psoriasis - home -nursing in practice events€¦ · phototherapy •narrowband uvb for plaque...
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Psoriasis
Name: Nicki Ball Title: Dermatology Nurse Specialist Galderma UK Ltd and Honorary contract at Bristol Royal Infirmary
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Learning Outcomes
• Overview of pathophysiology and aetiology of psoriasis including trigger factors
• Discuss assessment of disease severity
• Discuss identifying co-morbidities
• Describe 1st line management options in line with NICE guidance
• Describe impact on functional, psychological and social wellbeing
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Overview
Psoriasis is a complicated, chronic inflammatory, multi- aetiological auto-immune condition
– Non-contagious and re-occurring
– Predominantly affects skin and joints
Epidemiology • Affects between 1% and 3% of the UK population- up to 1.8
million people • Affects males and females equally • Can occur at any age; two peaks – late teens to early 30’s &
around 50 to 60 • Most common in white people, highest prevalence in Northern
Europe/Scandinavian countries • Several clinical variants exist but plaque psoriasis most common
form
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Normal skin cell matures in 21 to 28 days In psoriasis, the turnover of skin cells is much faster - 4 to 7 days Live cells can reach the surface and accumulate with dead cells Inflammatory cells accumulate in the dermis and infiltrate the epidermis, causing erythema Increased vascularisation and blood-vessel engorgement in the dermis
Pathophysiology
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Why does psoriasis occur?
• Changes begin in the immune system when T cells lymphocytes are triggered and become overactive
• The T cells produce inflammatory chemicals leading to the rapid growth of skin cells causing psoriatic plaques to form
• Not yet clear what initially triggers the immune system to act in this way
• 10% of the population inherits one or more of the genes that create a predisposition to psoriasis.
• Only 2 to 3% of the population develops the disease • For a person to develop psoriasis, the individual must have
a combination of the genes that cause psoriasis and be exposed to a trigger factor
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Trigger factors
• Stress and other lifestyle factors - such as smoking and alcohol • Injury to skin – psoriasis can occur in skin that has been traumatized or
injured (Koebner phenomenon)
• Medications: lithium
rapid cessation of topical or systemic corticosteroids ACE Inhibitors beta-blockers anti-malarials non-steroidal anti-inflammatories
• Infection – particularly the streptococcal B throat infection associated with guttate psoriasis
• Endocrine - disease state may fluctuate with hormonal changes (puberty, pregnancy and menopause)
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Diagnosis
Most cases of psoriasis can be reliably diagnosed by simple physical examination
• skin, scalp, nails, joints • Ruby-red, well defined plaques • Silvery surface scale • Often symmetrical • Extensor surfaces or can be widespread • Examine joints for psoriatic arthritis • Punctuate bleeding points (Auspitz’s sign) • Lesions on lower legs may be less typical
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Assessment
For people with any type of psoriasis assess: • Presenting condition • Medical history • Family history • Previous treatments and responses • Disease severity – patients global assessment, physicians
global assessment, PASI score • Impact of disease on physical, psychological and social
wellbeing – DLQI • Presence of psoriatic arthritis - PEST • Presence of comorbidities
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PASI Score
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Dermatology Life Quality Index score
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Psoriatic Arthritis - PEST
As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care
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When to assess
Assess the severity and impact of any type of psoriasis:
• at first presentation
• before referral for specialist advice and at each referral point in the treatment pathway
• to evaluate the efficacy of interventions
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Physical Co-morbidities
Disease Impact
Psoriatic arthritis Up to 35% of people living with psoriasis
Crohns disease 2.5X higher risk
Metabolic syndrome (combination of diabetes, hypertension & obesity)
2X higher risk if have severe psoriasis
Atrial Fibrillation 3X higher risk if aged <50 with severe psoriasis
Stroke 3X higher risk if aged <50 with severe psoriasis
Heart attack 3X risk if aged 30 with severe psoriasis
Non-alcoholic fatty liver disease Can affect 17-60%
Squamous cell carcinoma 5X higher risk
Basal cell carcinoma 2X higher risk
Uveitis Can affect 7–20%
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Co-morbidities
Discuss risk factors for cardiovascular comorbidities:
• Lipid modification
• Obesity
• Preventing type 2 diabetes
• Prevention of cardiovascular disease
• Alcohol use
• Smoking cessation
Assess cardiovascular risks at diagnosis and at 5 yearly intervals or more frequently if intervention required
Offer preventative advice, healthy lifestyle information & support for behavioural change
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Disease Impact
Encompasses functional, psychological and social dimensions: • Symptoms related to skin – chronic itch, bleeding,
scaling, nail involvement • Problems related to treatments – mess, odour,
inconvenience and time • Effect of living with highly visible, disfiguring skin
disease – difficulties with relationships, securing employment and poor self esteem
• About 1/3rd of people with psoriasis experience major psychological distress (1)
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Psychological Co-morbidities with psoriasis
• At least as severe as those seen with heart disease, kidney failure, cancer and liver disease (1)
• Compared with people with other skin conditions, more likely to suffer from psychological problems that may in themselves trigger or worsen psoriasis symptoms(2)
• Regardless of location or extent of disease, anxiety and depression are common. One study reported 60% of people with psoriasis had symptoms of depression (3)
• It is estimated that more than 10,400 diagnoses of depression, 7,100 of anxiety and 350 of suicidal thoughts and behaviour are attributable to psoriasis each year in the UK (4)
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Impact of psoriasis
Assess the impact of any type of psoriasis on physical, psychological and social wellbeing by asking: • what aspects of their daily living are affected by the
person's psoriasis • how the person is coping with their skin condition and any
treatments they are using • if they need further advice or support • if their psoriasis has an impact on their mood • if their psoriasis causes them distress (be aware the patient
may have levels of distress and not be clinically depressed) • if their condition has any impact on their family or carers
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Treatment Systemic biological therapy
For severe and very severe psoriasis • Etanercept * • Adalimumab * • Infliximab * • Ustekinumab
*recommended for the treatment of adults with active and progressive psoriatic arthritis
• Methotrexate • Ciclosporin • Acitretin
• Narrowband UVB for plaque or guttate
• Psoralen (oral or topical) with local ultraviolet A (PUVA) for palmoplantar pustulosis
• Risk of skin cancer!
• Emollients • Corticosteroids • Vitamin D/Vitamin D analogues • Vit D analogue/potent steroid combination • Dithranol • Tar preparations
Topical therapy
Phototherapy
Systemic therapy
Increasing toxicity
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Topical Treatments -Emollients
• NICE CG153 2012 starts the treatment pathway
with the assumption that, when appropriate,
emollients have been prescribed
• Emollients reduce dryness, cracking, scaling of the skin, including itch
• May be the only treatment necessary for mild psoriasis
• Consider using humectants
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Plaque Psoriasis
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Topical Treatment – Trunk & Limbs
Ist Line
• Potent topical steroid OD and a Vitamin D or Vitamin D analogue OD for up to 8 weeks
2nd Line • Vitamin D or Vitamin D analogue alone BD for 8 – 12 weeks
3rd line • Potent topical corticosteroid BD or a coal tar preparation OD/BD for up to 4 weeks
4th line
• if above cannot be used or a OD preparation would improve adherence offer a combination product of Calcipotriol and Betamethasone Dipropionate OD for up to 4 weeks
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Scalp Psoriasis
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Topical Scalp Treatments
1st line • Potent topical corticosteroid OD for up to 4 weeks
2nd line
• A different formulation of the potent corticosteroid for up to 4 weeks and/or • Topical agents to remove adherent scale before application of the steroid for up to 4 weeks
3rd line
• A combination product containing calcipotriol monohydrate and betamethasone dipropionate OD or • Vitamin D or vitamin D analogue OD up to 8 weeks
4th line
• Very potent topical corticosteroid up to BD for 2 weeks or • Coal tar applied OD or BD or • Referral to specialist for additional support with topical applications and/or advice on other treatment
options
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Face, Flexural and Genital Psoriasis
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Topical treatment Face, Flexures & Genitals
1st Line
• First line – short-term mild to moderate potency corticosteroid applied OD or BD for up to max 2 weeks
2nd Line
• Second line – calcineurin inhibitor applied BD for up to 4 weeks
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Guttate Psoriasis
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Guttate
• Multiple small ‘tear drop’ scaly lesions
• Can affect most of the body
• Comes on quickly
• May follow 7 – 10 days after an URTI
• Tends to affect children & young adults
• Can spontaneously clear within 2-3 months
• May progress into chronic plaque psoriasis
Differential Diagnosis:
Pityriasis rosea, viral exanthems, drug eruptions
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Treatment
• Treat with emollients first
• Also tar preparations, Vitamin D/Vitamin D analogues
• Refer for narrow band UVB if unresponsive
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Referral
Following assessment in a non-specialist setting refer if:
• There is diagnostic uncertainty
• Any type of psoriasis is severe or extensive e.g. more than 10% of the BSA affected
• Any type of psoriasis cannot be controlled with topical therapy
• Acute guttate psoriasis requires phototherapy
• Nail disease has a major functional or cosmetic impact
• Any type of psoriasis is having a major impact on a person’s physical, psychological or social wellbeing
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In summary
• Psoriasis is a complex auto-immune disease which require accurate assessment for impact on physical, psychological and social well being
• Risk factors for co-morbidities should be assessed
• Topical treatments are first line therapy and patients should be involved in treatment choices to aid concordance
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Resources
• www.psoriasis-association.org.uk • www.papaa.org • www.pcds.org.uk • www.bad.org.uk • NICE Clinical Guidelines 153 October 2012 (updated November 2014) • www.nice.org.uk/guidance/cg153/chapter/1-Guidance#assessment-and-referral • Moller et al 2015. A systematic literature review to compare quality of life in
psoriasis with other chronic diseases uisng EQ-5D derived utility values. Patient related outcome measures 2015;6:166-77
• Ferreira et al 2016 .Psoriasis and associated psychiatric disorders: a systematic review on etiopathogenesis and clincial correlation. J Clin Aesthet Dermatol. 2015; 9: 36-43
• Esposito et al 2006 .An Italian study on psoriasis and depression. Dermatol. 2006;9(36-43)
• Kurd et al 2017 The risk of depression, anxiety and suicidality in patients with psoriasis; a population based cohort study. Ann Dermatol. 2017;146:891-5