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Ask The Expert
Welcome to the Ask the Expert. In this forum, you will have the opportunity to submit challenging questions regarding psoriatic conditions.
The information contained on PsoriasisHQ.org is selected and prepared by various authors.
All recommendations or suggestions for the use of drugs, devices, or techniques reflect their opinions.
No responsibility or liability in submitting this information is assumed by the authors, the editors,
the accrediting institution(s), the supporting company, or the publisher.
Before employing any such drugs, devices, or techniques, medical practitioners should secure and review complete,
detailed information available from the appropriate manufacturers.
Ask The Expert
Jeffrey M Weinberg, MD, FAAD
Assistant Clinical Professor
Columbia University College of Physicians and Surgeons
New York, NY
Latest Questions (Click question for answer)
- It seems common that psoriasis flares up when other health conditions do. should we look for a trigger, or just treat the flare?
Answer: Psoriasis has several well-known triggers, including some medications, infections, skin injury, and stress. The major reason to look for a trigger is that, if this factor can be removed, the psoriasis may abate. Several years ago, a young woman presented with nail complaints consistent with psoriasis. Upon taking her history, she was taking lithium for bipolar disorder. The changing of this medication improved her nail dystrophy. Therefore, a detailed history, including potential triggers, may be useful and should be performed. If there is no obvious trigger, appropriate therapy can be instituted.
- Any tricks for treating widespread guttate psoriasis in children/young adults?
Answer: Guttate psoriasis can often present a therapeutic challenge, given its diffuse and patchy nature. Obviously topical therapy and phototherapy are options, but there are limitations to both of these. It is hard to apply topicals to diffuse guttate lesions, and phototherapy, while effective, can often be inconvenient. In the setting of streptococcal pharyngitis, a positive throat culture, or a positive AASO titer, an empiric course of antibiotics may be an option to remove the potential stimulus for the guttate flare. In extreme cases, a short course of systemic therapy, with appropriate monitoring, may be an option.
- When do you typically decide to start a patient with psoriasis on a systemic agent?
Answer: Although practitioner experience as well as clinician and patient preferences guide the answer to this question, some general guidelines can be recommended: Patients with psoriasis and psoriatic arthritis should be started on an anti-TNF agent with or without methotrexate. Patients with limited psoriasis may respond to topical therapy or targeted phototherapy while individuals with extensive disease are candidates for systemic intervention, which may include UVB/PUVA, traditional systemic (eg, cyclosporine), or biologic agents. In addition, patients with limited disease who do not respond to topical or targeted phototherapy should be considered for treatment with a traditional systemic or biologic.
- Any recommendations for selecting a particular biologic to treat a patient with psoriasis?
Answer: Many factors come in to play when selecting a biologic. These include the presence or absence of psoriatic arthritis, the presence of any relative contraindications to therapy such as history of demyelinating disease (for TNF-inhibitors) or history of malignancy, and preferred route of administration. I generally review the risks and benefits of available therapies when counseling a potential biologic candidate.
- What baseline tests are recommended prior to initiating treatment with a biologic?
Answer: General recommendations for baseline evaluation prior to initiating treatment with a biologic are: obtain a complete blood count, chemistry screen with liver function tests, hepatitis screen, CD-4 count (alefacept, only), and HIV test (alefacept, only). A tuberculosis test (PPD) should also be performed.
[source: Menter A et al. J Am Acad Dermatol. 2008;58(5):826-860]
- What medication combinations are safe and effective for patients not experiencing adequate improvement on monotherapy?
Answer: Combination therapy with a biologic and phototherapy may offer greater response than either medication alone. Combination therapy with a biologic and cyclosporine may be useful for a limited period of time while the cyclosporine is being tapered off. Topical therapies can also be used in combination with biologics to provide greater efficacy. Low-dose methotrexate is sometimes administered in conjunction with biologics, particularly infliximab, to minimize antibody formation, which may otherwise cause a decline in efficacy.
[Source: Kircik LH, Del Rosso JQ. Skin and Aging. Supplement to July 2008 issue; Bahner JD, Cao LY, Korman NJ. Clinical, Cosmetic and Investigational Dermatology. 2009;2:111-128]
- What are the pregnancy categories for FDA-approved systemic medications used to treat psoriasis?
Answer: Methotrexate and acitretin are category X and should never be used in a pregnant patient or one who is planning to become pregnant. Cyclosporine is category C; premature birth and low-birth weight for gestational age are consistently observed among transplant patients treated with cyclosporine. Etanercept, infliximab, adalimumab, alefacept, and ustekinumab are category B. Golimumab was recently FDA-approved for the treatment of psoriatic arthritis and it is also pregnancy category B.
- Can vaccinations be given or should vaccinations be given to patients with psoriasis receiving treatment with biologics?
Answer: Live vaccines must be avoided in patients treated with biologics. Live vaccines include varicella; mumps, measles, rubella; oral typhoid; yellow fever. It has been suggested that recommendations for psoriatic patients follow those that are standard of care for organ transplantation -- standard vaccinations, including pneumococcal, hepatitis A and B, influenza, and tetanus-diphtheria should be administered prior to initiation of immunosuppressive therapy and transplantation. For patients with psoriasis, vaccinations should be given before biologic therapy starts; however, if the patient requires a vaccine once therapy has begun, the advantages and disadvantages of killed virus vaccines (eg, influenza) must be considered.
[source: Menter A et al. J Am Acad Dermatol. 2008;58(5):826-860]
- How concerned should I be about heart disease in my patients with psoriasis?
Answer: An association between psoriasis and heart disease has been suggested in the past; however, authors of a recent study have found evidence to “firmly establish” psoriasis as a risk factor for heart disease. The study documented rates of cardiovascular events and death between 1997 and 2006 and compared results from 40,000 patients with psoriasis with 4 million people without psoriasis. Relative risk of cardiac events in patients with psoriasis versus without psoriasis and according to psoriasis severity is summarized in the following table: [source: http://www.medscape.com/viewarticle/718466 ] Event | Mild psoriasis | Moderate-to-severe psoriasis | Atrial Fibrillation | 1.22 | 1.51 | Stroke | 1.19 | 1.45 | Myocardial infarction | 1.10 | 1.24 | All-cause mortality | 1.04 | 1.67 |
- We often talk about stress as a trigger for psoriasis flares. Is there documented evidence that shows a link between the two or is the association more of an anecdotal assumption?
Answer: The association is more than anecdotal with clinical research providing evidence to support the claim that stress and psoriasis flares are linked. A recent publication in the British Journal of Dermatology followed patients (N=62) for 6 months, measuring self-reported stressors, itch, disease severity, and individual reactivity factors. Researchers found when patients experienced high levels of daily stressors, cognitive and behavioral patterns of worrying and scratching were independently related to an increase in disease severity and itch 4 weeks later.
[source: Verhoeven EWM, Kraaimaat FW, de Jong EMGJ, et al. The British Journal of Dermatology. 2009;161(2):295-299.]
- Several medication classes are approved to treat psoriatic arthritis and it is often challenging to decide which one to select. Which are the most thoroughly evaluated medications?
Answer: The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), a multinational group of rheumatologists, dermatologists, and patients, reviewed psoriasis literature and graded treatment recommendations. Treatment rated as grade A for patients with moderate-severe peripheral arthritis included sulfasalazine, leflunomide, and TNF-alpha inhibitors. Methotrexate scored grade B.
[source: Ritchlin CT, Kavanaugh A, Gladman DD, et al; Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) Ann Rheum Dis. 2009;68:1387-1394]
- How common is psoriasis in the pediatric population?
Answer: The overall prevalence of psoriasis in the U.S. is approximately 2.6% (7.5 million people). An estimated one-third of patients are diagnosed when they are younger than 20 years of age. Approximately 20,000 children under the age of 10 years are diagnosed with psoriasis annually. Prevalence rates seem to increase linearly with age. It is important to realize that even in the pediatric population, the rates of other illnesses, including hyperlipidemia, obesity, hypertension, diabetes mellitus, and Crohn’s disease, are twice as high in patients with psoriasis than without the condition.
[sources: National Psoriasis Foundation, About psoriasis in children. http://www.psoriasis.org/netcommunity/learn_children ; Augustin M et al. Epidemiology and comorbidity of psoriasis in children. Br J Dermatol 2009 Nov 18; [e-pub ahead of print]. (http://dx.doi.org/10.1111/j.1365-2133.2009.09593.x)
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