1

Learning ObjectivesUpon completion of this educational activity, participants should be able to:• Summarize the epidemiology and pathophysiology

of psoriasis and PsA.• Describe the diagnosis, disease classification, and

assessment associated with psoriasis and PsA.• Incorporate patient preferences and shared

decision making into tailored treatment plans for patients with psoriasis and PsA.

• Evaluate the efficacy and safety of recently available therapies for the management of psoriasis and PsA.

Psoriasis

2

Psoriasis

• Chronic, immune-mediated skin disease– Most common autoimmune disease– Correlation between skin and systemic

inflammation

• High comorbidity burden

• Affects almost 8 million Americans

Rachakonda TD, et al. J Am Acad Dermatol. 2014;70(3):512-516; Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923; Helmick CG, et al. Am J Prev Med. 2014;47(1):37-45; Nestle FO, et al. N Engl J Med. 2009;361(5):496-509.

Psoriasis

Tollefson MM, et al. J Am Acad Dermatol. 2010;62(6):979-987; Icen M, et al. J Am Acad Dermatol. 2009;60(3):394-401; Rachakonda TD, et al. J Am Acad Dermatol. 2014;70(3):512-516; Helmick CG, et al. Am J Prev Med. 2014;47(1):37-45.

050

100150200250300

18-29 30-39 40-49 50-59 60-69 70-79 >80

# o

f P

ati

en

ts w

ith

P

so

ria

sis

Age in Years

Men

Women

Psoriasis in Adults (n=2564)

• Pediatric incidence: 40.8/100,000 population• Adult incidence: 78.9/100,000 population

0%10%20%30%40%50%60%70%80%90%

100%

No

Yes

Impact of Psoriasis on QoLEmotional and Physical Impact of Psoriasis

Pso

riasi

s P

atie

nts

(%)

Adapted by Lilian McVey from Armstrong AW, et al. PLoS One. 2012;7(12):e52935. Used with permission.

~80% to 90% of psoriasis patients experience significant impairment of QoL and work productivity

3

Pathogenesis

Ainsworth C. Nature. 2012;492(7429):S52-S54. Used with permission.

Psoriasis Types

Photos courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP. Used with permission.

Erythrodermic

Nail psoriasis

Scalp

Genital/Inverse

Plaque

Plaque

Psoriasis Assessment: Types• Plaque psoriasis

– Well-defined erythematous plaques– Elbows, knees, scalp, lower trunk

• Scalp psoriasis– Presentation ranges from slight scaling to thick, crusted

plaques that cover the scalp

• Nail psoriasis– Nail pitting and crumbling, separation of nail plate from

bed with white discoloration, nail thickening

• Inverse psoriasis– Shiny, erythematous plaques with minimal scaling– Groin and/or other intertriginous areas (eg, under

breasts, in abdominal skin folds)

Young M, et al. J Am Assoc Nurse Pract. 2017;29(3):157-178.

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Psoriasis Assessment: Types (cont’d)• Pustular psoriasis

– Eruption of sterile pustules– Generalized and extensive or localized to existing plaques

• Palmoplantar pustular psoriasis– Yellow-brown sterile pustules on hands and feet– May include scaling and severe pruritis

• Erythrodermic psoriasis– Generalized exfoliative dermatitis, often with hair loss

and nail dystrophy– Affects large body surface area (BSA); ≥80%

• Guttate psoriasis– Small, scattered, pink, oval-shaped papules

w/silvery scaling– Affects trunk and extremities

Young M, et al. J Am Assoc Nurse Pract. 2017;29(3):157-178.

Psoriasis Assessment• Comprehensive exam• Medication history• Assess for comorbidity

– Psoriatic arthritis (PsA) and other arthropathies

– Diabetes– Hyperlipidemia– Obesity– Cardiovascular disease– Malignancy– Depression

• Differential diagnoses– Eczema– Contact dermatitis– Seborrheic dermatitis– Drug eruption– Tinea infections– Pityriasis rosea– Lichen planus– Candidal intertrigo– Onychomycosis

Psoriasis can be difficult to diagnose…When in doubt, REFER!

Young M, et al. J Am Assoc Nurse Pract. 2017;29(3):157-178.

Clinical Pearls for Diagnosis

• Distribution– Eczema common on flexors– Psoriasis common on extensors

• Auspitz sign• Well-defined

– vs eczema with diffuse border

• Consider treatment secondary infection– Inverse psoriasis vs candidiasis vs intertrigo

• Skin biopsy if unsure (punch biopsy)

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Psoriasis Assessment: Severity

• Scoring tools:– PASI: Psoriasis Area and Severity Index

– BSA: Body Surface Area

– DLQI: Dermatology Life Quality Index

• Remember:– Severity ≠ amount of area affected

– Consider Area(s) of involvement

Palms, genitals, soles, scalp, nails

Interference with QoL

US Perspectives: MAPP Survey

• Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey– N=1,005 patients, 101 dermatologists, and

100 rheumatologists

• Key findings– Both psoriasis and PsA remain undertreated

in patients with moderate-to-severe disease– Gaps in care include screening, assessing,

diagnosing and treating psoriasis patients with symptoms of PsA

Lebwohl MG, et al. Am J Clin Dermatol. 2016;17(1):87-97.

US Perspectives: MAPP Survey

• Key findings (cont’d)– Widespread dissatisfaction with current

treatment options Lack of efficacy

Long-term safety unknown

Administration challenges

Cost

– Difference in perceptions of severity, treatment impact in patients vs clinicians

Lebwohl MG, et al. Am J Clin Dermatol. 2016;17(1):87-97.

6

Perceptions of Disease Severity: MAPP Survey

• Perceptions of disease severity differ between patients and clinicians

Adapted by Lilian McVey from Lebwohl MG, et al. Am J Clin Dermatol. 2016;17(1):87-97. Used with permission.

0102030405060708090

Patients (n=735)

Dermatologists(n=101)

Res

pond

ents

(%

)

36.1

11.9

21.8

76.2

8.34.0

11.44.0 5.4 0.0

Most important factors contributing to disease severity in psoriasis, as reported by patients and clinicians

Psoriatic Arthritis

PsA in Psoriasis Patients• Up to 30% of individuals with psoriasis will

develop PsA (higher than previously thought)

• Risk factors– Severe psoriasis

– Psoriatic nail pitting

– Uveitis

Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923.Karreman MC, et al. Arthritis Rheumatol. 2016;68(4):924-931.Photos courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP.Used with permission.

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PsA• Inflammatory arthritis

– Skin disease typically precedes joint disease

• Variable disease course– Flares and remission

• Severe disease is associated with:– Progressive joint damage– Increased mortality– Increase in cardiovascular

risk

Eder L, et al. Arthritis Rheumatol. 2016;68(4):915-923.Gladman DD. Clin Exp Rheumatol. 2008;26(5 Suppl 51):S62-S65.Arumugam R, McHugh NJ. J Rheumatol Suppl. 2012;89:32-35.Photo courtesy of Margaret Bobonich, DNP, FNP-C, DCNP, FAANP. Used with permission.

80%

20%

Diagnosis of PsA• High prevalence of undiagnosed PsA (~10%-15%)• Patients with PsA report a mean interval of 12.4

years between onset of skin symptoms and onset of joint symptoms

• Arthritis symptoms precede skin involvement in 13% to 17% of patients

• 15% of patients have undiagnosed or unrecognized psoriasis

1. Villani A, et al. J Am Acad Dermatol. 2015;73(2):242-248.2. Karreman MC, et al. Arthritis Rheumatol. 2016;68(4):924-931.3. Gottlieb A, et al. J Am Acad Dermatol. 2008;58(5):851-864.

Joint symptoms represent DESTRUCTIVE, IRREVERSIBLE DISEASE.

Early diagnosis is critical for preventing progression.

Diagnosis of PsA

• Common signs and symptoms‒ Musculoskeletal (32.1%) Joint symptoms (88.2%)

Tendon symptoms (50.4%)Dactylitis

Low back pain (73.9%)

Peripheral arthritis

‒ Psoriatic nail dystrophy (15.5%)

‒ Enthesitis (4.6%-7.0%)

‒ Uveitis

‒ Plaque psoriasisKarreman MC, et al. Arthritis Rheumatol. 2016;68(4):924-931.

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Diagnosis of PsA• 2 primary patterns

‒ Peripheral joint disease (~95% of PsApatients)

‒ Axial involvement only (~5% of PsApatients)

• Diagnosis is typically made in a patient with psoriasis and inflammatory arthritis in a PsA-type pattern– Patients with psoriasis may have other

types of arthritis including RA, OA, gout, reactive arthritis, and arthritis of IBD

Gottlieb A, et al. J Am Acad Dermatol. 2008;58(5):851-864.

Diagnosis Is Made Clinically• History

– Skin disease– Joints involved– Enthesitis, dactylitis, eye

disease, inflammatory back pain (age <40, worse at night with AM stiffness, better with activity)

– Family history• Physical exam• Laboratory testing

– CBC– BUN, creatinine, uric acid, and

UA– ESR and CRP (elevated in 40%

of patients)– RF (2%-10%), anti-CCP (8%-

16%) and ANA (low titer 50%)– HLAB27 (50%)

• Arthrocentesis– To rule out septic arthritis, gout

and CPPD• Imaging

– Plain film, ultrasound, MRI– Co-existence of erosive

changes and new bone formation, which may occur in same joint or within same digit

Menter A, et al. J Am Acad Dermatol. 2011;65(1):137-174; Alenius GM, et al. Ann Rheum Dis. 2006;65(3):398-400; Johnson SR, et al. Ann Rheum Dis. 2005;64(5):770-772; Eder L, et al. Ann Rheum Dis. 2012;71(1):50-55.

Diagnosis can be challenging:

REFER

ClASsification Criteria for Psoriatic ARthritis (CASPAR)

• Valuable in clinical trials, can be used for diagnosis– Limited to peripheral arthritis, axial disease, and

enthesitis

• Specificity of 98.7% and sensitivity of 91.4%

• Advantages over Moll and Wright Criteria*– High specificity and sensitivity– Includes family history of psoriasis– Includes inflammatory articular disease– Includes RF status

*To meet the Moll and Wright 1973 classification criteria for psoriatic arthritis, a patient with psoriasis and inflammatory arthritis who is seronegative for RA must present with 1 of 5 clinical subtypes: polyarticular, symmetric arthritis; pligoarticular (less than 5 joints), asymmetric arthritis; distal interphalangeal joint predominant; spondylitis predominant; or arthritis mutilans.Taylor W, et al. Arthritis Rheum. 2006;54(8):2665-2673; Congi L, Roussou E. Clin Exp Rheumatol. 2010;28(3):304-310; Gottlieb A, et al. J Am Acad Dermatol. 2008;58(5):851-864.

9

PsA is diagnosed when ≥3 points below are assigned in the presence of inflammatory articular disease (joint, spine, or entheseal)

Category Description Points

Current or personal history of psoriasis

Psoriatic skin or scalp disease confirmed by dermatologist or rheumatologist; history of psoriasis from patient, family physician, dermatologist, rheumatologist, or other qualified practitioner

2

Family history of psoriasis Patient-reported history of psoriasis in first- or second-degree relative

1

Psoriatic nail dystrophy on current physical exam

Includes onycholysis, pitting, and hyperkeratosis 1

Negative for RF Enzyme-linked immunosorbent assay or nephelometry preferred (no latex) using local laboratory reference range

1

Current dactylitis or history of dactylitis documented by a rheumatologist

Swelling of entire digit 1

Radiographic evidence of juxta-articular new bone formation

Ill-defined ossification near joint margins excluding osteophyte formation on plain X-rays of hand or foot

1

CASPAR

Taylor W, et al. Arthritis Rheum. 2006;54(8):2665-2673.

Treatment of Psoriasis and PsA

Treatment of PsoriasisType of treatment Recommended for Comments

Topical Therapy(emollients, corticosteroids, vitamin D analogues, calcipotriene, tazarotene, calcineurin inhibitors, anthralin)

Mild disease (standard) Limited by poor adherence rates

Ultraviolet (UV) Light(UVB radiation, narrow-band UVB, photochemotherapy [PUVA])

Moderate-to-severe disease

Associated with acceleratedphotodamage and increased risk of malignancy; will not treat PsA

Methotrexate Moderate-to-severedisease

Most widely used systemic treatment; inexpensive; pregnancy category X

Cyclosporine Psoriasis flares Used as a bridging agent during induction of other maintenance agents or for flares

Acitretin Moderate-to-severe disease

Low toxicity and no immunosuppression; can be used in patients with infection, malignancy, or HIV; need to monitor LFTs and triglycerides; contraindicated if considering pregnancy

Biologic Agents(infliximab, etanercept, adalimumab, ustekinumab, secukinumab, tofacitinib, apremilast)

Moderate-to-severedisease

May be used as first-line systemic agent depending on comorbidities and other considerations; highly efficacious; expensive

Menter A, et al. J Am Acad Dermatol. 2011;65:137-174.

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Treatment Considerations• Age• Pregnancy/lactation (current or future)• Patient/family medical history

– Malignancies– Multiple sclerosis or CHF– Inflammatory bowel disease– Depression or suicide– Chronic infections– Other autoimmune diseases (ie, lupus)

• Exposure to fungus or TB• History of HCV, HBV, HIV or high risk behavior• Social – alcohol consumption

Psoriasis Treatment AlgorithmPsoriasis

+ PsA

Anti-TNF +/-MTX*

Extent of disease

-Topicals-Targeted

phototherapy

-UVB/PUVA- Systemic-Biologic

Effective Not Effective†

Mild(limited)

No

Moderate/Severe(extensive)

Yes

*Patients with nondeforming PsA without any radiographic changes, loss of range of motion, or interference with tasks of daily living should not automatically be treated with tumor necrosis factor (TNF ) inhibitors. It would be reasonable to treat these patients with a nonsteroidal anti-inflammatory agent or to consult a rheumatologist for therapeutic options. †Patients with limited skin disease should not automatically be treated with systemic treatment if they do not improve, because treatment with systemic therapy may carry more risk than the disease itself.

Adapted by Lilian McVey from Menter A, et al. J Am Acad Dermatol. 2008;58(5):826-850. Used with permission.

Treatment of Mild-to-Moderate Psoriasis

• Topical therapy– Corticosteroids, vitamin D derivatives,

tazarotene, anthralin, tacrolimus, pimecrolimus, newer tar formulations

– Must be prescribed appropriately and used consistently for weeks to months for clinical improvement

– Potential AEs Cutaneous atrophy Telangiectasias Hypothalamic-pituitary axis suppression

Stein Gold LF. Semin Cutan Med Surg. 2016;35(2 Suppl 2):S36-S44.Koyama G, et al. Int J Pharm Compd. 2015;19(5):357-365.

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Treatment of Mild-to-Moderate Psoriasis

• Topical therapy (cont’d)– Primary limitation is medication adherence– Strategies to optimize adherence: Consider dosage/schedule, choice of vehicle

Fixed-combination gels, foams Address patient preference about treatment Address concerns about treatment-related toxicities Manage patient expectations

• Assess patient response and know when to refer!– Up to 80% of psoriasis patients receive no

treatment or only topical therapy

Stein Gold LF. Semin Cutan Med Surg. 2016;35(2 Suppl 2):S36-S44.Lebwohl MG, et al. Am J Clin Dermatol. 2016;17(1):87-97.

Treatment of Moderate-to-Severe Psoriasis

• Refer to dermatology• Primary care:

– Emphasize need for long-term follow-up and adherence to prescribed therapy

– Encourage lifestyle changes Smoking cessation Decreased alcohol consumption Healthy diet and increased physical

activity– Monitor for AEs– Consider early

screening/intervention for CVD and metabolic disease

Treatment Potential AEs

Phototherapy Squamous cell carcinoma, photoaging

Methotrexate Hepatotoxicity, bone marrow suppression, pneumonitis

Cyclosporin Impaired renal function, hypertension,lymphoma, cutaneousmalignancies

Acitretin Mucocutaneous side effects, dyslipidemia

Biologics Tuberculosis, and latent infections,hepatitis, CNS complications, cytopenia, multiple sclerosis, CHF

Aldredge LM, et al. J Dermatol Nurses Assoc. 2016;8(1):14-26.Menter A, et al. J Am Acad Dermatol. 2008;58(5):826-850.

Treatment of PsA

• Treatment is guided by disease severity and symptoms

• Treat to target (T2T) approach • Comorbidities may limit options (diabetes, metabolic

syndrome, fatty liver, CAD)• Screening

– CV risk factors (BP, lipids, smoking)– Weight loss counseling– Ultrasound of liver with elevated LFTs– Hepatitis screening – Tuberculosis screening – quantiferon gold TB is standard

(or PPD skin test)– Vaccinations

12

Treatment of PsA

NSAIDs

Intra-articular injections

Nonbiologic DMARDsmethotrexate, sulfasalazine,

leflunomide, cyclosporin,

Biologic DMARDsanti-TNF, PDE4 inhibitors, anti-IL-12/23, anti-IL-17A

Adapted by Lilian McVey from Gossec L, et al. Clin Exp Rheumatol. 2015;5 (Suppl 93):S73-S77. Used with permission.

Will not affect plaque psoriasis

Can also treat plaque psoriasis

Biologic Agents for Psoriasis/PsADrug Target FDA-Approved for

PsoriasisFDA-Approved for

PsA

Etanercept TNF-receptor X X

Infliximab TNF-alpha X X

Adalimumab TNF-alpha X X

Ustekinumab Anti-IL-12/-23 X X

Brodalumab IL-17 receptor X

Ixekizumab IL-17A X

Secukinumab IL-17A X X

Apremilast Phosphodiesterase 4 (PDE4)

X X

Tofacitinib Janus Kinase (JAK-STAT pathway)

X

Golimumab TNF-alpha X

Certolizumab TNF-alpha X

Alwan W, Nestle FO. Clin Exp Rheumatol. 2015;33(5 Suppl 93):S2-S6.

Biologic Agents in PsA

Benefits• Induce a durable long-term

response– 56% improvement in tender

joint counts– 70% improvement in swollen

joint counts– 64% improvement in CRP

level– 36% improvement in overall

disease activity score (DAS)

• Improve Health Assessment Questionnaire (HAQ) scores

• Long-term safety confirmed

Drawbacks• Potential AEs

– Injection site reactions– Serious infections– Possible association with

increase of some malignancies

• Lack of sustained response to TNF inhibitors in some PsA patients

• Intravenous dosing of some medications

• Cost

Coates LC, et al. Ann Rheum Dis. 2008;67(5):717-719.Cawson MR, et al. BMC Musculoskelet Disord. 2014;15:26.Bissonnette R, et al. J Cutan Med Surg. 2009;13(Suppl 2):S67-S76.

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Treatment of PsA• Mild arthritis

– NSAIDs

• Moderately severe arthritis or resistant to NSAID– Methotrexate– Leflunomide– Apremilast

• Severe peripheral arthritis/adverse prognosis– TNF inhibitor

Etanercept Infliximab Adalimumab Golimumab Certolizumab pegol

– Other biologic DMARDs Secukinumab Ustekinumab

• Axial disease– NSAIDs

– Biologic DMARD

• Enthesitis– NSAIDs

– Biologic DMARD

• Dactylitis– NSAIDs

– DMARD

. 

Stay Tuned• American College of Rheumatology and

the National Psoriasis Foundation Guideline for the Management of Psoriatic Arthritis– Anticipated completion 2018

Monitoring• National Psoriasis Foundation (NPF)

treatment targets for plaque psoriasis– Acceptable: Either BSA ≤3% or BSA

improvement ≥75% from baseline at 3 months after treatment initiation

– Target: BSA ≤1% at 3 months after treatment initiation

• Monitor at least every 3 to 6 months during maintenance therapy

• Reassess if skin symptoms or arthritis not under control

Armstrong AW, et al. J Am Acad Dermatol. 2017;76(2):290-298.

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Comorbidities Established in Psoriasis and PsA

• Cardiovascular disease (CVD)

• Metabolic syndrome

• Obesity

• Dyslipidemia

• Diabetes

• Mood disorders

• Inflammatory bowel disease

• Malignancy

• Uveitis

• Alcohol and addictive behaviors

Abuaara K, et al. Br J Dermatol. 2010;163(3):586-592; Armstrong AW, et al. J Hypertens. 2013;31:433-442; discussion 442-443; AzfarRS, et al. Arch Dermatol. 2012;148(9):995-1000; Gelfand JM, et al. JAMA. 2006;296(14):17351-741; Gelfand JM, et al. J Invest Dermatol. 2006;126(10):2194-2201; Kurd SK, et al. Arch Derm. 2010;146:891-895; Langan SM, et al. J Invest Derm. 2012;132(3 Pt 1):556-562; Li W, et al. Am J Epidemiol. 2012;175(5):402-413; Ma C, et al. Br J Dermatol. 2013;168(3):486-495; Mehta NN, et al. EurHeart J. 2010;31(8):1000-1006; Najarian DJ, et al. J Am Acad Dermatol. 2003;48(6):805-821; Yeung H, et al. JAMA Derm. 2013;149(10):1173-1179.

Emerging Comorbidities

Psoriatic disease

Sleep apnea

Nonalcoholic steatohepatitis

COPD

Adverse infectious disease

outcomes

Renal disease

Peptic ulcer disease

Callis Duffin K, et al. J Am Acad Dermatol. 2009;60(4):604-608; Wakkee M, et al. J Am Acad Dermatol. 2011;65(6):1135-1144; Van der Voort ET, et al. J Am Acad Dermatol. 2014;70:517-524; Yeung H, et al. JAMA Derm. 2013;149(10):1173-1179; Yang YW, et al. Br J Derm. 2011;165(5):1037-1043.

Risk of Cardiometabolic Disease in Patients with More Severe Psoriasis

Clinical significance:• Increased risk of MI, stroke, CV death, and diabetes

• 5 years shorter life expectancy

• 10-year risk of major CV event attributable to psoriasis = 6%

• Risk of CV disease in patients with severe psoriasis similar to risk conferred by diabetes

• Patients treated for severe psoriasis are 30 times more likely to experience MACE (attributable to psoriasis) than to develop a melanoma

MI = myocardial infarction, MACE = major adverse cardiac events, RR = relative risk.1. Abuaara K, et al. Br. J. Dermatol. 2010;163(3):586-592; 2. Gelfand JM, et al. JAMA. 2006;296(14):1735-1741. 3. Gelfand JM, et al. J Invest Derm. 2009;129(10):2411-2418; 4. Mehta NN, et al. Eur Heart J. 2010;31(8):1000-1006. 5. Mehta NN, et al. Am J Med. 2011;124(8):775.e1-6. 6. Azfar R, et al. Arch Derm. 2012;148(9):995-1000.

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Cardiovascular Comorbidity in PsA

PsA patientsIR/1000 PYs

Non-PsA patients IR/1000 PYs

Rates of incident CVD – All 12.8 9.6

Rates of MACE 4.6 3.5

• Rates of CVD and MACE are higher in patients with PsA compared to those without PsA

IR = incidence rate, PY = person-years.Li L, et al. J Clin Rheumatol. 2015;21(8):405-410.

Case Study28-year-old female nurse being followed in rheumatology

clinic for fibromyalgia diagnosed 5 years prior presents c/o worsening back and hand pain over the last several months.

• History– Inflammatory back pain– Somewhat responsive

to NSAIDs, h/o gastric ulcer

– No h/o psoriatic disease

• Physical exam– Scalp psoriasis– Dactylitis right second

finger

• Laboratory – ANA 1:40– Neg RF, anti-CCP– ESR 35, CRP 7– HLAB27 positive

Case Study• Diagnosed with psoriasis and PsA after review

of labs and films• Treatment considerations

– Negative hepatitis and TB screening– History of gastric ulcer– Considering pregnancy in the next year

• Options– Methotrexate

Unable to tolerate: GI distress and hair loss

– TNF inhibitor Etanercept

At 3-month follow-up, dactylitis absent, scalp psoriasis clear, AM stiffness 30 minutes, back pain improved though not gone

16

Case Study• Two years later, stopped etanercept with

pregnancy confirmation• Back pain worse during pregnancy• At 2 months postpartum

– Scalp psoriasis worse, patches on elbows and hands

– Joint pain and stiffness in hands and knees– Difficulty with ADLs– Resumed etanercept with reduction in

symptoms

Primary Care Pearls

• Take a good history from the patient• Complete a thorough skin

examination• Assess for joint signs and symptoms• Monitor patients for comorbidities

sooner than the general population• Monitor for side effects and treatment

complications

Primary Care Pearls• Assess for adherence to therapy• Ensure all age-appropriate screening• Assess for QoL and ADLs• Assess for psychosocial• Patients on biologics or

immunosuppressants– Do not give live vaccines– Notify specialist (dermatology or

rheumatology) if patient develops Serious signs or symptoms of infection Change in medical condition

Updates in Psoriasis and Psoriatic Arthritis Management: Best Practices for Effective Care

References

Abuaara K, Azfar RS, Shin DB, Neimann AL, Troxel AB, Gelfand JM. Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the U.K. Br J Dermatol. 2010;163(3):586-592.

Ainsworth C. Immunology: A many layered thing. Nature. 2012;492(7429):S52-S54.

Aldredge LM, Young MS. Providing guidance for patients with moderate-to-severe psoriasis who are candidates for biologic therapy: role of the nurse practitioner and physician assistant. J Dermatol Nurses Assoc. 2016;8(1):14-26.

Alenius GM, Berglin E, Rantapää Dehlqvist S. Antibodies against cyclic citrullinated peptide (CCP) in psoriatic patients with or without joint inflammation. Ann Rheum Dis. 2006;65(3):398-400.

Alwan W, Nestle FO. Pathogenesis and treatment of psoriasis: exploiting pathophysiological pathways for precision medicine. Clin Exp Rheumatol. 2015;33(5 Suppl 93):S2-S6.

Armstrong AW, Diegel MP, Bagel J, et al. From the Medical Board of the National Psoriasis Foundation: Treatment targets for plaque psoriasis. J Am Acad Dermatol. 2017;76(2):290-298.

Armstrong AW, Harskamp CT, Armstrong EJ. The association between psoriasis and hypertension: a systematic review and meta-analysis of observational studies. J Hypertens. 2013;31(3):433-442; discussion 442-443.

Armstrong AW, Schupp C, Wu J, Bebo B. Quality of life and work productivity impairment among psoriasis patients: findings from the National Psoriasis Foundation survey data 2003-2011. PLoS One. 2012;7(12):e52935.

Arumugam R, McHugh NJ. Mortality and causes of death in psoriatic arthritis. J Rheumatol Suppl. 2012;89:32-35.

Azfar RS, Seminara NM, Shin DB, Troxel AB, Margolis DJ, Gelfand JM. Increased risk of diabetes mellitus and likelihood of receiving diabetes mellitus treatment in patients with psoriasis. Arch Dermatol. 2012;148(9):995-1000.

Bissonnette R, Ho V, Langley RG. Safety of conventional systemic agents and biologic agents in the treatment of psoriasis. J Cutan Med Surg. 2009;13(Suppl 2):S67-S76.

Callis Duffin K, Wong B, Horn EJ, Krueger GG. Psoriatic arthritis is a strong predictor of sleep interference in patients with psoriasis. J Am Acad Dermatol. 2009;60(4):604-608.

Cawson MR, Mitchell SA, Knight C, et al. Systematic review, network meta-analysis and economic evaluation of biological therapy for the management of active psoriatic arthritis. BMC Musculoskelet Disord. 2014;15:26.

Coates LC, Cawkwell LS, Ng NW, et al. Sustained response to long-term biologics and switching in psoriatic arthritis: results from real life experience. Ann Rheum Dis. 2008;67(5):717-719.

Congi L, Roussou E. Clinical application of the CASPAR criteria for psoriatic arthritis compared to other existing criteria. Clin Exp Rheumatol. 2010;28(3):304-310.

Eder L, Chandran V, Pellet F, et al. Human leucocyte antigen risk alleles for psoriatic arthritis among patients with psoriasis. Ann Rheum Dis. 2012;71(1):50-55.

Eder L, Haddad A, Rosen CF, et al. The incidence and risk factors for psoriatic arthritis in patients with psoriasis: a prospective cohort study. Arthritis Rheumatol. 2016;68(4):915-923.

Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735-1741.

Gelfand JM, Shin DB, Neimann AL, Wang X, Margolis DJ, Troxel AB. The risk of lymphoma in patients with psoriasis. J Invest Dermatol. 2006;126(10):2194-2201.

Gelfand, JM, Dommasch ED, Shin DB, et al. The risk of stroke in patients with psoriasis. J Invest Derm. 2009;129(10):2411-2418.

Gladman DD. Mortality in psoriatic arthritis. Clin Exp Rheumatol. 2008;26(5 Suppl 51):S62-S65.

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