Refer or get help to learn to use oral and biologic therapy for your patients



Oral steroids

• DO NOT USE ORAL or SYSTEMIC STEROIDS for psoriasis

• Prednisone even when tapered can precipitate generalized pustular psoriasis

Ointments • Use topical corticosteroid ointments rather than

creams because they are usually more effective than creams for psoriasis.

• On the face and flexures only mild to moderately potent topical corticosteroids should be used.

• On the other body areas treatment results will only be achieved with potent to very potent ointments.

• EBM Guideline. Essential Evidence Plus. SOR A.

• www.infopoems.com/inforetriever/display_article.cfm?resource=G&article=288



EBM - potent topical steroids

• Clobetasol is an ultra high potency steroid that is generic and comes in many vehicles for use on the body and scalp.

• A meta-analysis of the studies with clobetasol demonstrated 68-89% of patients had clear improvement or complete healing. SOR A.

• German evidence-based guidelines for the treatment of Psoriasis vulgaris. Arch Dermatol Res. 2007;299:111-138.

Taclonex

o combines betamethasone and calcipotriene to be applied once dailyo $573 for 60 gram tube of ointmento Convenient but costly

o Calcipotriene (Dovonex)o<$200 for 60 gram of generic



Topical Steroid Treatment of Psoriasis

• most common treatment• strong ointments are most effective• risks - skin atrophy, telangiectasias,

suppression of HPA

• intralesional steroid (up to 5 mg/ml) - good for isolated patches

Tacrolimus ointment(off-label)

Clinical trials suggest that tacrolimus 0.1 % ointment twice a day produces a good response in a majority of patients with facial, genital and inverse psoriasis. SOR B.

• Martin EG, et al. Topical tacrolimus for the treatment of psoriasis on the face, genitalia, intertriginous areas and corporal plaques. J Drugs Dermatol. 2006;5: 334–336.



Phototherapy• Extensive and widespread disease • Psoriasis not responding to topical therapy.• Narrowband UVB is more effective than

broadband UVB and approaches PUVA (psoralen and UVA) in efficacy.

• 63–80% of patients will clear with a course of narrowband UVB (equivalent relapse rates compared with PUVA).

• An update and guidance on narrowband ultraviolet B phototherapy: a British Photodermatology Group Workshop Report. Br J Dermatol. 2004;151:283-297.

MethotrexateVery effective for psoriasis and psoriatic arthritis. SOR ANeed to get PPD and check LFTs firstStart with weekly dose of 7.5 mg/week and taper up (max 25 mg/week)Follow LFTs and CBC regularlyreliable contraceptive methods should be used during and for at least three months after therapy in both men and women inexpensive medication with an over 40-year track record, but with known potential for hepatotoxicity Consider liver biopsy based to assess liver damage based on guidelines



Biologics

TNF inhibitors:•Adalimumab Humira•Etanercept Enbrel•Infliximab Remicade

Blocks interleukin 12 and 23:•Ustekinumab Stelara

Either monoclonal antibodies or receptor-antibody fusion protein• $20,000 - $40,000 per year

Scalp psoriasis

• Generic fluocinonide solution daily to the scalp is effective and affordable.

• Mineral oil or agents containing peanut oil may be used to moisturize and remove scale.

• Shampoos with tar and/or salicylic acid can help to dissolve and wash away some of the scale.



Palmar-plantar psoriasis

• Mild disease - start with topical treatments as in plaque psoriasis.

• For moderate to severe cases, systemic therapy such as oral acitretin, MTX, or biologic may be needed.

Life threatening psoriasis

• Erythrodermic/generalized psoriasis• Pustular/generalized psoriasis

–Treatment considerations include: Hospitalization for dehydration and close monitoring,

–Start cyclosporine or methotrexate–Consult a local expert for these cases



Seborrhea



Seborrheic dermatitis

• is a common inflammatory skin disorder

• Found in sites dense with sebaceous glands that support growth of the lipophilic yeast Malassezia furfur

• Also called Pityrosporum ovale or orbiculare – same organism as in tinea versicolor



Seborrheic dermatitis

• Inflammation is probably related to the overgrowth of the Pityrosporum

• Treatment will be two-pronged to diminish yeast overgrowth and fight inflammation

• Some conditions predispose to SD–HIV–Parkinson’s



HIV and Seborrheic Dermatitis

• common HIV-related opportunistic event

• May be an initial marker of immunodeficiency

• Improves with anti-viral therapy



Parkinson's increases risk of Seborrhea

Seborrhea flare in a hospitalized patient



Seborrhea in the nasolabial fold

with hyperpigmentation

Lupus spares the nasolabial fold andSeborrhea does not



Two Prong Treatment of Seborrhea

• Treat inflammation – steroids– 1% HC cream or lotion on face– lotion preferred on hair covered area – Desonide cream or lotion on face– if severe on scalp - may use fluocinonide

(Lidex) or clobetasol solution – Fluocinonide solution is affordable in 60 ml

bottles – use once daily

• Treat fungus - Antifungals

Treatment

• Antifungals -–skin: Ketoconazole (Nizoral) or

ciclopirox (Loprox) cream or any OTC azole antifungal

– scalp: Ketoconazole shampoo, Selenium sulfide, Zinc pyrithione



Steroids on face

• Hydrocortisone to start• Desonide 0.05% lotion – studied

twice weekly for 3 weeks with 88% clearing

– Efficacy, cutaneous tolerance and cosmetic acceptability of desonide 0.05% lotion (Desowen) versus vehicle in the short-term treatment of facial atopic or seborrhoeic dermatitis. The Australasian journal of dermatology. 43(3):186-9, 2002 Aug.

EBM - Antifungals

• Washing the scalp with ketoconazole shampoo and using topical treatment with creams containing imidazole derivatives can cut down on fungal growth and help treat seborrhea. SOR B

• Finnish Medical Society Duodecim. Seborrhoeic dermatitis. In: EBM Guidelines. Evidence-Based Medicine [CD-ROM]. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2004 Apr 23



Cradle cap

• Start with selenium based shampoo – burns the eyes less than zinc containing shampoos

• Daily hair washing• 1% hydrocortisone or 0.05%

desonide cream or lotion• Mineral oil for scale as needed

Conclusions for Seborrhea

• Seborrheic dermatitis is found where Pityrosporum grows

• Treat inflammation – topical steroids• Treat fungus – antifungals• Frequent hair washing with

medicated shampoos



Conclusions for Psoriasis• Psoriasis can be a tough disease to diagnose and

treat.• First, don’t miss the diagnosis – pay attention to

the scalp, intertriginous areas and the nails.• Investigate for psoriatic arthritis.• Assess the type, severity, distribution, patient’s

resources and preferences to choose initial therapy

• Try new therapies when initial therapies fail.• Refer or get a consult on the tough cases.• Learn how to use methotrexate and/or the

biologics if you have the motivation to do so.

References• Foulkes AC, et al. What's new in psoriasis? An analysis of

guidelines and systematic reviews published in 2009-2010. ClinExp Dermatol 2011.

• Paul C, et al. Evidence-based recommendations on conventional systemic treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists. J Eur Acad Dermatol Venereol 2011;25 Suppl 2:2-11.

• Bansback N, et al. Efficacy of systemic treatments for moderate to severe plaque psoriasis: systematic review and meta-analysis. Dermatology 2009;219:209-218.

• Mason AR, et al. Topical treatments for chronic plaque psoriasis. Cochrane Database Syst Rev 2009;CD005028.

• 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;60:643-659.

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