FY10 Pocket Guide WEB PDF

the
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
treatmentsparticularly biologicshave
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
Department of Dermatology Psoriasis is as Debilitating as Other
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
Baylor University Medical Center PASE Questionnaire . . . . . . . . . . . . . . . . . . . . . . 30
Clinical Professor of Dermatology Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . 37
University of Texas
Southwestern Medical School Comorbidities and Psoriasis . . . . . . . . . . . . . . . 43
Dallas, Texas
The Psoriasis and Psoriatic Arthritis Pocket Guide | i

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
ii | The National Psoriasis Foundation The Psoriasis and Psoriatic Arthritis Pocket Guide | iii
Unapproved Agents . . . . . . . . . . . . . . . . . . . . . 120
chapter 1
Hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 120
Mycophenolate Mofetil . . . . . . . . . . . . . . 121
6-Thioguanine . . . . . . . . . . . . . . . . . . . . . . 122
CHAPTER 6: TRANSITIONAL STRATEGIES

FOR SWITCHING THERAPY................. 123 Introduction
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
iv | The National Psoriasis Foundation

Introduction
CHAPTER 1: introduction
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
The Psoriasis and Psoriatic Arthritis Pocket Guide | 1

Introduction
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
patients 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 physicians Arthritis 6 7
judgment and assessment of the extent of Hypertension 5 2
Depression 4 11
the disease, specific locations involved, and 3 6
Cancer
the effect of the disease on the patients 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
2 | The National Psoriasis Foundation The Psoriasis and Psoriatic Arthritis Pocket Guide | 3
Introduction
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 Crohns 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 patients 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
Introduction
Figure 1-2: Systemic Therapy Algorithm
immunologic disease such as psoriasis can
1. Does the psoriasis affect > 3% body be difficult for both patient and physician.
surface area (BSA)?
This handbook is designed to facilitate
2. Is the patient disabled by the psoriasis?
3. Does the psoriasis have a significant
No to all. successful treatment. To help you choose
impact on the patients 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
Yes to any of the above. phototherapy or types, recommended treatments, side
systemic treatment.
effects and management options. We have
also suggested treatment sequences. The
5. Does the patient have psoriatic arthritis?* therapies reviewed in Chapter 4 vary in the
6. Was systemic treatment required in the seriousness of their side effects, which are
past? No to all.
7. Is phototherapy contraindicated or
always to be weighed in the balance when
unavailable, or is the psoriasis resistant you consider using a course of therapy.
to phototherapy?
The patient is not

a candidate for How Much, How Often and at What Dose?
Yes to any of the above.
phototherapy or
systemic treatment.
Once you have chosen a treatment strategy,
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
psoriasis skin lesions in patients with psoriatic ment to the next, as in sequential therapy.
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.
chapter 2
Objectives
After studying this handbook, you should
be able to:
Define the severity of psoriasis and

develop an appropriate therapy plan.
Explain the profound emotional, social

and physical impact psoriasis has on Assessing
a psoriasis
the patient.
Understand the important comorbidi-
patient
ties associated with psoriasis.
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
assessing
PATIENT
assessing
Clinical Presentation
a patient
The clinical manifestations of psoriasis
are well-known and are usually recognized
a patient
easily, although presentation and the loca-
tion of the psoriasis may vary at different
stages of the disease.12 (See Table 2-1.)
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.

Table 2-2: Discussion Points for M.D./Patient
Pustular psoriasis is of two types. Patients
on Initial Visit
with pustules localized to the palms and
assessing a patient
soles have palmoplantar psoriasis; patients Symptoms/lesions/diagnosis
with generalized pustulosis have the von Hereditary aspect
Systemic manifestations
Zumbusch form of psoriasis, usually in Exacerbating factors
association with erythroderma. Ameliorating factors
Past treatment responses
Less common forms include guttate, which Range of therapeutic options
is characterized by numerous small, Chronic long-term disease
Psychological ramifications
drop-like lesions frequently following a
Optimism for tomorrow
throat infection, and occurs most often Support/services available from the
in children; and inverse or intertriginous, National Psoriasis Foundation
which is a seborrheic-dermatitis-like form
Adapted from Menter and Weinstein12
of psoriasis in which moist erythematous
lesions appear in skin folds of the body (e.g., Determining Disease Severity
the armpit, under the breast, the buttocks The severity of psoriasis is determined by
or genitals). measuring the percent of BSA affected,
determining the location of lesions and
Initial Work-up considering other factors such as the effect
A total body evaluation, including the nails of psoriasis on the patients quality of life
and scalp, should be performed at the first and ability to function. (See Table 2-3.)
visit. Patients should be routinely asked Psoriasis involving the palms and soles
about joint symptoms, which might be may be considered severe.
indicative of psoriatic arthritis. In addition,
factors relating to the clinical presentation Table 2-3: Severity of Psoriasis and Percent
should be discussed with the patient. of Body Surface Affected
(See Table 2-2.) Severity % of Body Surface
Mild Up to 3%
Moderate 3%-10%
Severe > 10%
Figure 2-1: Prevalence in Psoriasis Patients
Mild psoriasis: Affects up to 3% of the
of Mild, Moderate and Severe Disease
body, generally in isolated patches on
assessing a patient
the knees, elbows, scalp, hands and feet.
2%
8% It can often be controlled with topical
Mild therapy.
Moderate
25% Severe
Moderate psoriasis: Affects 3% to 10%
65% of the bodys surface. It often appears
Mild BSA, treated
with systemic
on the arms, legs, torso, scalp and other
areas. Topical agents, phototherapy,
systemic medications, including
biologics, may be appropriate.
Assessing a Patient
Psoriasis has traditionally been classified Severe psoriasis: Affects >10% of
as mild, moderate or severe. As shown in the body. It may be extensive with
Figure 2-1, about 65% of patients have mild plaques, pustules or erythroderma.
disease and about 35% have moderate to Phototherapy, systemic medications,
severe disease.1-3 The National Psoriasis including biologics or a combination
Foundation defines moderate to severe of these, with or without a topical
disease not only in terms of BSA (>3%) but agent, are usually necessary to achieve
also includes patients with a BSA of < 3% adequate results.
who are being treated with a systemic
medication or with phototherapy. Quality of Life and Severity
Disease severity classifications serve as
For practical treatment purposes, it is a reference point for the physical aspects
helpful to define psoriasis as either limited of the disease, but not the emotional and
(BSA <3%) or extensive (BSA >3%). Extensive social aspects.14 Psoriasis can profoundly
psoriasis (as well as palmoplantar affect a persons life and negatively affect
psoriasis) generally cannot be treated his/her lifestyle, emotional well-being,
with topical treatments alone. Patients social life and ability to work.
with extensive psoriasis are candidates for
phototherapy and/or systemic treatment. Clinical assessment should include
the patients perspective on subjective
Measuring BSA factors such as itching, pain, loss of
The patients hand, including the palm, sleep and effect on daily activities, as
fingers and thumb, is used as the reference well as the clinicians perspective.
point for measuring how much of their
skin is affected by psoriasis, representing
roughly 1% of the bodys surface.
A patient may have psoriasis that covers Psoriasis Is as Debilitating as Other Major
only a small area, but if it is highly Diseases
assessing a patient
visible or debilitating, it could be consid- The physical and mental functioning of
ered a severe case despite the small patients with psoriasis is reported to be
area involved. affected as much as that of patients with
cancer, arthritis, hypertension, heart
The Koo-Menter Psoriasis Instrument disease, diabetes and depression. 8
(KMPI) was designed to be a practical
assessment tool that dermatologists can Physical- and mental-functioning
use to aid in clinical decision-making and scores for psoriasis patients are among
in documentation for third-party payers.15 the lowest of all groups (10/11 for
The KMPI is short enough for the patient physical and 9/11 for mental functioning,
and the physician to quickly complete, 11representing the lowest functioning).8
with items that are simple and easy to
understand and answer. At the same time, Burning sensations, joint pain and
it is comprehensive enough to include a appearance were negative physical
Validated Health Related Quality of Life factors.
(HRQOL) Index, a psoriasis Quality of Life
index (PQOL-12) and other assessments Itching, skin soreness and the negative
from both the patients and the physicians or dismissive attitude of their doctors
perspective. The patient completes one side regarding psoriasis negatively affected
(prior to being seen by the physician) and mental function.8
then the physician completes the other.
A copy of the KMPI instrument can be found

on page 16. For additional copies, contact
the National Psoriasis Foundation at educa-
tion@psoriasis.org or call 503.244.7404.
Koo-Menter Psoriasis Instrument
Patient Self-Assessment Name: __________________________________ Date: ________________
Part 1: Quality of Life - Please answer each

of the following questions as they pertain
assessing a patient
to your psoriasis during the past month.
(Circle one number per question) Not at All Somewhat Very Much
1. How self-conscious do you feel
0 1 2 3 4 5 6 7 8 9 10
with regard to your psoriasis?
2. How helpless do you feel with
0 1 2 3 4 5 6 7 8 9 10
regard to your psoriasis?
3. How embarrassed do you feel
0 1 2 3 4 5 6 7 8 9 10
with regard to your psoriasis?
4. How angry or frustrated do
you feel with regard to your 0 1 2 3 4 5 6 7 8 9 10
psoriasis?
5. To what extent does your
psoriasis make your appearance 0 1 2 3 4 5 6 7 8 9 10
unsightly?
6. How disfiguring is your
0 1 2 3 4 5 6 7 8 9 10
psoriasis?
7. How much does your psoriasis
impact your overall emotional 0 1 2 3 4 5 6 7 8 9 10
well-being?
8. Overall, to what extent does
your psoriasis interfere with 0 1 2 3 4 5 6 7 8 9 10
your capacity to enjoy life?
How much has each of the following been

affected by your psoriasis during the past
month?
(Circle one number per question) Not at All Somewhat Very Much
9. Itching? 0 1 2 3 4 5 6 7 8 9 10
10. Physical irritation? 0 1 2 3 4 5 6 7 8 9 10
11. Physical pain or soreness? 0 1 2 3 4 5 6 7 8 9 10
12. Choice of clothing to conceal
0 1 2 3 4 5 6 7 8 9 10
psoriasis?
12-item Psoriasis Quality of Life Questionnaire Total Quality-of-Life Score (0-120)
(PQOL-12), Copyright 2002, 2003, Allergan, Inc. (Medical staff to calculate)
Part 2: Part 3:
A. Using the figures below, place an X on the parts of A. Have you ever been diagnosed with
your body that currently have psoriasis. psoriatic arthritis? Yes No
B. Do you have swollen, tender, or stiff joints
assessing a patient
(e.g., hands, feet, hips, back)?
Yes No
If yes, how many joints are affected?

(Check one box)
1 2 3 4 More than 4
If yes, how much have your joint symptoms

affected your day-to-day activities?
Not at all A little A lot
Very much
Once completed, please

STOP return to medical staff
front back
Koo-Menter Psoriasis Instrument

Physician Assessment Name: __________________________________ Date: ________________
Part 1: Total Quality-of-Life assessment

score (from part 1 of previous page)
Part 2: Area of Involvement: % BSA (body

surface area)
Head % Head: up to 9% of total BSA Note: Patients open hand (from wrist to
tips of fingers) with fingers tucked together
Anterior Trunk % Anterior Trunk: up to 18% and thumb tucked to the side equals
approximately 1% body surface area
Posterior Trunk % Posterior Trunk: up to 18%
Right Leg: up to 18% (includes

Right Leg % buttock)
Left Leg % Left Leg: up to 18% (includes

buttock)
Both arms % Both Arms: up to 18%
Genitalia % Genitalia: 1% Total BSA %
Part 3: In terms of psoriasis severity, does
the patient have:
Plaque, erythrodermic, or pustular psoriasis
Yes No
assessing a patient
with >10% BSA involvement?
Guttate psoriasis? Yes No
Localized (< 10% BSA) psoriasis but resistant

to optimized attempts at topical therapy
Yes No
or physically disabling (e.g., palmoplantar
psoriasis)?
Localized (< 10% BSA) but serious subtype

with possibility of progression (e.g., pustular Yes No
or pre-erythrodermic psoriasis)?
Clinical evidence of psoriatic joint disease

as assessed by physician (e.g., examine IP,
MCP and MT joints of hands, wrists, feet and Yes No
ankles, plus patient responses from Part 3 of
patient self-assessment)?
Substantial psychosocial or quality-of-life

impact documented by patient Quality-of-Life Yes No
self-assessment score of 50?
Part 4: Is phototherapy an option?

Is a suitable phototherapy unit readily
Yes No
accessible to the patient?
Does the anatomical location or form of

psoriasis (e.g., scalp, inverse, erythrodermic) Yes No
preclude phototherapy?
Does the patient have the dedication, time,
Yes No
stamina, or transportation for phototherapy?
Has phototherapy, as monotherapy, failed in
Yes No
the past?
Is phototherapy contraindicated (e.g.,
photosensitive drugs, history of multiple skin Yes No
cancers)?
In your clinical judgment, is phototherapy

likely to yield substantial improvement to Yes No
justify its use before systemic therapy?
Physician/Nurse comments:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
assessing a patient
_____________________________________________________________________________________________________
If at least one of the shaded boxes in both

Part 3 and Part 4 on the previous page are
checked, then the patient is a candidate for
systemic therapy.
Conclusion: The patient is a candidate for

systemic therapy.
Yes No
These results suggest that physicians plan- 26% had to alter or stop their normal
ning treatment options should consider daily activities.
assessing a patient
psychological and social aspects of the
disease, as well as the physical aspects (e.g., 40% chose clothing to cover up their
severity of skin lesions and the possibility condition.
of associated joint disease).
36% had problems with sleep.
Psoriasis Affects Social and Economic
Well-being These studies confirm the major impact
In a mail survey conducted by the Psoriasis that psoriasis has on patients lives.
Foundation, patients were asked to assess Physicians must recognize this impact and
the effects of psoriasis on their lifestyle, work with their patients to control both the
emotional well-being and social interac- disease and all the sequelae.
tions with others.14 The following problems
were identified in this survey: Types of Psoriasis
A patients psoriasis may present in
Difficulty finding a job varying degrees of severity during the
course of the disease. Individual lesions
Job complications (e.g., 2.3 days/year may range from pinpoint lesions to large
were missed due to psoriasis) plaques. The size of the lesions helps deter-
mine the psoriasis type.
Financial distress (reported by about
one-third of respondents) Plaque psoriasis is the most common type
of psoriasis.13
Suicide contemplation
Diagnosed in 80% to 90% of patients
Sexual activity concerns
Characterized by sharply defined
Embarrassment when people saw their erythematosquamous plaques that are
psoriasis (81% of respondents); frustra- distributed somewhat symmetrically
tion with ineffective treatments (90%);
feeling unattractive (75%); depression Most commonly seen on the scalp
(54%)
Coin-sized to palm-sized plaques,
In a 2002 study conducted by the Psoriasis usually present for months to years.
Foundation, patients with moderate to Lesions larger than palm-sized are
severe psoriasis said that their disease often due to coalescence of individual
affected their quality of life in the following plaques, as seen in geographic psoriasis.
ways7:
Nail involvement in up to 55% of patients, Pustular palmoplantar psoriasis occurs in
with findings such as pitting, onycho- less than 5% of patients, often presenting with
assessing a patient
lysis, subungual hyperkeratosis and oil erythematous, scaly plaques with pustules on
drops. palms and soles. Pustules vary in size from
1mm to 1 cm and are yellow at first, turning to
Erythrodermic psoriasis consists of brown.
inflammation of the skin with replace-
ment of the skin surface by generalized Pustular psoriasis, seldom seen in children,
erythema, scaling and exfoliation.13 affects mostly the elderly. Only 12% of patients
This type is sometimes called exfoliative develop it before age 60. Between 70% and 90%
psoriasis. of patients are female; 10% to 25% have a posi-
tive family history.
It is diagnosed in about 10% of patients
at certain times in their lifetime; Generalized forms of the disease (e.g., von
repeated episodes are not uncommon. Zumbusch), though uncommon, are frequently
associated with arthritis and a stormy course
Patients may be ill and have hypo- or of disease.
hyperthermia, protein loss, dehydration,
renal failure and cardiac abnormalities. Guttate psoriasis is characterized by mostly small
Death may occasionally ensue. Gross papules of short duration (weeks to months).13
nail deformations are frequent.
It usually affects children and young adults.
Previous history with signs of psoriasis
and skin biopsy is helpful in the differ- Many patients suffer from an infection before
ential diagnosis (e.g., eczema, Sezarys the lesions appear, particularly an upper respi-
syndrome, pityriasis rubra pilaris ratory infection, commonly of the streptococcal
[PRP], etc.). variety.
It may occur at any age. Droplet lesions occur over the entire body
surface. The trunk is most commonly affected
Pustular psoriasis is characterized by indi- with the palms and soles usually being spared.
vidual or coalescing sterile pustules.13
Inverse/flexural psoriasis is a seborrheic-derma-
When inflammatory processes titis-like form that occurs in the armpit, under the
dominate, patients may develop either breast and in skin folds around the groin, buttocks
generalized (von Zumbusch psoriasis) and genitals.13
or localized pustules, most often on the
palms or soles (palmoplantar).
Nail and Mucosal Manifestations of Psoriasis Various factors that may trigger or exacer-
Both the nail bed (onycholysis, yellowish discol- bate psoriasis are listed in Table 2-4.
assessing a patient
oration and/or hyperkeratosis) and the nail
matrix (pitting) can be observed in psoriasis.13 Table 2-4: Triggers for Psoriasis
Fingernails are more often involved than Stress

toenails. Most patients with psoriatic arthritis
Winter weather
have co-existent nail involvement. About half of
these patients have pain and are restricted in Physical trauma to the skin
their daily activities because of nail changes.
Phototoxic reactions (solar, UVB or PUVA
About 50% of all patients with psoriasis have nail induced)
involvement.
Activation of local cellular immunity by
allergens, infections and immunizations
Lesions can occur on mucosal membranes,
including the geographic tongue in psoriasis Systemic immunological activation or
patients. alteration (e.g. hypersensitivity to a
drug or other antigen such as Group A
streptococcal or HIV infection
Drugs (e.g. corticosteroids, lithium,

antimalarials, beta-blockers,
nonsteroidal anti-inflammatory drugs,
angiotensin converting enzyme inhibitors)
Adapted from Menter and Weinstein12
Psoriatic Arthritis patients for the signs and symptoms of
Joints are affected in as many as 30% psoriatic arthritis.
assessing a patient
of patients with psoriasis. Psoriasis of
the joints is called psoriatic arthritis Table 2-5: Five Types of Psoriatic Arthritis
(PSA) and is characterized by inflam- (PSA)
mation and stiffness in the soft tissue Type Characteristics
around the joints. There are five clinical
Affects about 15% of PSA
subtypes of joint involvement, and the patients. Involves multiple
fingers and toes are frequently involved Symmetric symmetric pairs of joints
(Table2-5).16 arthritis in the hands and feet;
resembles rheumatoid
arthritis.
Assessing joint signs and symptoms is a
key component of evaluating psoriasis The most common type of
patients. Skin lesions of psoriasis PSA, found in about 80% of
tend to occur before joint symptoms. patients. Usually involves only
1-3 joints in an asymmetric
Moreover, joint involvement can cause Asymmetric
pattern and may affect any
irreversible damage to the joint, so arthritis
joint (e.g. knee, hip, ankle,
early recognition and treatment is and wrist). Hands and feet
important. may have enlarged sausage
digits.
Finally, the presence or absence of joint This classic type occurs
involvement may help determine whether in only about 5% of PSA
Distal
systemic treatments are used to control the patients. Primarily involves
interphalangeal
disease. distal joints of the fingers
predominant
and toes. It is sometimes
(DIP)
confused with osteoarthritis,
Pase Questionnaire but nail changes are common.
Complications of psoriatic arthritis can be
prevented with early diagnoses and appro- Inflamation of the spinal
priate treatment. The Psoriatic Arthritis column causing a stiff
neck and pain in the lower
Screening and Evaluation (PASE) question- Spondylitis back and sacroiliac area.
naire was developed using standardized Peripheral disease may be
methodology using both functional and seen in the hands, arms, hips,
health-related instruments focused on legs and feet.
musculoskeletal disease.
A severe, deforming type of
PSA affecting <5% of patients
The Psoriatic Arthritis Screening and Arthritis with PSA. Usually affects a
Evaluation tool is included in this pocket mutilans few joints in the hands and
guide, page 32. It is a validated patient self- feet. Has been associated
with pustular psoriasis.
administered tool to help screen psoriasis
Please circle or mark ONLY ONE of the answers to the
Psoriatic Arthritis Screening and following questions. The answers to these questions will
Evaluation (PASE) questionnaire help us better understand your symptoms.This should
Identifier take about 5-6 minutes to complete. Thank you for your
time.
assessing a patient
A. Have you ever been diagnosed with psoriatic YES NO
arthritis by a rheumatologist?
YOUR Symptoms Strongly Disagree No Agree Strongly
Disagree Opinion Agree
1. I feel tired during most of the day. 1 2 3 4 5
2. My joints hurt. 1 2 3 4 5
3. My back hurts. 1 2 3 4 5
4. My joints become swollen. 1 2 3 4 5
5. My joints feel hot. 1 2 3 4 5
6. Occasionally, my entire finger or toe 1 2 3 4 5
becomes swollen, making it look like a
sausage.
7. I have noticed that the pain in my joints 1 2 3 4 5
moves from one joint to another. For
example, my wrist will hurt for a few days,
then my knee will hurt, and so on.
Total Symptom Score
your ability to do daily activities Strongly Disagree No Agree Strongly

Disagree Opinion Agree
8. I feel that my joint problems have affected 1 2 3 4 5
my ability to work.
9. My joint problems have affected my ability 1 2 3 4 5
to care for myself (for example, getting
dressed or brushing my teeth).
10. I have had trouble wearing my watch or 1 2 3 4 5
wearing rings on my fingers.
11. I have had trouble getting into or out of a car. 1 2 3 4 5
12. I am unable to be as active as I used to be. 1 2 3 4 5

13. I feel stiff for more than 2 hours after waking 1 2 3 4 5
up in the morning.
14. The morning is the worst time of day for me. 1 2 3 4 5
15. It takes me a few minutes to get moving as 1 2 3 4 5
well as I can, at any time of the day.
Total Function Score
Total PASE Score
PASE design and scoring system Table 3:
PASE is composed of 15 items scored on a five- 36 37 - 43 44
point scale. The scale ranges from Strongly Agree
to Strongly Disagree (Table 1). Re-administer Consider Refer for a
PASE quarterly referral for a rheumatology
or at the next rheumatology evaluation
assessing a patient
TABLE 1: Points follow-up visit, evaluation, or
Five-point scale scoring system if longer re-administer
than 3 months PASE at a
Strongly Agree 5 follow-up visit
Agree 4
Neutral 3
Disagree 2 For individuals whose PASE score <44 AND their
Strongly Disagree 1 response to question A is YES, please refer
Item left blank or unanswered 0 individual for rheumatology evaluation. PASE
score is not reliable in these individuals who may
PASE Total score is calculated by summing the either not be currently symptomatic with psoriatic
scores for all 15 items. The Total score ranges arthritis or may be on therapy.
from a minimum of 15 to a maximum of 75 (Table2).
PASE has two sub-scale scores, Function and
Interpretation of Incorrectly Completed Paper
Symptoms. The Function sub-scale has 7 items,
and the maximum Function score is 35. The
Questionnaires
When PASE is being administered on paper, please
Symptom sub-scale has 8 items, and the maximum
use the following guidelines to score:
Symptom score is 40.
1. One item is left blank or unanswered: Please
TABLE 2: Symptom Function Total PASE score this item 0 and calculate the Total score.
score score score
2. Two or more items left blank or unanswered:
Minimum 7 8 15 Please do not score this questionnaire, and
score re-administer PASE when possible.
Maximum 35 40 75 3. Two or more responses are selected for an item,
score e.g., item 8 is answered as both Strongly Agree
and Agree: Please select the higher score.
In this example, score item 8 with 5 points for
Interpretation of the Total score Strongly Agree.
At this point, we have evaluated the Total score
in preliminary studies. Recommendations on
use of the Symptom and Function scores are not An item is marked incorrectly between two
available at this time. The Total score may be responses, e.g. item 10 is marked between
interpreted as below in Table 3, although these Neutral and Disagree: Please score this item 0
data are preliminary. Please read the disclaimer and calculate the Total score.
at the bottom of the PASE questionnaire carefully,
Copyright 2006-2009, Brigham and Womens Hospital, Inc.
and return the agreement that accompanied the
All Rights Reserved. Reprinted with permission.
PASE tool to the Director, Corporate Sponsored BRIGHAM AND WOMENS HOSPITAL HAS MADE NO INVESTIGATION AND
Research and Licensing, Brigham and Womens MAKES NO REPRESENTATIONS OR WARRANTIES, EXPRESS OR IMPLIED,
AS TO THE QUESTIONNAIRE. BRIGHAM AND WOMENS HOSPITAL MAKES
Hospital, prior to using PASE. PASE was developed NO REPRESENTATIONS OR WARRANTIES OF MERCHANTABILITY OR
as a screening tool to evaluate psoriasis patients FITNESS FOR ANY PARTICULAR PURPOSE OR THAT THE USE OF THE
QUESTIONNAIRE WILL NOT INFRINGE ANY PATENTS, COPYRIGHTS,
for the presence of active inflammatory arthritis TRADEMARKS OR OTHER RIGHTS OF ANY THIRD PARTY. IN NO EVENT
SHALL DATA GENERATED BY OR CONCLUSIONS DRAWN FROM USE OF
and must not be used to replace a rheumatology THE QUESTIONNAIRE BE USED FOR THE PROVISION OF PATIENT CARE.
evaluation, for patient care or for treatment BRIGHAM AND WOMENS HOSPITAL SHALL NOT BE LIABLE FOR ANY
DIRECT, INDIRECT OR CONSEQUENTIAL DAMAGES TO LICENSEE OR ANY
recommendations. THIRD PARTY, OR WITH RESPECT TO ANY CLAIM BY ANY THIRD PARTY, ON
ACCOUNT OF OR ARISING FROM USE OF THE QUESTIONNAIRE.
PASE Questionnaire references Differential Diagnosis
1. Domingez PL, Husni ME, Holt EW, Tyler S, Patients with typical psoriatic lesions are
assessing a patient
Qureshi AA. Validity, reliability and sensitivity relatively easy to diagnose, but difficul-
to change properties of the psoriatic arthritis ties may arise when asymmetrical, indi-
screening evaluation questionnaire. Arch. vidual lesions are present; when eruptive,
Der. Res. 2009; 301(8):573-579. pustular or erythematous phases are
evolving; or when the patient has concomi-
2. Husni ME, Meyer KH, Cohen DS, Mody E, tant diseases.17 Diagnoses to rule out are as
Qureshi AA. The PASE questionanaire: Pilot follows:
testing a psoriatic arthritis screening and
evaluation tool. J. Am. Acad. Dermatol. 2007; Bowens disease (in situ squamous cell
57(4):581-587. carcinoma), often presenting as a single
lesion, is found in both sun-exposed and
If you are interested in obtaining the PASE sun-protected areas of the body.
questionnaire for your practice, please
contact either Dr. Elaine Husni The plaque is well demarcated, pink to
(husnie@ccf.org) or Dr. Abrar Qureshi red in color, with varying amounts of
(aqureshi@bics.bwh.harvard.edu). scale.
A biopsy of the skin lesion is diagnostic.
Eczema may be confused with discoid

plaque psoriasis, erythrodermic psori-
asis, generalized pustular psoriasis (von
Zumbusch) or palmoplantar psoriasis.
Primary lesions may include papules,

patches and plaques; in severe eczema,
weeping and crusting may predominate.
Long-standing eczema may become
lichenified, characterized by thickened,
scaling skin that resembles psoriasis.
Acute eczema with vesiculation is easily

differentiated from psoriasis, as vesicu-
lation is seldom seen with psoriasis.
Hyperkeratotic eczema of the palms As CTCL develops within plaque
and soles is more of a problem, as it is lesions, the palpable component of the
assessing a patient
not a specific diagnosis but is used to plaque increases.18
describe several disorders, such as the
following: A skin biopsy in which atypical
T lymphocytes are found in the
Chronic palmoplantar eczema (e.g., epidermis and dermis is diagnostic.
allergic contact dermatitis, irritant
dermatitis or atopic dermatitis) Pityriasis rubra pilaris (PRP) may be
confused with erythrodermic psoriasis.
Dermatitis of palms and soles that is
not eczema or psoriasis, i.e., overlap Follicular papules are characteristic,
with follicular hyperkeratosis on the
Dyshidrotic eczema of palms and back of the finger.19 The scalp may show
soles psoriasis-like changes.
A skin biopsy may sometimes help Patients with PRP are differentiated
differentiate chronic hyperkeratosis by having islands of unaffected skin
and erythema of the palms and (skip areas) surrounded by involved
soles from psoriasis. Unfortunately, skin and yellowish or palmoplantar
biopsies often reveal a combination of keratoderma.
spongiotic and psoriasiform changes
that are not specific to either psori- Classic psoriatic nail changes are
asis or allergic/irritant dermatitis. absent.
Mycosis fungoides, patch or plaque Histologic examination of a hyperkera-

stage (cutaneous T cell lymphoma) totic papule may be diagnostic.
In its early stages cutaneous T cell PsEma is a term coined to describe

lymphoma (CTCL) may be confused with signs and symptoms of a combination of
psoriasis; but unlike psoriasis, it tends psoriasis and eczema. 20
not to have the true micaceous scale.
An overlap syndrome with clinical
CTCL may present as erythroderma features of both diseases.
(Sezarys syndrome) and should be
considered when no apparent cause Not at present widely accepted. It is not
of erythroderma is found. a recognized diagnosis.
Reiters syndrome should be differenti- trachomatis may initiate Reiters
ated from psoriatic arthritis. These syndrome.
assessing a patient
two diseases have many similarities,
but differ significantly in their clinical In the majority of cases, a history will
presentation and natural history. reveal an infection one to four weeks
before symptoms appear; however, some
Psoriatic arthritis occurs in as many show no signs of an earlier infection.
as 30% of psoriasis patients, often Some patients report a new sexual
when skin involvement is severe. It partner.
is more gradual in onset, affects the
upper extremities and is not associated Lab findings: elevated ESR during acute
with mouth ulcers, urethritis or bowel phase, mild anemia, elevated WBC in
symptoms.16 synovial fluid, positive HLA-B27 antigen,
and serologic evidence of infection.
In Reiters syndrome, the onset of Culture is likely to be negative.
arthritis is acute, with symptoms occur-
ring in new joints over a period of a few Secondary syphilis-psoriasiform type
days to a few weeks. The arthritis is may be difficult to differentiate from
asymmetric and additive. Joint symp- guttate psoriasis. Syphilis may involve
toms may persist in as many as 30% to the face and often involves the palms
60% of patients. 21 and soles, producing psoriasiform
papules with collarette of scale.
The most common sites of involvement
in Reiters syndrome are the knee, ankle Patients may also have nonscarring
and toe joints, but the wrist and fingers alopecia, mucous patches in the mouth,
can also be affected. A sausage digit lymphadenopathy, malaise, fever, head-
a diffuse swelling of a single finger or ache and myalgias.18
toeis typical of both Reiters arthritis
and psoriatic arthritis. Low back and The primary lesion may or may not still
spinal pain are common. be evident.
Patients with Reiters syndrome often Lab tests: VDRL and skin biopsies are
have conjunctivitis, mucocutaneous diagnostic.
lesions and genitourinary disease. Nail
changes are common. Subacute cutaneous lupus erythema-
tosus (SCLE) is characterized by a
Infection with Shigella, Salmonella, widespread photosensitive, nonscar-
Yersinia, Campylobacter species, ring eruption that can present in two
clostridium dificile, and Chlamydia different forms. 22
The first form is a psoriatic-like papu- Table 2-6 lists the types of psoriasis and
diagnosing
losquamous eruption with discrete differential diagnosis
assessing
erythematous patches on the back,
Table 2-6: Differential diagnosis
chest, shoulders, arms and the backs of
Type of Psoriasis Differential Diagnosis
psoriasis
the hands. The scaling patches tend to
merge into large plaques. Eczema, PsEMA
a patient
(combination of psoriasis
The second is an annular form with and eczema), mycosis
central clearing and peripheral scale. Chronic Plaque fungoides, patch or
plaque stage CTCL,
tinea corporis, Bowens
Acute SCLE is characterized by a
disease, SCLE
butterfly rash on the face, which
consists of erythema of the nose and Secondary syphilis,
cheeks. psoriasiform type
Guttate
tinea corporis, Sezary
Lab tests: a panel of antibody tests helps syndrome
differentiate various forms of lupus PRP, eczema, SCLE,
Erythrodermic
erythematosus (Ro and La). Sezary syndrome
Pustular Eczema, PsEma,
Tinea corporis is a localized-to-wide- PSA Reiters syndrome
spread fungal infection of non-hair-
bearing skin with a varying presenta-
tion, depending on the severity of the Comorbidities and Psoriasis
inflammatory response. 23 There is growing recognition that psoriasis
is a systemic inflammatory disease that
It may have the appearance of ring- is associated with increased cardiovas-
worm or appear as deep inflammatory cular morbidity and mortality. Diabetes,
nodules or granulomas. obesity and metabolic syndrome, as well as
myocardial infarction and depression, are
Characterized by papulosquamous more common in patients with psoriasis
pink-red skin lesions with central than in the general population.9,10
clearing and peripheral scale.
Screening for these comorbidities is
Lab tests: KOH stain and/or fungal appropriate. While definitive guidelines
culture of scale or biopsy. have not been established, patients with
chapter 3
psoriasis should at the very least have the
recommended evaluations and prevention
strategies that are appropriate for their
age. Smoking cessation should be encour-
aged. Patients should also be encouraged
to let their primary care physician know
Choosing a
about the psoriasis, as psoriasis is an
independent cardiovascular risk factor.
Depending on other risk factors, blood
treatment
pressure, body mass index and cholesterol
levels may be checked more frequently in
this at-risk population. 24
strategy

CHAPTER 3:
CHOOSING A TREATMENT STRATEGY
There are multiple treatment options, as

well as several strategies, that can be
chosen to treat patients. The options are
topical therapy, phototherapy and systemic
therapy. (See Table 3-1.) When choosing
a therapy, remember that the goals of
therapy in treating patients with psoriasis
are to:
treatment strategy
Gain initial rapid control of the disease.
Decrease the involvement of BSA.
Decrease erythema, scaling and the

thickness of lesions of individual
plaques.
Maintain the patient in long-term remis-

sion and avoid relapse.
Avoid adverse effects as much as

possible.
Improve the patients quality of life.
In addition to choosing a treatment option,

you must also determine which treatment
strategy is most appropriate for your
patient. The following are the four types
of therapeutic strategies you can use when
you prescribe the various agents listed in
Table 3-1:

Table 3-1: Psoriasis Treatment Options
Topical Therapy Phototherapy Systemic Therapy
Goeckerman
Anthralin Retinoids
(tar and UVB)
Corticosteroid creams, lotions, ointments, gels, Broad-band Methotrexate immune-
foams, shampoos, patches and solutions UVB modulating therapy
Narrow-band Other cytotoxic immune-
Tars
UVB modulating therapy
Vitamin D PUVA Cyclosporine
Retinoid gel and creams Excimer laser Biologics - TNF blockers
treatment strategy
Topical immunomodulators Biologics Anti-CD2
Biologics IL12/23
blockers
Monotherapy, the use of one therapeutic the risk of psoriasis flare between the
agent during one treatment time. clearing and maintenance phases.
Combination therapy, the use of two Monotherapy

or more agents in combination during Monotherapy is often used as initial
one treatment time. In combination, therapy.
the agents are sometimes used at
lower doses than when they are used in The advantage of monotherapy is
monotherapy. that one drug may limit side effects,
decrease costs and improve adherence
Rotation therapy, the use of therapeutic to the treatment regimen.
agents for a specified period of time
(usually 1 to 2 years), after which they Long-term monotherapy with some
may be switched to alternative agents to agents may lead to toxicity at high doses.
avoid cumulative toxicity. Risk factors may accumulate with
continuing therapy.
Sequential therapy, the use of a
stronger agent(s) initially to clear the When monotherapy fails or toxicity
psoriasis rapidly, followed by a less develops, another agent or several
toxic agent(s) for maintenance therapy agents may be added in combination,
with transitional strategy to minimize rotation or sequential therapy.
Combination Therapy Allows the combination of a more potent,
Combination therapy generally allows less safe agent for initial clearing with
lower doses of individual agents to be a safer agent for use in long-term
used, helping to minimize toxicity and control.
improve efficacy. Topicals are often used
in combination with a systemic agent; Will become more important as new
however, combinations of systemic agents immunosuppressive biologic agents
are often underused. 25 The combination become available (e.g., a cytotoxic agent
of two systemic agents, or of a systemic [methotrexate] has been used with
agent with phototherapy, is often more immunosuppressive biologics).
effective than each agent individually.
treatment strategy
When deciding what combination to use Table 3-2 lists frequently used combina-
or to continue to use, you should evaluate tion therapies, and combination thera-
product safety or the agent with the most pies to be used with caution.
favorable side-effect profile.
Rotational Therapy
Allows for a lower dose of each agent to Rotational therapy may facilitate long-term
be used. One agent may be discontinued treatment; in theory it helps minimize
after the psoriasis has cleared and the chronic toxicity by periodically rotating
safer of the two agents used for main- various therapies before respective drug
tenance therapy. Treatment-resistant toxicities occur. (See Figure 3-1.)
patients may be continued on both
agents. 26 Treatments are rotated, usually at
intervals of 1 to 2 years for treatments
Allows the lowest possible effective with known cumulative toxicity, possibly
doses to be used in an effort to mini- returning to the original therapy
mize toxicity. For example, retinoid thereafter.
doses can be reduced to limit mucocuta-
neous toxicity and enhance tolerance.
Table 3-2: Combination Therapy Figure 3-1: Rotational Therapy
Combinations
Frequently Used
with Increased PUVA MTX
Combinations
Toxicity
Retinoids and broad-band Hydroxyurea and
UVB methotrexate
Retinoids and narrow-band Bone marrow

UVB suppressants Acitretin UVB
(e.g. hydroxyurea, +/- Tar
methotrexate,
treatment strategy
6-thioguanine)
Immune
Modulators
Retinoids and PUVA Drugs that -Biologics
(Ultraviolet light A with the increase cutaneous -Cyclosporine*
drug psoralen) carcinogenicity
(e.g. cyclosporine
and PUVA)
Side effects (e.g., methotrexate-induced
Retinoids and methotrexate hepatic changes, cyclosporine-induced
hypertension and renal changes, and
Retinoids and cyclosporine to phototherapy-induced skin changes)
decrease cyclosporine dose may be fully or partially reversed when
a drug is discontinued. 26
Cyclosporine and
methotrexate (low doses
of both) Retinoid mucocutaneous side effects
are completely reversed when the drug
Mycophenolate mofetil and is discontinued.
cyclosporine in order to
taper off cyclosporine
As new forms of therapy become avail-
Oral agents (methotrexate, able, the circle of rotational therapies
retinoids, cyclosporine) with grows larger and the rotation intervals
any biologic may change as we gain additional
knowledge about new treatments.
Cytotoxics (e.g.
methotrexate) and
phototherapy *In patients who have developed multiple
skin cancers as a result of long-term PUVA,
Topicals and retinoids cyclosporine should be avoided, as it may
produce further skin cancers.
The concept of rotational therapy was while minimizing side effects by smoothly
developed before the availability of transitioning from an initial rapid improve-
biologics. Rotation is used less often with ment strategy to a long-term maintenance
biologics, as some of the biologics lose strategy. 27 Sequential therapy is adminis-
efficacy if they are discontinued and then tered in the following three steps:
restarted. In the case of infliximab, not
only is efficacy reduced, but infusion reac- Step 1: Clearing or quick-fix phase
tions are increased.
Step 2: Transitional phase
Sequential Therapy
Sequential therapy involves using specific Step 3: Maintenance phase
treatment strategy
therapeutic agents in a deliberate
sequence to maximize the initial speed of Topical therapy can be administered
improvement and probability of success sequentially to maximize initial clearing,
Table 3-3: Sequential Therapy Examples

Topical Traditional Systemic Biologic
1 month for clearing
Cyclosporine initially
Phase Etanercept 50 mg
Calcipotriene or Calcitriol in 3-5 mg/kg/day for rapid
1 s.c. 2x/week
combination with superpotent topical improvement
corticosteroid*, BID
1 month (or longer) for transition Add acitretin 10-25 mg/

day and gradually titrate
Calcipotriene or Calcitriol BID on upward to maximally
Phase Etanercept 50 mg
weekdays tolerated dose.
2 s.c. 1x/week
Then start tapering
Superpotent topical corticosteroid BID cyclosporine by 1 mg/
on weekends kg/day each month
Maintenance
Phase
Calcipotriene or Calcitriol BID, which
3
may be tapered to once/day and
discontinued if appropriate
* Superpotent topical corticosteroid and topical proportions just prior to application, they can
tazarotene may be combined in a similar fashion. be applied separately or at the same time or
Brand name calcipotriene and halobetasol are different times, or they can be mixed and used
compatible. They can be mixed fresh in equal over a prolonged period.
minimize psoriasis recurrence and avoid Table 3-4: Systemic sequential therapy
steroid rebound. 28 For example, halobetasol using cyclosporine or infliximab followed
propionate and calcipotriene may be used by transition to oral retinoids, etanercept,
as shown in Table 3-3. Sequential therapy adalimumab or alefacept
regimens are also used with systemic
agents (Table 3-3). Oral
retinoid or
etanercept or
When considering the use of systemic Infliximab or adalimumab
therapy, you should keep in mind that cyclosporine or alefacept UVB/PUVA
the rationale for sequential therapy is Phase 1
that some therapies are better suited for Month 0-2
treatment strategy
rapid clearance (e.g., methotrexate and
cyclosporine) whereas others are less toxic
and more appropriate for long-term main-
tenance (e.g., acitretin). (See Table 3-4.) Phase 2A
Month 2-3
Phase 2B
Month 3-7
Phase 3A
Month >7
Phase 3B
Month >7
(if needed)
chapter 4
Treatment
algorithms for
specific patient
types

CHAPTER 4: TREATMENT ALGORITHMS FOR
SPECIFIC PATIENT TYPES
Psoriasis is a complex, multi-faceted

disease with a diverse array of clinical
manifestations and patient expectations.
The authors have spent considerable time
creating the following algorithms in an
attempt to help the reader with specific
situations encountered in clinical practice.
These algorithms are meant purely as
an outline for clinicians in managing
their individual patients. It is hoped that
the algorithms will help every patient to
be treated in a comprehensive fashion,
using the algorithms as a general guide to
therapy.
Treatment algorithms for various types

of patients are included to assist you
in choosing optimal treatments. More
algorithms
detailed information on drug dosing
and side effects for the individual agents
can be found in Chapter 5, Therapeutic
Treatment Options and Their Side Effect
Profiles.
In general, topicals are used for limited

disease or as an adjunct to systemic or
phototherapy for patients with extensive
(so-called moderate to severe) psoriasis.
There is no universally effective therapy

or therapy combination for psoriasis and
psoriatic arthritis. All treatment must
be individually tailored to each patients
needs and the type of disease being
addressed. The following algorithms offer

HEALTHY male ADULT WITH CHRONIC
guidelines for treating specific patient
PLAQUE PSORIASIS (> 5% BSA), W/O
types but are not meant to be restrictive.
Keep in mind the following points: PSORIATIC ARTHRITIS
If UVB phototherapy If UVB phototherapy
Patients should not be forced to fail one
available, feasible, unavailable,
therapy in order to qualify for a more
practical and suitable contraindicated,
appropriate therapy.
ineffective or patient
unable to comply
Ongoing therapy is often required to
maintain remission.
Life factors such as employment, child- First line First line

bearing potential, alcohol intake, access
to therapies, concomitant conditions
such as arthritis or diabetes, response UVB phototherapy Adalimumab
(NB or BB)
to sunlight, and response to prior thera- Alefacept
pies must be considered in selecting the UVB phototherapy
Cyclosporine
ideal treatment for a patient. alone
Etanercept
UVB phototherapy
Psoriasis can cause as much disability + adjuvant topical Infliximab
as cancer, diabetes and other major agents Methotrexate
algorithms
diseases. UVB phototherapy PUVA
+ systemic
Systemic retinoids
retinoids
Ustekinumab
Goeckerman
Second line
Combination therapies
CsA + MTX
MTX + biologic
CsA + biologic
UVB + biologic
Systemic retinoid + biologic
HEALTHY CHILDREN UNDER 18 WOMEN TRYING TO BECOME PREGNANT
WITH CHRONIC PLAQUE PSORIASIS WITH CHRONIC PLAQUE PSORIASIS
(>5%BSA), W/O PSORIATIC ARTHRITIS (> 5% BSA), W/O PSORIATIC ARTHRITIS
If UVB phototherapy If UVB phototherapy If UVB phototherapy If UVB phototherapy
available, feasible, unavailable, available, feasible, unavailable,
practical and suitable contraindicated, practical and suitable contraindicated,
ineffective or patient ineffective or patient
unable to comply unable to comply
First line First line First line First line
UVB phototherapy Adalimumab* Topical Adalimumab

(NB or BB)
Cyclosporine* calcipotriene/
UVB phototherapy Alefacept
Etanercept* calcitriol
alone Cyclosporine
Infliximab* Topical
UVB phototherapy corticosteroids Etanercept
+ adjuvant topical Methotrexate*
Moisturizers and Infliximab
algorithms
agents PUVA (dark skin)* UVB phototherapy PUVA
UVB phototherapy (NB and BB)
+ systemic Ustekinumab
Goeckerman
retinoids (for
special cases)
Goeckerman
* Not approved for treatment of psoriasis in children
GUTTATE PSORIASIS (> 5% BSA), ERYTHRODERMIC PSORIASIS in males
W/O PSORIATIC ARTHRITIS or females not of childbearing
potential
If UVB phototherapy If UVB phototherapy First line
ineffective or patient Cyclosporine
unable to comply Infliximab
Methotrexate
Systemic Retinoids
First line First line
UVB phototherapy PUVA

(NB or BB)
Short course MTX
or CsA Second line
Adalimumab
Etanercept
algorithms
Combinations: MTX and TNF, retinoids and TNF,
retinoids and CsA, CsA and MTX
Second line
Adjunctive topicals such as wet compresses, cool

Adalimumab
baths, mid-potency steroid ointment, hospitalization
Alefacept
Cyclosporine Once stable, initiate maintenance with plaque psoriasis
algorithm
Etanercept
Infliximab
Ustekinumab
CURRENTLY HEAVY ALCOHOL INTAKE HEPATITIS C WITH CHRONIC PLAQUE
WITH CHRONIC PLAQUE PSORIASIS PSORIASIS (> 5% BSA), W/O PSORIATIC
(> 5% BSA), W/O PsA in males or ARTHRITIS in males or females not
females not of childbearing of childbearing potential
potential
If UVB available, If UVB unavailable,
If UVB phototherapy If UVB phototherapy feasible, practical and contraindicated,
available, feasible, unavailable, suitable ineffective or patient
practical and suitable contraindicated, unable to comply
unable to comply
UVB phototherapy Adalimumab*

First line First line (NB or BB)
Etanercept*
UVB phototherapy
Infliximab*
UVB phototherapy Adalimumab alone
PUVA
(NB or BB) UVB phototherapy
Alefacept
+ adjuvant topical Systemic retinoids
UVB phototherapy
Cyclosporine (short agents
alone
term)
algorithms
UVB phototherapy UVB phototherapy
Etanercept + systemic
+ adjuvant topical
agents Infliximab* retinoids (for
special cases)
+ systemic Goeckerman
Systemic retinoids*
retinoids (for
Ustekinumab
special cases)
Goeckerman Second line
Alefacept
Second line Azathioprine
Cyclosporine
Combination therapies Combination therapies
* Liver studies should be monitored * Strength of data regarding safety of use greater for
etanercept than adalimumab or infliximab.
HEALTHY ADULTS WITH PALMOPLANTAR HIV INFECTION WITH CHRONIC
PSORIASIS, W/O PSORIATIC ARTHRITIS PLAQUE PSORIASIS (> 5% BSA), W/O
in males or females not of PsA in males or females not of
childbearing potential childbearing potential
Topical corticosteroids Adequate HIV control with antiviral treatment

Topical calcipotriene/calcitriol
Topical calcipotriene-steroid combination
If UVB available, If UVB phototherapy
Topical tazarotene unavailable,
feasible, practical and
Keratolytics suitable contraindicated,
Moisturization ineffective or patient
unable to comply
Second line
Second line Second line
Systemic retinoids
Targeted UVB phototherapy UVB phototherapy Systemic
(NB or BB) retinoids
UVB phototherapy alone
Third line UVB phototherapy +

adjuvant topical agents
algorithms
Goeckerman
Adalimumab
PUVA photochemotherapy
Alefacept
PUVA
Cyclosporine
photochemotherapy
Etanercept
alone
Infliximab
PUVA
Methotrexate
photochemotherapy +
PUVA/topical or systemic
adjuvant topical agents
Ustekinumab
Third line
Fourth line
Adalimumab
Combination therapies Cyclosporine
CsA + MTX Etanercept
CsA + biologic Hydroxyurea
MTX + biologic Infliximab
Methotrexate
PUSTULAR PSORIASIS in males or CHRONIC PLAQUE PSORIASIS
females not of childbearing (> 5% BSA), WITH CONCURRENT
potential PSORIATIC ARTHRITIS
First line First line*
Cyclosporine Adalimumab
Infliximab Etanercept
Methotrexate Golimumab
Systemic retinoids Infliximab
Methotrexate
Biologic + MTX
Second line Consider referral for rheumatology evaluation, X-ray

studies and range-of-motion studies
Adalimumab * Mild psoriatic arthritis can be treated with

non-steroidal anti-inflammatory agents.
Etanercept
PUVA photochemotherapy
algorithms
In conjunction with adjunctive topicals such as
wet compresses, cool baths, mid-potency steroid
ointment, hospitalization
Rule out sepsis
Once stable, initiate maintenance with plaque

psoriasis algorithm
HYPERTENSION WITH CHRONIC PLAQUE HEALTHY ELDERLY PATIENT WITH
PSORIASIS (> 5% BSA), W/O PSORIATIC CHRONIC PLAQUE PSORIASIS (> 5% BSA),
ARTHRITIS in males or females not W/OUT PSORIATIC ARTHRITIS
of childbearing potential If UVB phototherapy If UVB phototherapy
If UVB phototherapy If UVB phototherapy practical and suitable contraindicated,
available, feasible, unavailable, ineffective or patient
practical and suitable contraindicated, unable to comply
unable to comply
UVB phototherapy Adalimumab

First line First line (NB or BB) Alefacept
UVB phototherapy Etanercept
alone Infliximab
(NB or BB) UVB phototherapy + Systemic retinoids
Alefacept
UVB phototherapy systemic retinoids Ustekinumab
Etanercept
alone UVB phototherapy
UVB phototherapy Infliximab + adjuvant topical
+ systemic Methotrexate agents
retinoids PUVA Goeckerman
UVB phototherapy Systemic retinoids PUVA
algorithms
+ adjuvant topical
agents Ustekinumab
Goeckerman Second line
Methotrexate*
Second line
Combination therapies Third line

MTX + biologic
Retinoid + biologic Cyclosporine*
Biologic + UVB phototherapy
MTX + CsA*
MTX + biologic*
CsA + biologic (short term only)*
Biologic + UVB
* When using these medications, screen for possible

impairment of renal and/or hepatic function.
HEALTHY ADULT WITH SEVERE NAIL HEALTHY PERSON OF COLOR WITH
PSORIASIS, W/O PSORIATIC ARTHRITIS CHRONIC PLAQUE PSORIASIS
(> 5% BSA), W/O PSORIATIC ARTHRITIS
in males or females not of
Patients desiring non- Patients desiring more
childbearing potential
invasive treatment aggressive treatment
unable to comply

Cosmetic treatment Intralesional
Topical steroids steroids UVB phototherapy Adalimumab
(NB or BB) Alefacept
UVB phototherapy Cyclosporine
alone Etanercept
UVB phototherapy + Infliximab
algorithms
Second line systemic retinoids Methotrexate
UVB phototherapy Systemic retinoids
Adalimumab + adjuvant topical Ustekinumab
agents
Alefacept
Goeckerman
Cyclosporine
PUVA
Etanercept
Infliximab
Methotrexate
Second line
Systemic retinoids
Ustekinumab
CsA + MTX
CsA + biologic
MTX + biologic
Biologic + systemic retinoid
Biologic + UVB
HEALTHY ADULTS WITH CHRONIC Cyclosporine and PUVA should be avoided if possible,
as they may increase the risk for both non-melanoma
PLAQUE PSORIASIS (> 5% BSA),
skin cancer, especially in fair-skinned patients, and
AND HISTORY OF SKIN CANCER, W/O melanoma. At the present time there is no known
PSORIATIC ARTHRITIS in males or contraindication to biologic therapies in patients with a
females not of childbearing significant past medical history of various skin cancers.
However, as experience with these agents increases,
potential
this recommendation may need to be modified as there
have been case reports about the development of skin
First line
cancers when some of these agents are used.
Systemic retinoids, if baseline lipids WNL

unable to comply
Second line Second line
algorithms
UVB phototherapy
Etanercept
alone
UVB phototherapy Infliximab
+ systemic Methotrexate
retinoids Ustekinumab
UVB phototherapy
+ adjuvant topical
agents
Goeckerman
Third line
MTX + biologic
UVB + biologic (only if absolutely necessary)
WOMEN OF CHILDBEARING POTENTIAL *Women of childbearing potential should be
informed about the need to abstain from
USING APPROPRIATE CONTRACEPTION
becoming pregnant and remain on appropriate
WITH CHRONIC PLAQUE PSORIASIS contraception for the recommended interval after
(> 5% BSA), W/O PSORIATIC ARTHRITIS the discontinuation of these medications. Other
oral retinoids with a short half-life similar to
isotretinoin would also be appropriate for short-
available, feasible, unavailable, term use if needed in this setting.
unable to comply

UVB phototherapy Cyclsosporine
alone Etanercept
UVB phototherapy + Infliximab
systemic retinoids* Methotrexate
algorithms
+ adjuvant topical Ustekinumab
agents
UVB + short-term
isotretinoin, if
necessary*
Goekerman
Second line
MTX + CsA
MTX + biologic
Isotretinoin (short term, if necessary)*
+biologic
Biologic + UVB
HEALTHY ADULT WITH SCALP
chapter 5
PSORIASIS, W/O PSORIATIC ARTHRITIS
in males or females not of
childbearing potential
First line
Therapeutic
Medicated shampoos including tar, salicylic acid,
selenium, topical steroid, zinc or ketoconazole
treatment
Topical steroidsvariety of vehicles
Topical tars options and
their side effect
Topical calcipotriene
Topical tazarotene
Anthralin
profiles
Second line
Alefacept
Adalimumab
Cyclosporine
Etanercept
Infliximab
Methotrexate
Systemic retinoids
Targeted UVB phototherapy
Ustekinumab

chapter 5
CHAPTER 5: THERAPEUTIC TREATMENT
OPTIONS & THEIR SIDE EFFECT PROFILES
The three types of therapies available for

treating psoriasis are:
Therapeutic
1. Topical therapies
2. Phototherapies
3. Systemic therapies
treatment
Topical Therapies
Steroids
options and
Topical corticosteroids, formulated as
lotions, solutions, creams, foams, ointments,
gels, sprays and shampoos are the most
commonly prescribed agents for treating
their side effect

mild to moderate psoriasis. In severe psori-
asis, they may be prescribed as adjunctive
therapy along with systemic therapy or
profiles
phototherapy.
Dosing
Topical corticosteroids are available in
many different strengths, ranging from
class 7 steroids such as 1% hydrocortisone
to superpotent class 1 corticosteroids
such as clobetasol propionate, halobetasol
propionate, 0.1% fluocinonide, diflorasone
diacetate and betamethasone dipropionate.
Superpotent corticosteroids should not be
used continuously for more than two to
four weeks, and dosage should not exceed
50 g/week. 29
Side Effects
Suppression of the hypothalamic-
pituitary-adrenal (HPA) axis may occur
with medium-to-superpotent topical
corticosteroids. 30

Infants and children are more suscep- skin temperature; hence, although the
tible to HPA suppression because of patients skin may be stained, clothing
their high ratio of skin surface to body and furniture may not be.
mass.
Skin irritation. After anthralin is
Atrophy of the epidermis and dermis. washed off, triethanolamine may be
applied to prevent or lessen irritation. 35
Long-term use may result in thin, shiny,
fragile skin that is easily lacerated and Coal Tar Preparations: Psorent, Scytera
subject to purpura and striae. Tar preparations have been used for many
years as adjunctive therapy. They are used
Tachyphylaxis. The repeated use of less often since the introduction of calcipot-
topical corticosteroids is problematic, riene and tazarotene.
since effectiveness appears to gradually
decrease. 31 This drawback has led to Dosing
the development of intermittent therapy, Tar-containing compounds are available
in which the superpotent topical as shampoos, creams, gels, solutions,
steroid is only applied in pulses (e.g., on foams or ointments that can be applied to
weekends). 32 lesions or as solutions to be added to the
bath.
Anthralin: Psoriatec
Anthralin is a yellowish cream used to Side Effects
treat mild to moderate psoriasis and Stains skin and clothing; preparations
refractory scalp psoriasis. Its use has are usually smelly.
declined since the introduction of calcipot-
riene and tazarotene. Sensitivity to sun is increased.
Dosing Clinical Pearls
therapies
Anthralin cream <1% is applied overnight. Tar preparations increase skin sensi-
Anthralin 1% is applied for a shorter period tivity to ultraviolet light; they are often
of time (for only a few minutes up to 60 combined with UVB phototherapy to
minutes). Short-contact anthralin therapy enhance efficacy. 36
(SCAT) may minimize staining and irrita-
tion. 33, 34 Vitamin D Analogs: Calcipotriene , Cream and
Scalp Solution, 0.005% (Dovonex), Calcitriol
Side Effects Ointment (Vectical)
Stains skin, clothing and furniture. Calcipotriene is a vitamin D analog indi-
Micanol releases anthralin as it melts at cated for the topical treatment of plaque
psoriasis and moderately severe psoriasis Do not combine with salicylic acid or
of the scalp. Calcipotriene does not stain other acids.
like anthralin and is less irritating. It
does not have corticosteroid side effects. Use after phototherapy. Calcipotriene
Calcipotriene combination therapy with a is inactivated by UVA and may cause
superpotent corticosteroid is superior to burning sensation if applied just before
either agent alone. 37 UVB phototherapy. Calcitriol is inacti-
vated by UVA and by UVB and prevents
Calcitriol, a naturally occurring form of transmission of ultraviolet light.40
vitamin D, is comparable to calcipotriene
in efficacy, but is less irritating when Combination Products: Calcipotriene/betame-
applied to intertriginous psoriasis. Like thasone dipropionate (Taclonex ointment and
calcipotriene, it does not have corticos- scalp suspension)
teroid side effects. 38 The combination of calcipotriene and
betamethasone dipropionate is available
Dosing as a fixed combination for psoriasis and
Apply to affected area twice daily. 38, 39 is superior to either ingredient alone. It
is applied once daily and its use on an as
Side Effects needed basis has been studied for up to a
Irritant contact dermatitis at the site of year.
application.
Retinoids: Tazarotene Topical Gel and Cream
Hypercalcemia has been reported in 0.05% and 0.1% (Tazorac)
rare instances in patients who applied Tazarotene, a topical retinoid, is not associ-
large quantities over much of their body ated with the side effects of corticosteroids.
(>120 g/week for calcipotriene, Tazarotene topical cream is indicated for
200 g/week for calcitriol). the treatment of stable-plaque psoriasis
therapies
involving up to 20% of BSA. The combina-
Clinical Pearls tion of tazarotene with corticosteroid
Topical Vitamin D analogs may be therapy helps avoid irritant dermatitis and
used on the face or the genital area produces better results than corticosteroid
without risk of atrophy; however, there monotherapy. 30
is increased risk of irritation in these
areas. Diluting with petrolatum or Dosing
concomitant treatment with a topical Apply once a day, usually in the evening.41
corticosteroid may prevent irritation
of the face or intertriginous areas. 30
Calcitriol is less irritating on intertrigi-
nous sites. 38
Side Effects two or three times a week; after 20 to 30
Retinoid dermatitis at the site of applica- treatments, nearly 90% of patients are
tion, especially with 0.1% gel. markedly improved or clear.45
Increased sunburn risk. Despite being one of the most effective

treatments for psoriasis, PUVA use is
Clinical Pearls declining because of its association with
If irritation occurs, minimize the appli- cutaneous malignancies. 30 However, this
cation amount and frequency; consider association has been demonstrated only
adding topical corticosteroids. in Caucasian patients. None of the studies
on non-Caucasian patients have shown
Its combination with UVB may make evidence of cutaneous malignancies,
UVB more effective; however, UV doses including squamous cell skin cancers.
should be reduced by at least one-third PUVA therapy may be used in combination
to reduce burning.42,43 with acitretin or methotrexate.
Pregnancy Category X: Retinoids Dosing

should not be used by women who are or Oxsoralen-Ultra 0.4 mg/kg PO 90
may become pregnant.41 minutes before UVA.
Oxsoralen (crystalline) 0.6 mg/kg orally

Phototherapy 2 hours before UVA.
UVA
Treatment with ultraviolet light A (UVA) UVA dosing depends on Fitzpatrick skin
exposes the patient to an indoor artificial type. Monitor the output of the UVA box
source of UVA (320-400 nm) radiation. with a photometer.
UVA radiation as monotherapy produces
therapies
only mild to moderate improvement and is Consider rePUVA (retinoid + PUVA)
not recommended if other forms of photo- for any patients with concerns
therapy are available. UVA treatment is about skin cancer risk or who want
most often used as a component of PUVA faster and more effective PUVA
therapy.44 photochemotherapy.
PUVA Side Effects

This approach involves the use of methox- Melanoma. One U.S. study found that
salen (Oxsoralen) prior to UVA radiation PUVA increased the risk of malignant
for the treatment of moderate to severe melanoma, especially among those who
psoriasis. Treatments are administered received more than 250 treatments.46
However, other U.S. and European No facial exposure to PUVA
studies have not shown the same asso-
ciation. A large Swedish study with the Elimination of nausea
same length of follow-up as the U.S.
study did not demonstrate an associa- Minimal risk of ocular changes
tion between melanoma and PUVA.47
Lessening of total UVA irradiation
Phototoxicity. Patients should avoid sun
or be instructed to wear UVA-blocking Possible reduction in the risk of PUVA-
sunscreens on days they are given induced cutaneous cancers (long-term
methoxsalen. bath PUVA studies have uniformly
failed to show increase in skin cancer
Nausea after methoxsalen dose. To risk)
avoid nausea, the methoxsalen dose
is divided and given over a 15-minute Clinical Pearls
period with food. Also, the patient No increase in skin cancer of any type
may take 1,500 mg of ginger 20 in non-Caucasians.
minutes before methoxsalen treatment.
Antiemetics such as trimethobenzamide Advise patients not to use tanning beds.
HCL (Tigan) 250 mg may be given The combination of Oxsoralen and
30 minutes before methoxsalen, or tanning beds can result in life-threat-
promethazine suppositories 12 to 25 mg ening burns.
(which may cause drowsiness) may be
used. Advise patients taking a photosensi-
tizing drug (e.g., quinolones) to take
PUVA bath therapy, which obviates GI the drug only after PUVA therapy, not
tract exposure, can be used as an alterna- before, and only if such agent cannot be
therapies
tive to oral methoxsalen if UVA exposure is discontinued.
practical within 30 minutes of PUVA bath
therapy at home. In PUVA bath therapy, Use phototherapy carefully in patients
50 mg of 8-methoxypsoralen (Oxsoralen- taking drugs that increase photosensi-
Ultra) is dissolved in a cup of hot water, tivity. Reduce the initial dose of UV, and
which is then mixed with about 100 liters of use smaller incremental doses. Advise
water in a bathtub. The tub must be filled patients to maximize the time period
to the same height each time. Non-oral or between the ingestion of photosensi-
bath delivery of psoralen has the following tizing drugs and phototherapy.
advantages48:
Table 5-1: Combination TherapySpecial Considerations for Monitoring
Therapy being added
MTX CsA Acitretin UVB

Current therapy
Monitor CBC &

renal function,
electrolytes,
MTX Monitor LFTs
Mg2+; use lower
doses of both
drugs
Monitor
CBC & renal
function, Monitor lipids, renal Monitor for
CsA electrolytes, function, electrolytes squamous cell
Mg2+; use and Mg2 carcinoma
lower doses
of both drugs
Monitor lipids,
Monitor LFTs,
renal function, Decrease UVB
Acitretin lipids and
electrolytes and dose
CBC
Mg2+
Decrease acitretin dose
Monitor for
by 50% if given daily or
UVB squamous cell
give full dose every other
carcinoma
day
Decrease acitretin dose

Monitor for
Not to 25 mg/day or every Monitor for
PUVA squamous cell
recommended other day; decrease UVA photodamage
carcinoma
by 50%
MTX = methotrexate
therapies
CsA = cyclosporine A
CBC = complete blood count
LFT = liver function test
Broad-band UVB topical and/or systemic agents to enhance

In the U.S., broad-band ultraviolet light B efficacy, but some of these may increase
(UVB) phototherapy has been used for a photosensitivity and burning, or shorten
century for treating moderate to severe remission. 30,49 Combining UVB with
psoriasis or localized areas of stubborn systemic therapies may increase efficacy
plaques. UVB can be combined with other dramatically and allow lower doses of
the systemic to be used. (See Table 5-1 for Side Effects
combinations and monitoring.) Increased photosensitivity and burning
unless UVB dosing is individualized
Goeckerman (tar and UVB) is a very safe
and effective regimen. Suberythemogenic Clinical Pearls
doses of UVB can be used with up to 10% Can be used for long-term mainte-
crude coal tar, and up to 10% salicylic acid nance. If the patient is unable to return
in petrolatum. This preparation is messy for office UVB treatments, consider
and difficult to use at home; however, suggesting that the patient use a home
highly motivated patients with local resis- UVB unit. For a patient who cannot
tant lesionssuch as those on the elbows come to the office even for initial
may benefit. 50 therapy, consider suggesting the use
of a tanning bed or sunlight as a last
Dosing resort.
Dosing is based on minimal-erythema-
dose (MED) testing or skin types. For skin Salicylic acid blocks UVB.
type I, dosing may start at 10 mJ, whereas
dosing for a patient with skin type VI Increase monitoring during combina-
(black) may start at 50 mJ. 50 Broad-band tion therapy. (See Table 5-1)
UVB is administered three to five times a
week for 1 to 2 months or longer, especially Narrow-band UVB (nbUVB)
if maintenance therapy is indicated. The most effective wavelength of UVB for
treating moderate to severe psoriasis is
Combination Therapy Dosing 311 nm. Treatment with nbUVB is superior
UVB + low-dose methotrexate: three to treatment with broad-band UVB and is
doses taken within 24 hours (total: 15mg safer than PUVA treatment. 51,52 The effi-
a week; alternatively, the entire dose cacy of nbUVB is similar to that of PUVA
therapies
can be taken at one time per week) until in the initial clearing phase, but remissions
clearing to < 3% BSA. Avoid taking meth- are not as durable.
otrexate prior to UVB phototherapy
(rare methotrexate-induced acute photo- Side Effects
sensitivity may result in a burn). Burns that are more severe and longer-
lasting than those caused by broad-
UVB + low-dose acitretin: 10 to band UVB.
30 mg/day (most often 25 mg QD or
QOD with food) and lower doses of UVB. Clinical Pearls
May be less photocarcinogenic.
Particularly useful in treating psoriasis drug to be used. The following applies to
refractory to broad-band UVB. combination therapy including acitretin.
Use carefully in patients taking drugs Combination with PUVA or UVB light
that increase photosensitivity. therapies enhances efficacy in plaque
or guttate psoriasis and limits treat-
Systemic Therapies ment frequency, duration and cumula-
Acitretin (Soriatane) tive doses. 54
Acitretin is a synthetic retinoid that is
effective for treating plaque, pustular, Combination with methotrexate is effec-
palmoplantar, guttate and erythrodermic tive for severe, generalized pustular
psoriasis. An absolute drop in the psoriasis psoriasis.55
area and severity index (PASI) score of 57%
was observed by week 12. 53 Seventy percent Sequential therapy with cyclosporine
of patients with severe disease showed and acitretin is effective for severe,
marked improvement after one year of generalized psoriasis. Cyclosporine is
treatment.53 Long-term use is safe; there used initially as monotherapy to clear
are no time-limit restrictions, making it the psoriasis; acitretin is then added
useful for maintenance therapy. for maintenance and cyclosporine is
tapered. 56
Although infrequent, symptoms related
to bone changes or calcified ligaments or Dosing
tendons may limit long-term use in selected Monotherapy: 10 to 50 mg/day.
patients. Published prospective studies
on long-term, low-dose use of acitretin in Combination therapy: 10 to 25 mg PO,
psoriasis patients have all failed to demon- QD to QOD.
strate increased risk of hyperostosis such
Side Effects and Management Options
therapies
as bone spurs.
Table 5-2 details the side effects of acitretin
Acitretin is a potent teratogen and should and corresponding management options.
not be used in women of childbearing
potential if avoidable. Acitretin can be Clinical Pearls
converted to etretinate which has a long Essentially no known drug interactions
half-life; patients should avoid pregnancy with other psoriasis therapies except
for three years after taking acitretin. for possible enhanced hepatotoxicity
with methotrexate (FDA considers this
In combination therapy, acitretin enhances combination contraindicated). Can be
efficacy and allows lower doses of each combined with almost any other treat-
ment at lower doses to enhance efficacy.
Table 5-2: Side Effects of Acitretin and
Management Options
Side effects Mucocutaneous

Management tips Management tips
requiring therapy Changes
Eye exam; discontinue if Emolients (Bag
papilledema Balm, Aquaphor)
Headache Antifungal
If severe, discontinue Chelitis
acitretin (mycostatin)
Mild topical steroids
Often transient and reversible Lower dose
Ask if taking ASA,
Reversible and dose
acetaminophen, alcohol
Hair Loss dependent
Increased LFTs If LFT greater than Lower dose
2.5 x normal, decrease dose
and re-check Lower dose if
Skin fragility
Evaluate for other causes symptomatic
(e.g. hepatitis C) Sticky skin None
Pyogenic Lower dose Lacri-Lube, artificial
granulomas Dry eye
Consider using steroid gels, tears, cleansing
(frequently silver nitrate, cryotherapy, Dry nose Petroleum jelly
periungual) C&D or surgical removal
Thin nails Clear nail polish
Bone changes* If symptomatic, X-ray
Hyperostosis
(DISH syndrome) Treat according to National Pregnancy
Osteoporosis Guidelines
Management tips
Osteoporosis considerations
Check triglycerides (TG) at Category X, cannot use
baseline; monitor every 2-4 Female on acitretin if pregnant or thinking
weeks until stable, every 3-6 of becoming pregnant
months after that
No action, reassure
TG>400 mg/dl: gemfibrozil female exposure to
(Lopid) 600 mg, BID Partner of male on
males semen not
Hyperlipidemia TG>700 mg/dl: discontinue acitretin
associated with birth
acitretin, start lipid defects
therapies
lowering drugs
Cholesterol >300 mg/dl: * Association with retinoids is questionable
atorvastatin (Lipitor) and subject to controversy, especially in low-
10-80 mg, fenofibrate dose combinations or maintenance therapy for
(TriCor) psoriasis patients.
Side effects To date, only isoretinoin, not acitretin, has been

Management tips
requiring therapy associated with depression.
Depression Discontinue acitretin ASA = acetylsalicylic acid

DISH = diffuse idiopathic skeletal hyperostosis
Important drug Glibenclamide, ethanol,
interactions progestin contraceptives
Alcohol should be avoided in women who A 16-week study compared methotrexate
may become pregnant because alcohol and cyclosporines effectiveness in treating
facilitates the conversion of acitretin to moderate to severe chronic plaque
etretinate.57-59 psoriasis. Complete remission (defined as
a reduction in the baseline score for the
Lipid changes are easily managed with Psoriasis Area and Severity Index [PASI]
lipid-lowering agents. of more than 90%) occurred in 40% of
those patients treated with methotrexate
Data on hyperostosis is contradictory and 33% in the patients treated with
and subject to controversy.60-61 cyclosporine. Partial remission (defined as
a reduction in the baseline score of more
Retinoid with phototherapy than 75%) was achieved in 60% of the meth-
(acitretin-UV) is more effective, better otrexate-treated patients and 71% of the
tolerated and perhaps safer for long- cyclosporine-treated patients. In this study,
term therapy than phototherapy alone. 55 there was no significant difference in
UVB and UVA doses can be lowered by efficacy found between methotrexate and
about 50% and acitretin doses of cyclosporine for the treatment of moderate
10 to 25 mg/day can be used.62 The treat- to severe chronic plaque psoriasis.
ment is better tolerated and limits the However, many more patients dropped out
frequency, duration and cumulative of methotrexate arm of the study due to
doses of individual therapy. hepatotoxicity and other adverse events.63
Cyclosporine (Neoral) Dosing

The immunosuppressant cyclosporine Starting dose is 4 to 5 mg/kg/day for
was introduced in the 1970s to prevent erythroderma, 3 to 5 mg/kg/day for severe
kidney transplant rejection. Since then, psoriasis and 3 to 5 mg/kg/day for chronic
a microemulsion form of cyclosporine thick plaques.
therapies
called Neoral has been developed that
is absorbed better from the GI tract and Reduce dose if creatinine rises >30%, if
is indicated for the treatment of severe, hypertension develops or if potassium (K+)
recalcitrant plaque psoriasis. Cyclosporine is persistently above normal.
is highly effective against psoriasis and
in short-term therapy may be safer than Side Effects
methotrexate, as bone marrow toxicity is Nephrotoxic unless psoriasis guidelines
not a concern and it is not usually hepato- (as above) are followed. Uninterrupted
toxic. Owing to nephrotoxicity concerns, long-term use of more than two years
cyclosporine use is limited in the United may produce irreversible vasculopathy
States to one year of therapy. and interstitial fibrosis even if the crea-
tinine is kept within acceptable range.
Table 5-3: Side Effects of Cyclosporine and
Management Options
Side effects Side effects not

Management tips Management tips
requiring therapy requiring Tx
Discontinue K+-rich Educate patients; often
foods (e.g. bananas) transient; divide dose
Paresthesias
Consider HCTZ further to reduce peak
(50 mg, QOD); may CsA blood levels.
Increased K+ reduce creatinine Good dental hygiene;
Gingival
clearance consider adding
hyperplasia
retinoids
K+> 5.5 mEg/L,
discontinue drug Hypertrichosis Hair removal methods
Give OTC Mg +
Decreased Mg2+ Acne Treat accordingly
supplements
Common, easily Not contraindicated in
controlled; monitor pregnant women, but
weekly has been associated
Pregnancy
with reduced birth
Use of calcium
weight and premature
channel blockers,
labor.
nifedipine (Adalat,
Procardia) and Rarely requires
Hypertension felodipine (Plendil) treatment. If so,
Hyperlipidemia
(DBP>90 mmHg) may help limit consider a statin such
nephrotoxicity as atorvastatin.
No ACE inhibitors; Increased bilirubin,
may increase nausea, headache, No treatment
creatinine and fatigue, myalgia
decrease GFR
No thiazide diuretics Nothing unless
Increased uric acid symptomatic or has
Increased CrCl
Reduce CsA dose history of gout.
>30%
Some antibiotics, HCTZ = hydrochlorothiazide
melphalan GFR = glomerular filtration rate
(Alkeran),
antifungals,
NSAIDS, cimetidine
(Tagamet),
Drug interactions ranitidine (Zantac),
tacrolimus
(Prograf), calcium
channel blockers,
methylprednisolone,
anticonvulsants and
others.
In one study, no patient treated for more Table 5-3 details the side effects of
than two years with cyclosporine had a cyclosporine, drug interactions and corre-
normal kidney biopsy.64 Another renal sponding management options.
biopsy study showed features of neph-
rotoxicity in six of eight patients treated Clinical Pearls
with 1-6 mg/kg/day of cyclosporine for When adding drugs that interact with
an average of five years.65,66 Irreversible cyclosporine, monitor blood pressure,
kidney damage is extremely unlikely if renal function and clinical response.
dermatologic guidelines are followed.
Cyclosporine should not be used for
Malignancies, including skin cancers more than one year at a time, according
and lymphoma, have been reported to FDA recommendations.
in transplant patients on long-term,
high-dose therapy.67-69 However, no International guidelines approve up to
increase in internal cancers, including two years of continued use at a time.
lymphoma, has been seen in psoriasis
patients treated according to the derma- If longer than one-year, uninterrupted
tologic guidelines. These guidelines, use is contemplated, consider checking
developed at an international consensus GFR annually (not required by interna-
meeting, are as follows70: tional guidelines).
Use CsA for no longer than two years at Rotate therapy if possible.
a time.
In patients with relative contraindi-
Keep serum creatinine increase to <30% cations (older patients, diabetes or
of the pretreatment baseline creatinine. controlled hypertension), caution is
advised when used for more than one
therapies
Start at 2.5 mg/kg/day in BID divided year.
doses. Based on patient response,
increase up to a maximum of 5 mg/kg/ Grapefruit juice can raise cyclosporine
day in BID divided doses. levels.
If the patient is in a crisis and in need of Cyclosporine is usually given in two

rapid improvement, cyclosporine can be divided doses but may be given as a
started at 4-5 mg/kg/day in BID divided single daily dose. If the patient misses
doses. one of two daily doses, he/she can
double up on the next dose.
Calcium channel blockers may limit Side Effects and Management Options
nephrotoxicity. Hepatotoxicity. Liver biopsies were
once advocated for all patients starting
Methotrexate methotrexate. Biopsies are now advo-
In the United States, methotrexate as cated after a cumulative dose of 3.5 g in
treatment for psoriasis was originally low-risk patients and 1.5 g in high-risk
approved in 1971. It is still one of the most patients.71,72 Alternatively, consider
effective therapies, particularly for psori- switching to another agent or discon-
atic arthritis. It is also indicated for the tinuing therapy.
management of severe erythrodermic and
pustular psoriasis. However, it is hepato- Bone marrow suppression can be
toxic, teratogenic and immunosuppressive. lethal, especially in elderly patients
with impaired renal function.71,72
Dosing Additional risk factors include: renal
Consider test dose: 2.5 to 5.0 mg insufficiency, lack of folate supplemen-
tation, medication errors, drug interac-
Average dose: 10 to 15 mg/week tions, hypoalbuminemia and excess
alcohol intake.
Maximum dose: 30 mg/week
Acute photosensitive reactions may
Upon improvement, taper by 2.5 mg follow dosing, especially in patients
every four weeks who developed burns during prior
phototherapy.
Table 5-4: Risk Factors for Liver Disease
Lymphoma risk increased according
Primary to FDA black-box warning in PI, but
History of or current excessive alcohol scientific basis for this warning is
abuse
therapies
debatable.
Abnormal liver function test
History of liver disease, including chronic Table 5-5 details the side effects of metho-
hepatitis trexate and corresponding management
Secondary options.
Diabetes mellitus
Obesity
Exposure to hepatotoxic drugs or
chemicals
Table 5-5: Side Effects of Methotrexate and
Management Options
Side effects Side effects
requiring Management tips requiring Management tips
therapy therapy
1-5 mg folic acid; do not give on day
of MTX treatment due to possible WBC Consider lowering dose
reduction in efficacy WBC < normal and repeat WBC more
Nausea Accupressure (e.g. Sea-Band or often
similar device) WBC 3000 to Reduce dose or
Decrease or divide MTX dose normal discontinue MTX
Administer SQ or IM WBC < 3000 Discontinue MTX
Check CBC
Dose related and reversible: lower Pulmonary Monitor for new cough
dose toxicity-acute Stop MTX; do chest X-ray
Aphthous Add topical TX pneumonitis immediately
stomatitis Folic acid, although it may reduce
the efficacy Men and women must
Leucovorin-do not give on day MTX be off MTX for 3 months
is given before conception
If women becomes
Check LFTs 5-7 days after dose (see Pregnancy/ pregnant during therapy,
Table 5-6: WHO Guidelines for Liver reproduction discontinue MTX
Toxicity) contraindicated If partner of man on
Ask about alcohol, meds such as MTX becomes pregnant,
Increased LFTs acetaminophen, ASA. man stays on MTX, uses
Increased GGT and alkaline condoms, gets genetic
phosphatase not related to MTX counseling
Consider liver biopsy (see Table 5-7:
Liver Biopsy Findings) Barbiturates,
Bone marrow Monitor for drug interaction phenylbutazone, phentoin
suppression with NSAIDs, trimethorprim/ (Dilantin), probenecid
(decreased Hct, sulfamethaxazole (Benemid), salicylates
megaloblastic Lower MTX dose if symptomatic and sulfonamides may
anemia) Folate, 5 mg/day raise free MTX levels
therapies
NSAIDs, phenylbutazone,
Any sudden and/or significant probencid, salicylates,
reduction in platelet count from Important drug
sulfonomids,
Platelets pre-treatment level, repeat CBC interactions
dipyridamole
and platelet count in 1 week and (Persentine) increase
consider reducing dose half-life of MTX
Platelets < Considering lowering dose and Trimethorprim (in Sepra
normal repeat platelet count more often and Bactrim) and MTX
Platelets can cause severe bone
100,000 to Reduce dose or discontinue MTX marrow suppression and
normal should be avoided
Platelets <
Discontinue MTX WBC = white blood count
100,000
Clinical Pearls Table 5-6: WHO Guidelines for Liver Toxicity
Give patients the risks of methotrexate
Grade 0 toxicity ALT/AST <1.25x
in writing. The National Psoriasis
(none) normal
Foundation brochure on systemic treat-
ments is a convenient, free resource in ALT/AST 1.26-2.5x
this regard www.psoriasis.org/severe/ Grade 1 (mild) normal; re-check in
2-4 weeks
systemics
ALT/AST 2.6-5x
Grade 2 (moderate) normal; lower MTX
Do not discontinue MTX abruptly, dose
unless doing so is essential.
ALT/AST 5.1-10x
Grade 3 (severe) normal; stop MTX and
Drug interactions are numerous. re-check in 2 weeks
NSAIDs impair the excretion of MTX, ALT/AST >10x normal;
Grade 4 (life-
causing bone marrow suppression, but stop MTX, life-
threatening)
the most lethal combination is MTX threatening
with trimethoprim/sulfamethoxazole.
ALT = alanine aminotransferase,
AST = aspartate aminotransferase
Use special care when prescribing for
the elderly.
Table 5-7: Liver Biopsy Findings
The liquid formulation has a bioavail- Grade I (normal;

mild fatty
ability similar to that of the tablets and infiltration, nuclear Continue MTX
is less expensive, but is more difficult variability, portal
to titrate for elderly patients with poor hypertension)
eyesight. Grade II
(moderate-severe; Continue MTX;
Investigations into the use of non- fatty infiltration, these changes are
invasive monitoring proceduressuch nuclear variability, relatively common
as serologic markers of hepatic fibrosis portal tract pre-therapy
inflammation)
including serum aminoterminal
propeptide of type III procollagen May continue MTX;
(PIIINP)may help reduce the need for Grade IIIA (mild
repeat biopsy in 6
fibrosis)
biopsies. months
Grade IIIB
(moderate-severe Discontinue MTX
fibrosis)
Grade IV (cirrhosis) Discontinue MTX
Biologics Development of positive anti-
Adalimumab (Humira )
nuclear antibodies is not uncommon.
Adalimumab inhibits tumor necrosis Developments of lupus-like syndromes
factor-alpha (TNF-alpha), a key inflam- occur rarely in patients treated with
matory cytokine. It is FDA-approved TNF inhibitors.
for psoriasis, psoriatic arthritis, and
rheumatoid arthritis. Adalimumab is a Injection site reaction. These are gener-
recombinant IgG1 monoclonal antibody ally well tolerated.
that binds to TNF-alpha. Adalimumab also
lyses surface TNF-expressing cells in vitro Anaphylaxis.
in the presence of complement. In clinical
trials, 53-80% of patients achieved PASI 75 Pregnancy Category B.
with doses of 40 mg every other week and
40 mg every week, respectively.73 Clinical Pearls
In rheumatoid arthritis patients, no
Dosing adjustment in dosing appears to be
In psoriasis, two doses have been tested: needed when taking adalimumab and
an 80-mg loading dose followed by 40 mg methotrexate concurrently.
every other week or an 80-mg loading dose
weekly for two weeks followed by 40 mg Patients should not receive live vaccina-
weekly. tins while on adalimumab.
Dosing can be increased to 40 mg weekly Monitoring Information

in some patients depending on the Test for TB (PPD or QuantiFERON-TB
response to treatment. Gold test) before initiation of treatment.
Side Effects Alefacept (Amevive)
therapies
Use of TNF inhibitors has been associ- Alefacept is FDA-approved for the treat-
ated with increased risk of infection, ment of adults (over age 18) with chronic
heart failure and lymphoma. The moderate to severe plaque psoriasis who
apparent increase in lymphoma may are candidates for systemic therapy or
be due to increased risk of lymphoma phototherapy. Alefacept is a human fusion
in the treated population (rheumatoid proteinobtained by recombinant DNA
arthritis patients). technologythat modulates the activity
of T cells. Alefacept appears to selectively
New onset or exacerbation of demyeli- deplete activated T cells, and its use seems
nating disorders. to result in long periods of remission in
some patients. Since it targets T cells,
T-cell counts decrease during therapy Increased duration of use (up to
and should be monitored.74-77 In clinical 16consecutive weeks) appears to
trials, 15-25% of patients achieve PASI 75 increase efficacy and was well-tolerated
at 14weeks (two weeks after completion of in a small trial.
the first 12-week course), with substantially
more patients achieving PASI 75 later and Increased benefit noted when given with
after subsequent courses. UVB during first six weeks of alefacept
therapy.
Dosing
Recommended dosing is a once-weekly Pregnancy Category B.
15-mg intramuscular injection for 12 weeks
(IV injection of 7.5 mg/week has also been No known drug interactions.
studied). Additional 12-week cycles of
weekly injections may be started as long Live or live-attenuated vaccines
as the CD4 lymphocyte counts are within should not be given concurrently with
normal limits, and a 12-week interval has alefacept. Non-live vaccines can be
passed since the prior course of therapy. given but for maximal protection should
be given before alefacept is started.
Side Effects
Frequently reported adverse effects Monitoring Information
include pharyngitis, dizziness, CD4 lymphocyte counts should be moni-
increased cough, nausea, pruritus, tored every other week during the 12-dose
myalgias, chills, injection site pain, and regimen and used to guide dosing (with-
injection-site inflammation. hold dosing if CD4 lymphocyte counts fall
below 250 cells/L). Discontinue if CD4
Alefacept reduces circulating CD4 counts remain <250cells/L for one month.
and CD8 lymphocytes. Therefore,
Etanercept (Enbrel)
therapies
there is potential risk of infection and
malignancy. Etanercept is FDA-approved for treatment
of adult patients with chronic moderate
Clinical Pearls to severe plaque psoriasis and psoriatic
Alefacept should not be given to patients arthritis. Other FDA-approved indications
with clinically significant infections. include ankylosing spondylitis, polyartic-
Discontinue alefacept if serious infec- ular-course juvenile rheumatoid arthritis,
tion, malignancy, or clinically signifi- and moderate to severe rheumatoid
cant signs of liver injury occurs. arthritis. Etanercept is a fusion protein
consisting of tumor necrosis factor-alpha
(TNF-alpha) receptor components bound to
the Fc portion of IgG. Etanercept binds and Demyelinating disorders such as trans-
inactivates TNF-alpha. In phase III studies verse myelitis, optic neuritis, multiple
of psoriasis patients, about 30% of patients sclerosis and seizure disorder have
treated with 25 mg twice a week and nearly been associated with TNF inhibitors
50% of patients treated with 50 mg twice and these agents should be avoided in
a week had 75% improvement in PASI patients with demyelinating disorders.
(PASI 75) after 12 weeks of treatment.78,79
Rare cases of pancytopenia including
Dosing aplastic anemia have been reported.
For plaque psoriasis, 50 mg SQ is given
once or twice weekly for three months There have been reports of new onset
followed by a maintenance dose of 50 mg and worsening congestive heart failure
once weekly. The approved dose is 50 mg while on etanercept.
SQ weekly for psoriatic arthritis. Rotate
sites for injection (thigh, abdomen, upper Treatment with etanercept has been
arm). Do not inject in areas where skin is associated with development of anti-
tender, bruised, red or hard. nuclear antibodies and rarely can be
associated with a lupus-like syndrome.
Dosing can be increased up to 50 mg
2xweekly in some patients based on Pregnancy Category B.
response to treatment.
Clinical Pearls
Side Effects Concurrent therapy with anakinra is
Mild to moderate injection site reactions not recommended due to increased risk
are the most common side effect. They of infection.
are generally well-tolerated and can be
treated symptomatically. They do not Patients should not receive live vaccina-
therapies
require discontinuation of treatment. tions while on etanercept.
There is likely some increased risk of There is no need to alter methotrexate

infection and malignancy. Increased dosing when used concurrently with
risk of lymphoma has been observed, etanercept, based on experience in
but that may be due to the increased rheumatoid arthritis patients.
risk of lymphoma in the population of
patients in which etanercept has been Monitoring Information
used (primarily rheumatoid arthritis Testing for tuberculosis (PPD or
patients). QuantiFERON-TB Gold test) is required. If
positive, a chest X-ray may be needed.
Golimumab (Simponi) heart failure and lymphoma. The
Golimumab is a fully human IgG mono- apparent increase in lymphoma may
clonal antibody with specificity for be due to increased underlying risk of
TNF-alpha that is FDA-approved for the lymphoma in the treated population
treatment of active psoriatic arthritis (rheumatoid arthritis patients).
alone or in combination with methotrexate.
Other FDA-approved indications include New onset or exacerbation of demyeli-
active moderate-to-severe rheumatoid nating disorders.
arthritis (in combination with metho-
trexate) and active ankylosing spondylitis. Development of positive anti-
nuclear antibodies is not uncommon.
In the pivotal phase III clinical trial of Development of lupus-like syndromes
golimumab in patients with active psoriatic occurs rarely in patients treated with
arthritis, 51% of patients treated with 50 mg TNF inhibitors.
every 4 weeks and 45% of patients treated
with 100 mg every 4 weeks achieved a 20% Injection site reaction. These are gener-
improvement in the American College of ally well-tolerated.
Rheumatology criteria (ACR20) response
at week 14, compared to 9% of patients in Anaphylaxis.
the placebo control group.80 Patients in
the same study with psoriasis affecting 3% Pregnancy category B.
or more of their body surface area were
also evaluated for changes in the Psoriasis Clinical pearls
Area and Severity Index (PASI) score. At Patients should not receive live vaccina-
week 14, 40% of the patients receiving 50 mg tions while on golimumab.
and 58% of the patients receiving 100 mg of
golimumab achieved a PASI 75 compared Not to be used in combination with
therapies
to 3% of the placebo-treated patients.80 Abatacept or Anakinra.
Dosing Monitoring Information

Golimumab is administered in doses of Test for TB (PPD or QuantiFERON-TB
50 mg by subcutaneous injection once per Gold test).
month. It may be given alone or in combi-
nation with methotrexate.81 Infliximab (Remicade)
Infliximab, also a TNF-alpha inhibitor, is
Side effects a monoclonal antibody currently used to
Use of TNF inhibitors has been associ- treat psoriasis, psoriatic arthritis, Crohns
ated with increased risk for infection, disease, rheumatoid arthritis and ankylo-
sing spondylitis.
The safety and efficacy of infliximab was risk of lymphoma has been observed,
assessed in three randomized, double- but that may be due to the increased
blind placebo controlled studies. In the risk of lymphoma in the population of
pivotal EXPRESS II study of 835 patients, patients in which infliximab has been
75% of the 5 mg/kg group achieved a used (primarily rheumatoid arthritis
PASI75 compared to 2% of the placebo patients).
group at week 10.82
Demyelinating disorders such as trans-
Dosing verse myelitis, optic neuritis, multiple
Infliximab is used in doses of 5 mg/kg sclerosis, and seizure disorder have
infusions at 0, 2 and 6 weeks, then every been associated with TNF inhibitors
8weeks. Patients should be observed for and these agents should not be used in
side effects for at least one hour after infu- patients with demyelinating disorders.
sion. Appropriate staff, medication and
emergency equipment should be available Rare cases of pancytopenia including
for managing possible infusion reactions. aplastic anemia have been reported.
Dosing can be increased up to 10 mg/kg or There have been reports of new onset
the frequency increased up to every four and worsening congestive heart failure
weeks. while on infliximab.
Side Effects Treatment with infliximab has been

Acute infusion reactions can develop associated with development of anti-
immediately or within a few hours. nuclear antibodies and rarely can be
associated with a lupus-like syndrome.
A delayed hypersensitivity reaction
(myalgia, arthralgia with fever, rash, Pregnancy Category B.
therapies
pruritus, edema, dysphagia, urticaria,
sore throat, and headache) may occur. Clinical Pearls
This has been observed most commonly Formation of antibodies to infliximab
in patients with Crohns disease with may be reduced when the drug is
re-administration of infliximab after a given at regular intervals and when
drug-free interval of two to four years used concurrently with methotrexate,
following a previous infusion. azathioprine or 6-mercaptopurine.
There is likely some increased risk of Patients should not receive live vaccina-
infection and malignancy. Increased tions while on infliximab.
Monitoring Information than 100 kg should be given 90 mg also at
Test for TB (PPD or QuantiFERON -TB
0 and 4 weeks followed by a 90-mg dose
Gold test) before initiation of treatment. every 12 weeks. For those who do not
achieve adequate responses, dosing as
Liver function tests should be monitored often as every 8 weeks has been shown to
periodically. If >5 times the upper limit be effective.84
of normal, the dose should be withheld
until LFTs are lower. Side Effects
While no clear pattern of ustekinumab-
Patients should be observed for side specific side effects emerged in clinical
effects for at least one hour after infu- trials, this drug targets the immune
sion. Appropriate staff, medication and system. Consequently, patients should
emergency equipment should be avail- be cautioned about risk of infection and
able for managing possible infusion malignancy. It is not known whether
reactions. patients taking this medication may
be at increased risk of salmonella and
Ustekinumab (Stelara) mycobacterial infections. Diagnostic
Ustekinumab is a monoclonal antibody evaluation should be considered if
directed against the p40 subunit of IL-12 suggested by symptoms. There has been
and IL-23, thus blocking the interaction one case of reversible posterior leuko-
between those cytokines and their respec- encephalopathy syndrome which has
tive receptors. In pivotal trials, patients been reported that resolved with drug
were treated with either 45 mg or 90 mg of cessation.
ustekinumab or placebo at weeks 0, 4, and
every 12 weeks thereafter. PASI 75 was Clinical Pearls
achieved by 67% of patients treated with Efficacy of ustekinumab is inversely
the 45-mg dose of ustekinumab and 76% of related to the patients weight.
therapies
the patients treated with the 90-mg dose. Consequently, the higher 90 mg dose
Even higher response rates were achieved should be administered to patients
at week 28.83,84 weighing 100 kg or more.
Dosing Patients should not receive live vaccina-

For patients weighing less than 100 kg tions while on ustekinumab
(220 lb.) it is recommended that they
receive 45 mg at weeks 0, 4 and then every Monitoring Information
12 weeks thereafter. Those weighing more Test for TB before initiating treatment.
Unapproved Agents 1-3 months. Hold dosage if WBC is
Hydroxyurea (Hydrea )
<2,500 or platelet count is <100,000.
Hydroxyurea is an anti-metabolite that has
been used to treat psoriasis for 30 years. Mycophenolate Mofetil (CellCept)
It is effective as monotherapy, although Mycophenolate mofetil has been used to
about one-third of patients whose psoriasis prevent organ transplant rejection and has
improves develop bone marrow toxicity proven effective in the treatment of several
with leucopenia, thrombocytopenia or inflammatory or autoimmune skin disor-
megaloblastic anemia.85 Although bone ders. In the 1970s it was investigated for
marrow suppression is usually mild and the treatment of psoriasis; many patients
does not necessitate the discontinuation of had long-term remissions. Side effects were
therapy, it may occasionally be severe. tolerable.86-88
Dosing Dosing
Initial dose: 1 g PO/day (ie, 500 mg PO 500 mg PO 4 times/day based on clinical
BID). response
If no response, increase by 500 mg daily May be increased or reduced by

increments every month, up to 2.0 g/day. 250mg/day each month up to a
maximum of 4.0 g/day.
Side Effects
Cutaneous reactions may be seen in Side Effects
some patients. Nausea, vomiting, diarrhea.
Long-term therapy may cause skin or Herpes zoster and herpes simplex
leg ulcers. occurred in more than 31% of patients in
one study.87
Clinical Pearls
Narrow therapeutic index. Clinical Pearls
Can be administered with CsA and is
Useful in combination therapy, and for useful when tapering CsA.
recalcitrant palmoplantar psoriasis.
Since it is an immunosuppressive agent,
Of value in HIV-related psoriasis. patients should be followed to ensure
that they do not develop opportunistic
After increasing dose, repeat CBC and infections. It should not be given to
platelet counts weekly. Once the dose is patients with severe infections or
stable, CBC should be repeated every untreated malignancies.
chapter 6
6-Thioguanine
6-Thioguanine is a purine analog that
interferes with nucleic acid synthesis. It
is an analog of the nucleic acid guanine
and is closely related to mercaptopurine
(Purinethol). It is indicated for the treat-
ment of acute nonlymphocytic leukemia
and other neoplasms, but in a study by
Silvis and Levine, it helped 71% of patients
(10/14) clear >75% of psoriasis-affected
Transitional
areas.89
Dosing
strategies
Starting dose: 80 to 100 mg PO twice
weekly for switching
therapy
Increase by 20 mg every 2 to 4 weeks
Maximum dose: 160 mg PO 3 times a

week
Side Effects
Bone marrow suppression
GI complaints: nausea and diarrhea
Elevation of LFTs is common

CHAPTER 6: TRANSITIONAL STRATEGIES
FOR SWITCHING THERAPY
Once a patients psoriasis is adequately

controlled, the therapeutic regimen
that was used for clearing can be slowly
tapered to the minimal effective dose and
used in combination with another agent,
or the patient can be transitioned to a
less toxic therapy to maintain long-term
control. In addition, a sequential or rota-
tional schedule may be used to maintain
the patient in a state of remission.
Topical therapy, UVB and acitretin are

the safest modalities for long-term use.
TNF inhibitors also appear to be safe
treatments for long-term use, as they are
not associated with the cumulative organ
toxicity associated with methotrexate
and cyclosporine. When possible, they
should be used for the maintenance phase
of therapy. In sequential or rotational
strategy, the skillfulness of the clinician
in making a smooth transition from one
regimen to another is critical for the
overall therapeutic success. Details of
several different transitions and combina-
tions are contained in Table 6-1.
transitional strategies

Table 6-1: Transitional Issues
Drugs
being added Issue during transition Therapy time/Dose limit
or deleted
Use full doses of both and
taper MTX as patients improve
Transitioning MTX: rotate after cumulative dose of 3.5 g in low-
or
from MTX risk patients; 1.5 g in high-risk patients or obtain
Taper MTX slowly (2.5mg
to acitretin liver biopsy
every 4 weeks) while
(4-5 month
introducing acitretin
period) Acitretin: no limit
Monitor LFTs every week
when starting combination tx
Decrease MTX or discontinue MTX: rotate after cumulative dose of 3.5 g in low-
Transitioning abruptly; add CsA 2.5 to risk patients; 1.5 g in high-risk patients or obtain
from MTX to 5.0 mg/kg/day liver biopsy
CsA Increase frequency of CBC,
PLT and creatinine monitoring CsA: 1-2 years of continuous tx at a time
Add full dose of MTX or CsA

MTX: rotate after cumulative dose of 3.5 g in low-
With MTX: monitor LFTs and
Adding MTX risk patients; 1.5 g in high-risk patients or obtain
CBC weekly at first
or CsA to liver biopsy
With CsA: monitor renal
acitretin
function and lipids weekly at
CsA: 1-2 years of continuous tx at a time
first
Decrease UVB or UVA dose

Adding
by 50%
acitretin to Acitretin and phototherapy: no limit
Use low-dose acitretin
phototherapy
(25 mg/day or every other day)
Add the TNF inhibitor at the

Adding TNF
full/standard dose TNF inhibitors can be used in combination with
inhibitor to
Taper systemic treatment other systemic treatments with no known time-
systemic
once adequate disease control limitations
treatment
is achieved
Add the oral systemic

medication using the normal
dosing schedule
Adding Once adequate disease
acitretin or control is achieved, the TNF inhibitors can be used in combination with
methotrexate combination can be continued oral psoriasis treatments with no known time-
transitional strategies
to TNF Alternatively, the TNF limitations
inhibitors inhibitor can be withdrawn
or the dose of the of the oral
systemic medication can be
tapered
PLT = platelets
chapter 7
Medical
Professionals
and the National
Psoriasis
Foundation
teaming up
to make a
difference

National Psoriasis Foundation
CHAPTER 7: MEDICAL PROFESSIONALS AND
THE NATIONAL PSORIASIS FOUNDATION
TEAMING UP TO MAKE A DIFFERENCE
Who We Are
Welcome to the National Psoriasis
Foundation, the worlds largest nonprofit
patient-advocacy organization dedicated
to fighting psoriasis and psoriatic arthritis,
and the voice for millions of Americans
who are affected by these diseases. Our
mission is to find a cure for psoriasis and
psoriatic arthritis and to eliminate their
devastating effects through research,
advocacy and education.
As a medical professional, you are a

key contributor to the well-being of
psoriasis/psoriatic arthritis patients. Our
Professional Membership Program is
specifically designed for dermatologists
and rheumatologists, nurse practitioners,
physician assistants, nurses and other
medical specialists who are committed to
the highest quality of care for patients with
psoriatic diseases.
The Psoriasis Foundation is supported

and advised by a volunteer Medical Board
composed of thought leaders in the fields
of dermatology and rheumatology. We also
have a thriving relationship with medical
professionals nationwide who help support
our ability to achieve our mission.
When you join the Psoriasis Foundation as

a professional member, you are supporting
our efforts on behalf of the psoriasis

community. You also receive tangible bene- Web site:
fits that help you provide for your patients Send your
needs and keep you up to date on the latest patients to our
treatments. Web site. Most
of our publica-
Literature tions can be
Research shows that patients who are downloaded
well-informed about their disease are more at www.psoriasis.org. The site offers
compliant with treatments, tend to have comprehensive information on psoriasis
better treatment results and are more and psoriatic arthritis, treatment news,
satisfied than patients who lack informa- advocacy services, resources and
tion. Tell your patients about usthey will ways to connect with others who have
find information, support and connections psoriasis.
that will help them manage their disease.
When you become a professional member, Psoriasis Advance :
we can provide you with comprehensive Our magazine for
patient education literature, support Foundation members,
services and programs. We also have published four times
literature developed specifically to educate a year, offers news,
medical professionals and insurers. articles and columns
about psoriasis and
Educational booklets: The Psoriasis psoriatic arthritis.
Foundation publishes psoriasis As a professional
and psoriatic arthritis member, you will
educational booklets receive three copies
on subjects ranging of each quarterly issue to share with
from biologic medica- your patients and staff.
tions to steroids to
phototherapy options. We Psoriasis Forum : This quarterly,
also publish four youth- peer-reviewed journal,
oriented booklets. We can published especially
provide these materials to for our professional
professional members at a members, offers prac-
discounted price to stock at your office tical treatment advice
and distribute to your patients. Our from leading experts
entire patient-education library is also in the field.
available to download for free from our
Web site.
Insurance Advocacy department know about policies that pose
Insurance challenges can be a barrier treatment barriers and to involve us in the
to appropriate patient care. We have appeals process when we can help.
the resources to help. The Psoriasis
Foundations advocacy department offers The Psoriasis Foundation conducts public
direct assistance for patients and medical policy advocacy and education through
professionals dealing with insurers. We state and federal legislative initiatives.
make it easier to advocate for patients to Our priorities are to build greater federal
navigate todays managed health care investment in psoriasis research, improve
system by providing steps to appeal insur- access to treatments and move faster
ance denials, sample letters from medical toward a cure. By educating policymakers
professionals on patients behalf, and and through legislative action and grass-
research citations to support appeals. roots activity, we know it is possible to
strengthen and expand psoriasis research
The National Psoriasis and access to care, and that a cure is on
Foundation also provides the horizon.
resources to help patients
work with insurance compa- For more information or to submit an
nies to improve treatment insurance policy for investigation, call
coverage and to access 503.546.5550, e-mail
financial assistance with advocacy@psoriasis.org or fax us at
out-of-pocket costs. 503.245.0626.
The Foundation has Medical Education

conducted an audit of more than a The National Psoriasis Foundation is
hundred health insurance plans nation- committed to enhancing psoriasis treat-
wide and continues to identify problematic ment standards. We produce targeted
policies to target for improved access professional education programs and tools,
to treatment. The Psoriasis Foundation including:
initiates dialogue and negotiations with
insurers, and works in partnership with Chief Residents Meeting. This
health professionals to identify and imple- annual day-and-a-half meeting offers
ment more patient-centered policies. In fact, dermatology chief residents a compre-
in one year alone, these efforts improved hensive overview of treatments and
access to treatments for nearly 400,000 management of psoriasis and psoriatic
patients across the country with moderate arthritis. Participants evaluations
to severe psoriasis. We encourage the consistently rank the event as a high-
medical community to let our advocacy light of their training.
Continuing medical education that Join Hands with Us
focuses on treating psoriasis and psori- The Psoriasis Foundation maintains a
atic arthritis. strong relationship with the medical
community. Hundreds of Foundation
Ther apy of Moder ate to Severe members are medical professionals
Psoriasis, a clinical manual edited by committed to providing the best possible
Gerald D. Weinstein, M.D., and Alice B. care for psoriasis and psoriatic arthritis
Gottlieb, M.D., Ph.D., includes informa- patients. Please join us as a professional
tion from national psoriasis experts on member and become part of a growing
state-of-the-art clinical management. base of physicians and health care
providers who are playing a vital role in
The Psoriasis and Psoriatic the Psoriasis Foundations research, advo-
Arthritis Pocket Guide, published cacy and education efforts. Together we
by the Psoriasis Foundation, includes can make a difference.
algorithms that provide direction on
the medical management of psoriasis, Benefits of Professional Membership
based on specific patient types. The annual fee for professional member-
ship is $95 ($125 outside of the United
Online Physician Directory States). Membership is open to all medical
As a professional professionals. Youll receive:
member, youll
receive placement in Four issues annually of Psoriasis Forum,
our online Physician our peer-reviewed journal that provides
Directory, which practical treatment advice from leading
allows physicians experts.
treating psoriasis
and psoriatic Discounted patient education literature.
arthritis to list their
practices, indicate Placement in our online Physician
specific treatments offered and share Directory, where patients can easily
other key details with patients. The direc- find your practice.
tory, searched by more than 52,000 patients
annually, helps match psoriasis and psori- Three copies of each issue of Psoriasis
atic arthritis patients with the best medical Advance, the Foundations quarterly
care in their area. To access the directory member magazine, to share with
and list your practice, visit patients and staff.
www.psoriasis.org/medical/directory.
To join online, visit www.psoriasis.org/
promember. To receive information, call
800.723.9166 or e-mail member@psoriasis.org.
A Year in the Life of the National Psoriasis

Foundation
Circulate 65,000 educational booklets
Circulate 100,000 copies of our member

magazine, Psoriasis Advance
References
Educate 117,000 visitors a month on our
Web site
Educate 5,000 patients about psoriasis

and psoriatic arthritis via telephone
and e-mail
Deliver community education meetings

to 1,000 people
Circulate 10,000 copies of the medical

professional journal, Psoriasis Forum
Work with 500 volunteers across the

country
Present Webcast psoriasis education

sessions to 1,000 people
Bring 250 patients, families, volunteers

and manufacturers together at our
national conference

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Dec; 139(12):1627-32; discussion 1632. clonal antibody, in patients with psoriasis:
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BS, Zitnik R, Wang A, Gottlieb AB; Etanercept Lancet. 2008; 371:1675-1681.
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80. Kavanaugh A, McInnes I, Meese P, et.al. 1989; 121:647-653.
Golimumab, a new human tumor necrosis
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Notes Notes
Executives
Richard Seiden
Chair, Board of Trustees
Randy Beranek
President and CEO
Acknowledgements
The National Psoriasis Foundation
acknowledges the work of the authors.
Their time, energy and commitment to the
mission of finding a cure for psoriasis and
psoriatic arthritis and to eliminate their
devastating effects through research, advo-
cacy and education.
Production Editor
Bruce Bebo Jr., Ph.D.
Director of Research and Medical Programs
Editor
Mary Bellotti
Editor, National Psoriasis Foundation
Graphic Design
Carrie Geygan
Graphic Design Manager
National Psoriasis Foundation 2009

The mission of the National Psoriasis
Foundation is to find a cure for psoriasis
and psoriatic arthritis and to eliminate
their devastating effects through research,
advocacy and education.

6600 SW 92nd Ave., Suite 300
Portland, OR 97223-7195
800.723.9166
www.psoriasis.org
getinfo@psoriasis.org
The National Psoriasis Foundation

acknowledges Stiefel for the support of
this Pocket Guide through an unrestricted
www.psoriasis.org
educational grant. The authors of the
Pocket Guide were wholly responsible for
development and production.
National Psoriasis Foundation 2009

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the

Treatment algorithms and

Abby Van Voorhees, M.D. CHAPTER 2: ASSESSING A PSORIASIS

The Psoriasis and Psoriatic Arthritis Pocket Guide | i

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

Mycophenolate Mofetil . . . . . . . . . . . . . . 121

CHAPTER 6: TRANSITIONAL STRATEGIES

Who We Are . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

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

iv | The National Psoriasis Foundation

Although there is evidence that psoriasis

In addition, approximately $11.25 billion

Psoriasis: A Systemic Disease

The Psoriasis and Psoriatic Arthritis Pocket Guide | 1

The patient is not

Define the severity of psoriasis and

Explain the profound emotional, social

Understand the important comorbidi-

Differentiate psoriasis from other

Diagnose patients who have moderate

Discuss therapeutic options and appro-

Describe toxicities expected with

8 | The National Psoriasis Foundation

Table 2-1: The Most Common Locations of

Chronic plaque-type disease is the most

Erythroderma, especially of recent onset,

The Psoriasis and Psoriatic Arthritis Pocket Guide | 9

Severe > 10%

A copy of the KMPI instrument can be found

Part 1: Quality of Life - Please answer each

How much has each of the following been

If yes, how many joints are affected?

If yes, how much have your joint symptoms

Once completed, please

Koo-Menter Psoriasis Instrument

Part 1: Total Quality-of-Life assessment

Part 2: Area of Involvement: % BSA (body

Right Leg: up to 18% (includes

Left Leg % Left Leg: up to 18% (includes

Genitalia % Genitalia: 1% Total BSA %

Guttate psoriasis? Yes No

Localized (< 10% BSA) psoriasis but resistant

Localized (< 10% BSA) but serious subtype

Clinical evidence of psoriatic joint disease

Substantial psychosocial or quality-of-life

Part 4: Is phototherapy an option?

Does the anatomical location or form of

In your clinical judgment, is phototherapy

If at least one of the shaded boxes in both

Conclusion: The patient is a candidate for

Fingernails are more often involved than Stress

Drugs (e.g. corticosteroids, lithium,

Adapted from Menter and Weinstein12

your ability to do daily activities Strongly Disagree No Agree Strongly