What’s in the web for family physicians – update on psoriasis

Wilbert WB Wong 王維斌，Alfred KY Tang 鄧權恩

HK Pract 2021;43:48-50

Psoriasis is a common and chronic skin disorder characterized by erythematous papules and plaques with a silver scale. Psoriasis is frequently encountered by family physicians in our daily practice. Persistent itchiness and dry skin can affect the well being of patients, leading to other comorbidities such as anxiety and depression. It would be useful for family physicians to keep themselves updated on the topic.

An acceptable response for plaque psoriasis would be, after three months of treatment, as either less than 3 percent body surface area (BSA) involvement or 75 percent improvement compared with baseline. The target response after six months is recognized as 1 percent BSA.

For most patients, the initial therapy can either be topical or full body phototherapy (or systemic) therapy. Moderate to severe psoriasis is typically defined as involvement of more than 5 to 10 percent of the BSA (the entire palmar surface, including fingers, of one hand is approximately 1 percent of the BSA) or involvement of the face, palm or sole, or disease that is otherwise disabling.

Patients with more than 5 percent BSA affected are generally candidates for phototherapy or systemic therapy, since application of topical agents to a large area is not usually practical or acceptable for most patients.

Hong Kong Psoriasis Patients Association – white paper 2020

The Hong Kong Psoriasis Patient Association, established in December 2013, is the first mutual aid non-profit organization dedicated to psoriasis patients in Hong Kong. The Association aims to strengthen communication amongst patients, raise the awareness of patients, their families, medical staff and the public about psoriasis through different activities, and then to improve the treatment of psoriasis and patient services.

In 2020, the Association proposed a white paper report with dozens of short-term and long-term recommendations on how to improve the public awareness on the needs of patients. Short term suggestions include more rapid access to psoriasis clinic, better availability of biologics, more in-hospital services of dermatology and the setting up community psoriasis education centers. In the long run, the Association suggests an increase in the number of dermatologists, nurses in charge of psoriasis follow up and support clinics, multidisciplinary services include psychological support, and the increase of the use of telemedicine to shorten the waiting list.

Guidelines for the diagnosis and treatment of psoriasis in China : 2019 concise edition - International Journal of Dermatology and Venereology

In 1984, the prevalence of psoriasis in China was 0.123%, and according to a survey in 2008, the prevalence in nine major Chinese cities was 0.47%. Thus, there are approximately six million patients with psoriasis in China.

Based on the 2008 edition of the ‘Guidelines for psoriasis management in China’, the Committee of Psoriasis of Chinese Medical Association had compiled the ‘Guidelines for the diagnosis and treatment of psoriasis in China’. The new document was compiled after reviewing the latest guidelines in China and other countries, taking into account the situations across China, and setting up a panel of authoritative experts in Western medicine and traditional Chinese medicine (TCM) by a special committee. These guidelines integrated the features of TCM treatments with the guidelines for the diagnosis and treatment of psoriasis in China.

These concise guidelines constitute the major ideas and principles on the issue, and the full edition of the guidelines was published in Chinese Journal of Dermatology, 2019, 52(10):667-710.

NICE guidance – psoriasis assessment and management 2017

According to the guideline, the treatment pathway begins with active topical therapies. Emollient is recommended for all patients. Different potency of topical steroids is suggested according to location of skin patches like scalp, limbs or trunk. The guideline suggests offering narrowband ultraviolet B (UVB) phototherapy to patients with plaque or guttatepattern psoriasis that cannot be controlled with topical treatments alone. Treatment with narrowband UVB phototherapy can be given twice or three times a week depending on patient preference. Patients receiving narrowband UVB three times a week are more likely to achieve a better response.

Joint AAD – NPF guidelines of care for the management and treatment of psoriasis with systemic non-biologic therapies

For decades, many oral medications have been used to treat psoriasis, each with its own benefits and risks. Most work by targeting the immune system, whereas others, such as acitretin, work predominantly by decreasing keratinocyte hyperproliferation, thus restoring the normal epidermal differentiation. Psoriasis is an immune-mediated condition caused by inappropriate activation of T cells and dendritic cells with subsequent release of inflammatory cytokines including interleukin (IL) 17, IL-23, and tumou r nec rosis facto r-α. These soluble mediators are responsible for keratinocyte hyperproliferation, increased vascularity, and the inflammatory infiltration present in psoriatic plaques. These cytokines have also been implicated in a number of psoriasis comorbidities, including metabolic syndrome, heart disease, and arthritis. Because psoriatic plaques have robust infiltration of inflammatory cells, a number of systemic medications that suppress inflammatory responses such as methotrexate, cyclosporin, acitretin, apremilast and tofacitinib have been evaluated.

Joint AAD – NPF guidelines of care for the management and treatment of psoriasis with biologics

The majority of patients with mild-to-moderate psoriasis can be put under control with topical medications or phototherapy. However, topical therapies used alone or in combination with phototherapy may be insufficient for patients with moderate-to-severe disease. Biologic agents, as monotherapy or in combination with other topical or systemic medications, have a high benefit-to-risk ratio, and because of that, they are a useful addition to the armamentarium of psoriasis management.

This guideline reviewed the use and side effects of biologic agents like TNF-α inhibitors, IL-12 inhibitors, IL- 17 inhibitors and IL- 23 inhibitors in the treatment of adult psoriasis.

Nail psoriasis – Primary Care Dermatology Society

Psoriatic nail dystrophy mainly occurs in patients who are also suffering from psoriasis of the skin. Less than 5% of patients have psoriasis of the nails alone. It commonly affects patients with psoriatic arthritis. This chapter written by Primary Care Dermatology Society in the United Kingdom outlines the clinical findings, images and management of psoriatic nails. The clinical presentation of psoriatic nails may be in the form of pitting, onycholysis, subungual hyperkeratosis and salmon patch.

In case of adiagnostic uncertainty, it is recommended that samples must be sent for mycology to rule out tinea. It is important to not only include nail clippings but also scrapings from the undersurface of the nail plate, in case tinea may be missed. It must be remembered that psoriasis and tinea of the nails may coexist in nail beds.

A biopsy of the proximal nail matrix is occasionally needed to confirm the diagnosis of nail psoriasis, particularly if dystrophy affects a single nail and a tumour is a possible explanation. The biopsy can lead to permanent nail deformity.

It is difficult to treat nail psoriasis effectively. Topical treatment may be applied to the nail matrix and hyponychium for months or years, and its effects are often disappointing.

International Psoriasis Council (IPC)

Founded in 2004, the International Psoriasis Council (IPC) empowers a panel of physician experts working towards health of psoriasis patients around the world.

The IPC harnesses the collective expertise of over a hundred physicians to educate other physicians, on a range of topics related to psoriasis management. Courses are available online, via webinar or video ondemand. To reinforce its psoriasis curriculum, IPC publishes resources, tools and information available at no cost to clinicians.

Additionally, IPC conducts research in areas important to improving psoriasis care overall. These include developing a global epidemiological resource on psoriasis, reconsidering how disease severity is measured, and publishing a consensus statement on the use of biosimilars for the treatment of psoriasis.