Managing psoriasis: What’s best for your patient?

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Applied Evidence

Managing psoriasis: What’s best for your patient?

J Fam Pract. 2012 July;61(7):402-451

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References

1. Gelfand JM, Weinstein R, Porter SB, et al. Prevalence and treatment of psoriasis in the United Kingdom: a population-based study. Arch Dermatol. 2005;141:1537-1541.

2. Fortune DG, Richards HL, Griffiths CE. Psychologic factors in psoriasis: consequences, mechanisms, and interventions. Dermatol Clin. 2005;23:681-694.

3. Housman TS, Mellen BG, Rapp SR, et al. Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehicle preference. Cutis. 2002;70:327-332.

4. Pettey AA, Balkrishnan R, Rapp SR, et al. Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice. J Am Acad Dermatol. 2003;49:271-275.

5. Menter A, Korman NJ, Elmets CA, 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.

6. Kaufmann R, Bibby AJ, Bissonnette R, et al. A new calcipotriol/betamethasone dipropionate formulation (Daivobet) is an effective once-daily treatment for psoriasis vulgaris. Dermatology. 2002;205:389-393.

7. Koo JY, Martin D. Investigator-masked comparison of tazarotene gel q.d. plus mometasone furoate cream q.d. vs. mometasone furoate cream b.i.d. in the treatment of plaque psoriasis. Int J Dermatol. 2001;40:210-212.

8. Berger TG, Duvic M, Van Voorhees AS, et al. The use of topical calcineurin inhibitors in dermatology: safety concerns. Report of the American Academy of Dermatology Association Task Force. J Am Acad Dermatol. 2006;54:818-823.

9. Cornell RC, Stoughton RB. Correlation of the vasoconstriction assay and clinical activity in psoriasis. Arch Dermatol. 1985;121:63-67.

10. Lui H. Phototherapy of psoriasis: update with practical pearls. J Cutan Med Surg. 2002;6(suppl):17-21.

11. Walters IB, Burack LH, Coven TR, et al. Suberythemogenic narrow-band UVB is markedly more effective than conventional UVB in treatment of psoriasis vulgaris. J Am Acad Dermatol. 1999;40:893-900.

12. Stern RS, Laird N. The carcinogenic risk of treatments for severe psoriasis. Photochemotherapy follow-up study. Cancer. 1994;73:2759-2764.

13. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol. 2010;62:114-135.

14. Trehan M, Taylor CR. High-dose 308-nm excimer laser for the treatment of psoriasis. J Am Acad Dermatol. 2002;46:732-737.

15. Morison WL, Baughman RD, Day RM, et al. Consensus workshop on the toxic effects of long-term PUVA therapy. Arch Dermatol. 1998;134:595-598.

16. Spuls PI, Witkamp L, Bossuyt PM, et al. A systematic review of five systemic treatments for severe psoriasis. Br J Dermatol. 1997;137:943-949.

17. Murase JE, Lee EE, Koo J. Effect of ethnicity on the risk of developing nonmelanoma skin cancer following long-term PUVA therapy. Int J Dermatol. 2005;44:1016-1021.

18. Lowe NJ, Prystowsky JH, Bourget T, et al. Acitretin plus UVB therapy for psoriasis. Comparisons with placebo plus UVB and acitretin alone. J Am Acad Dermatol. 1991;24:591-594.

19. Torras H, Aliaga A, Lopez-Estebaranz JL, et al. A combination therapy of calcipotriol cream and PUVA reduces the UVA dose and improves the response of psoriasis vulgaris. J Dermatolog Treat. 2004;15:98-103.

20. Tanew A, Guggenbichler A, Honigsmann H, et al. Photochemotherapy for severe psoriasis without or in combination with acitretin: a randomized, double-blind comparison study. J Am Acad Dermatol. 1991;25:682-684.

21. Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009;61:451-485.

22. Strober BE, Menon K. Folate supplementation during methotrexate therapy for patients with psoriasis. J Am Acad Dermatol. 2005;53:652-659.

23. Taler SJ, Textor SC, Canzanello VJ, et al. Cyclosporine-induced hypertension: incidence, pathogenesis and management. Drug Saf. 1999;20:437-449.

24. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58:826-850.

25. Heydendael VM, Spuls PI, Opmeer BC, et al. Methotrexate versus cyclosporine in moderate-to-severe chronic plaque psoriasis. N Engl J Med. 2003;349:658-665.

26. Lloyd ME, Carr M, McElhatton P, et al. The effects of methotrexate on pregnancy, fertility and lactation. QJM. 1999;92:551-563.

27. Ellis CN, Fradin MS, Messana JM, et al. Cyclosporine for plaque-type psoriasis. Results of a multidose, double-blind trial. N Engl J Med. 1991;324:277-284.

28. Buccheri L, Katchen BR, Karter AJ, et al. Acitretin therapy is effective for psoriasis associated with human immunodeficiency virus infection. Arch Dermatol. 1997;133:711-715.

29. Lebwohl M, Bagel J, Gelfand JM, et al. From the Medical Board of the National Psoriasis Foundation: monitoring and vaccinations in patients treated with biologics for psoriasis. J Am Acad Dermatol. 2008;58:94-105.

30. Gordon KB, Vaishnaw AK, O’Gorman J, et al. Treatment of psoriasis with alefacept: correlation of clinical improvement with reductions of memory T-cell counts. Arch Dermatol. 2003;139:1563-1570.

31. Brown SL, Greene MH, Gershon SK, et al. Tumor necrosis factor antagonist therapy and lymphoma development: twenty-six cases reported to the Food and Drug Administration. Arthritis Rheum. 2002;46:3151-3158.

32. Fulchiero GJ, Jr, Salvaggio H, Drabick JJ, et al. Eruptive latent metastatic melanomas after initiation of antitumor necrosis factor therapies. J Am Acad Dermatol. 2007;56(suppl):S65-S67.

33. Leonardi CL, Kimball AB, Papp KA, et al. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1). Lancet. 2008;371:1665-1674.

34. US Food and Drug Administration. FDA approves new drug to treat psoriasis. Sept. 25, 2009. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm183851.htm. Accessed June 15, 2012.

35. Duchini A, Goss JA, Karpen S, et al. Vaccinations for adult solid-organ transplant recipients: current recommendations and protocols. Clin Microbiol Rev. 2003;16:357-364.

36. Mann DL, McMurray JJ, Packer M, et al. Targeted anticytokine therapy in patients with chronic heart failure: results of the Randomized Etanercept Worldwide Evaluation (RENEWAL). Circulation. 2004;109:1594-1602.

37. Griffiths CE, Strober BE, van de Kerkhof P, et al. Comparison of ustekinumab and etanercept for moderate-to-severe psoriasis. N Engl J Med. 2010;362:118-128.

38. Papp KA, Langley RG, Lebwohl M, et al. Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2). Lancet. 2008;371:1675-1684.

Common adverse effects of MTX, such as nausea, vomiting, stomatitis, and fatigue, may be minimized by IM or SC administration, splitting the dose, or providing folate supplementation.^21-24 Given in doses of 1 to 5 mg/d, folate may reduce adverse hematologic, gastrointestinal, and hepatic effects without decreasing efficacy.²²

FAST TRACK

Folate supplementation may reduce the adverse hematologic, GI, and hepatic effects associated with methotrexate, without reducing efficacy.

The major severe toxicities are myelosuppression, hepatotoxicity, and pulmonary fibrosis.²⁴ MTX-induced hepatotoxicity is similar to nonalcoholic fatty liver disease (NAFLD) and is thought to exacerbate preexisting NAFLD, which is common in patients with metabolic syndrome. A liver biopsy or serum assays for liver fibrosis (amino-terminal peptide of pro-collagen III) may be warranted during therapy.²⁴

MTX is an abortifacient and teratogen, so contraception during treatment and for up to 3 months thereafter is mandatory for women of childbearing age.²⁶ Men should be advised that MTX decreases sperm count. (For more on methotrexate, see: “When a fetus survives methotrexate exposure,” at http://www.jfponline.com/Pages.asp?AID=10299).

Cyclosporine (CSA), an oral calcineurin inhibitor, is a potent immunosuppressant that rapidly clears psoriasis.²⁷ Because duration of use correlates with permanent nephrotoxicity, hypertension, and potential increased risk of SCC and lymphoma, intermittent 12-week courses are recommended. Calcium channel blockers are the preferred treatment for CSA-induced hypertension because of their effect on smooth muscle vasodilation.²¹

Oral retinoids. Acitretin modulates epidermal proliferation and is anti-inflammatory. Because it lacks immunosuppression, acitretin is generally considered the treatment of choice in HIV patients with severe psoriasis.²⁸ Acitretin is teratogenic and contraindicated in women who plan to become pregnant or who are unwilling to use adequate contraception for 3 years after discontinuing the drug.²¹

CASE Given the significant percentage of body surface area involved and symptoms consistent with psoriatic arthritis, Tom required an aggressive therapeutic regimen. His history of nonalcoholic fatty liver and social drinking precluded the use of methotrexate. A biologic therapy was the next therapeutic choice that could relieve both his cutaneous and joint symptoms.

FIGURE
4 psoriasis patients, 4 different presentations

A. The linear erythematous, scaly plaque along this patient’s cardiac bypass scar demonstrates koebnerization of plaque psoriasis.

B. Diffuse erythematous scaly papules coalesce into plaques on this patient’s anterior chest, arms, abdomen, and periumbilicus.

C. The pinpoint pustules on an erythematous base on this patient’s lateral neck, shoulders, and upper back are characteristic of pustular psoriasis.

D. This patient has erythematous plaques with overlying silvery scale on the elbow—a classic

TABLE 2
Traditional systemic therapy^21-24

	Methotrexate (MTX)	Cyclosporine (CSA)*	Acitretin
Dosing	≤30 mg in one weekly dose (PO, IM, or SC)	2.5-5.0 mg/kg/d in 2 divided doses for 12 wk, then 12-wk nontreatment period Dose decreased (by 0.5-1.0 mg/kg) with disease clearance or when hypertension or nephrotoxicity are detected	10-50 mg/d given as a single dose Lower doses (25 mg/d) used to minimize adverse effects and in combination regimens When added to UV, light dose should be reduced 30%-50%
Contraindications	Pregnancy and nursing Alcoholism Chronic liver disease Immunodeficiency Bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia Hypersensitivity to MTX	Concomitant PUVA, UVB, MTX, or other immunosuppressant or coal tar History of >200 PUVA treatments or radiation therapy Abnormal renal function Uncontrolled hypertension Malignancy Hypersensitivity to CSA	Women with child-bearing potential Severely impaired liver or kidney function Chronically elevated lipid levels
Baseline monitoring^†	H&P, BUN, CBC, CR, LFTs Liver biopsy in patients with history of significant liver disease Pregnancy test HIV test in selected patients Consider: PPD, chest x-ray for patients with underlying pulmonary disease	H&P; BP, BUN, and CR (twice) Urinalysis LFTs, CBC, lipid profile, lab tests for magnesium, uric acid, and potassium Pregnancy test^‡ Consider: PPD	H&P, CBC, LFTs Lipid profile Renal function test Pregnancy test
BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CR, creatinine; H&P, history and physical; IM, intramuscular; LFTs, liver function tests; PO, by mouth; PPD, purified protein derivative; PUVA, psoralen and ultraviolet A; SC, subcutaneous; UV, ultraviolet; UVB, ultraviolet B. Avoid live vaccinations; caution required with major infection and poorly controlled diabetes. ^†Ongoing monitoring for MTX:* BUN, CBC, CR, LFTs; possible liver biopsy (for high-risk patients or cumulative dose >3.5-4 g); CSA: BP, BUN, CBC, CR, LFTs; lipd profile; magnesium, uric acid, potassium tests; pregnancy testing; Acitretin: CBC, LFTs, lipid profile, renal function test, pregnancy testing.

Biologics require lab work and a detailed medication list

Before beginning biologic therapy for a patient, the National Psoriasis Foundation²⁹ recommends obtaining a complete history, physical, medication list, future plans (ie, pregnancy or travel to locations requiring vaccinations), and baseline labs to identify possible risk factors and/or contraindications. Periodic evaluation to monitor development of new symptoms, including infection and malignancy ( TABLE 3 ),^24,30-33 is needed, as well.