Mild-to-Moderate Psoriasis - part 1 ppt

150 Combining Systemic Agents with Topical Therapies in the Treatment of Mild-to-Moderate Psoriasis.. Feldman Department of Dermatology, Center for DermatologyResearch, Wake Forest Unive

DK5988_title 6/22/06 10:21 AM Page 1

Mild-to-Moderate

PSORIASIS

John Y M Koo University of California San Francisco Medical Center

San Francisco, California, U.S.A.

Mark G Lebwohl Mount Sinai School of Medicine New York, New York, U.S.A.

Chai Sue Lee University of California Davis Medical Center

Sacramento, California, U.S.A.

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Preface

The goal of this book is to provide guidance on state-of-the-art clinicalmanagement of mild-to-moderate psoriasis, utilizing the experiences of agroup of experts well known in the psoriasis field The treatments coveredinclude topical corticosteroids, calcipotriene, tazarotene, tar, anthralin,salicyclic acid, phototherapy, and lasers There is a chapter highlightingrecent advances in combination therapy We have also included chapters

on palmar plantar psoriasis, scalp psoriasis, inverse psoriasis, and nail riasis because these are areas of the body that are frequently resistant toordinary forms of therapy The editors are hopeful that the comprehensiveyet practical and problem-focused approach to the management of mild-to-moderate psoriasis makes this a reference that dermatologists, primary carephysicians, residents, medical students, and other health care professionalscan turn to again and again for the most updated guidance in taking care

pso-of patients with mild-to-moderate psoriasis

John Y M KooMark G LebwohlChai Sue Lee

iii

3 The Koo–Menter Psoriasis Instrument for Identifying

Candidate Patients for Systemic Therapy 9 John Y M Koo, Jonathan W Kowalski, Mark G Lebwohl, Chris M Kozma, and Alan Menter

Introduction 9

Overview 10

Components of the Koo–Menter Psoriasis

Instrument 10

Background on the PQOL-12 14

Application of the Original PQOL 14

Development of the PQOL-12 15

v

Study 1: Multicentered Office-Based Study 15

Study 2: Using Data from the Randomized

Clinical Trial 24

Minimally Important Difference 26

Test–Retest Reliability of the PQOL-12 26

Calculating the PQOL-12 Score Within the KMPI 26 Discussion on KMPI 27

Conclusion 27

References 28

4 General Guidelines for Administration of Topical Agents

in the Treatment of Mild-to-Moderate Psoriasis 29 Jashin J Wu and Gerald D Weinstein

Factors of Psoriasis 30

Medications 32

References 38

5 Topical Corticosteroids 41 Jason Givan, Daniel Pearce, and Steven R Feldman

Introduction 41

Rationale for Psoriasis Therapy 42

Mechanism of Action and Biologic Potency 42

Delivery and Physiologic Potency 44

Practical Use of Topical Corticosteroids 52

Steroid Alternatives: Complementary, Not Really

Alternatives 53

Summary 54

References 55

6 Vitamin D3Analogs 59 Chai Sue Lee and John Y M Koo

Chemistry and Mechanism of Action 60

Calcipotriene Monotherapy 61

Calcipotriene in Children 61

Calcipotriene vs Other Topical Agents 62

Combination Therapy 63

Calcipotriene and Topical Steroids 63

Calcipotriene and Tazarotene 64

Calcipotriene and Phototherapy 64

Calcipotriene and Systemic Agents 65

Combination Corticosteroid/Calcipotriene Therapy 76 Clinical Trials and Analyses of Fixed-Combination

Formulation of Betamethasone

Dipropionate/Calcipotriene 77

The Fixed-Dose Combination Is More Effective Than

Steroid or Calcipotriene Monotherapy 77

The Fixed-Dose Combination b.i.d Achieves Greater

PASI Reduction Within One Week vs Steroid

Monotherapy 77

Once-Daily Fixed-Dose Combination

Is Safe and Effective 78

Once-Daily Fixed-Dose Combination Is as Safe

and Effective as b.i.d Therapy 80

Once-Daily Fixed-Dose Therapy Achieves Higher Clearance and Fewer Adverse Events vs Monotherapy 81 Once-Daily Fixed-Dose Therapy Is Effective for Patients with Mild, Moderate, and Severe Psoriasis 81

Investigators and Patients’ Assessments of Once-Daily

Fixed-Dosed Therapy Agree 82

Long-Term, Once-Daily Fixed-Dose Therapy

Is Safe and Effective 83

Potential Benefits of Fixed-Dose

Combination Therapy 84

In Combination with Biologics 86

In Combination with Other Systemic Agents 87

Potential Effects on Compliance 87

Conclusions 87

References 88

8 Tazarotene 91 Chai Sue Lee and John Y M Koo

Chemistry and Mechanism of Action 91

Tazarotene Monotherapy 93

Tazarotene vs Topical Steroids 93

Combination Therapy 94

Tazarotene and Topical Steroids 94

Tazarotene and Topical Steroid-Induced

Skin Atrophy 96

Tazarotene Chemical Compatibility with

a Topical Steroid 96

Tazarotene and Calcipotriene 97

Tazarotene and UVB Phototherapy 97

Tazarotene and PUVA Phototherapy 98

Tazarotene and Nail Psoriasis 99

Tazarotene Application in Psoriasis 99

10 Treatment of Mild-to-Moderate Psoriasis with Coal Tar,

Anthralin, Salicylic Acid, and Lactic Acid 115 Priya Sivanesan and John Y M Koo

11 Phototherapy and Laser for the Treatment

of Mild-to-Moderate Psoriasis 125 Holly A Kerr, Henry W Lim, and Jennifer Trepte

Introduction 125

Mechanism of Action 126

Ultraviolet B 126

Psoralen and UVA 131

Targeted (Localized) Phototherapy 137

Ultraviolet A1 141

Conclusion 142

References 143

12 Combination Therapy 147 Wendy Myers, Jennifer Tan, and Alice B Gottlieb

The Rationale for Combination Therapy 147

Phototherapy Combinations 148

UV Phototherapy and Topical Medications 150

Combining Systemic Agents with Topical Therapies in the Treatment of Mild-to-Moderate Psoriasis 154

Future Therapies for the Combination Treatment

Clobetasol Propionate Spray (Clobex Spray) 174 Clobetasol Propionate Shampoo (Clobex Shampoo) 175 Clobetasol Proprionate Lotion (Clobex Lotion) 176 Hydrogel Patch 176

Conclusions 181

References 181

15 Palmoplantar Psoriasis 183 Brian Bonish and Kenneth B Gordon

Descaling of the Scalp 199

Coal Tar and Dithranol 199

17 Inverse Psoriasis 207 Robert A Lee and Abby S van Voorhees

Manifestations of Nail Psoriasis 222

Association with Psoriatic Arthritis 226

Associated Genetic Haplotypes 228

Nail Psoriasis: Childhood vs Adult Onset 228

Diagnostic Challenge: Isolated Nail Psoriasis and Its

Impersonators 229

Diagnostic Procedure: The Nail Biopsy 231

Measurement of Severity: The Nail Psoriasis

Steven R Feldman Department of Dermatology, Center for DermatologyResearch, Wake Forest University School of Medicine, Winston-Salem,North Carolina, U.S.A.

Rianne M J P Gerritsen Department of Dermatology, RadboudUniversity Medical Center, Nijmegen, The Netherlands

Jason Givan Department of Dermatology, Center for DermatologyResearch, Wake Forest University School of Medicine, Winston-Salem,North Carolina, U.S.A

Kenneth B Gordon Feinberg School of Medicine, Evanston NorthwesternHealthcare and Northwestern University, Skokie, Illinois, U.S.A

xiii

Alice B Gottlieb Department of Dermatology, Tuffs-New EnglandMedical Center, Boston, Massachusetts, U.S.A.

Holly A Kerr Department of Dermatology, Henry Ford Hospital,Detroit, Michigan, U.S.A

Marloes M Kleinpenning Department of Dermatology, Radboud

University Medical Center, Nijmegen, The Netherlands

John Y M Koo Department of Dermatology, Psoriasis and SkinTreatment Center, University of California San Francisco Medical Center,San Francisco, California, U.S.A

Jonathan W Kowalski Global Health Outcomes Research, Allergan Inc.,Irvine, California, U.S.A

Chris M Kozma University of South Carolina, Columbia,

South Carolina, U.S.A

Mark G Lebwohl Department of Dermatology, Mount Sinai School ofMedicine, New York, New York, U.S.A

Chai Sue Lee Department of Dermatology, University of CaliforniaDavis Medical Center, Sacramento, California, U.S.A

Robert A Lee Department of Dermatology, Hospital of the University ofPennsylvania, Philadelphia, Pennsylvania, U.S.A

Henry W Lim Department of Dermatology, Henry Ford Hospital,Detroit, Michigan, U.S.A

Alan Menter Division of Dermatology, Baylor University Medical Center,Dallas, Texas, U.S.A

Wendy Myers Department of Medicine, Division of Clinical

Pharmacology, Robert Wood Johnson Medical School, New Brunswick,New Jersey, U.S.A

Maithily A Nandedkar-Thomas Professional Dermatology Care, PC,Reston, Virginia, U.S.A

Daniel Pearce Department of Dermatology, Center for DermatologyResearch, Wake Forest University School of Medicine, Winston-Salem,North Carolina, U.S.A

Richard K Scher Department of Dermatology, Columbia UniversityMedical Center, New York, New York, U.S.A.

Priya Sivanesan Department of Dermatology, University of CaliforniaSan Francisco, San Francisco, California, U.S.A

Jennifer Tan Department of Medicine, Division of Clinical

Pharmacology, Robert Wood Johnson Medical School, New Brunswick,New Jersey, U.S.A

Patricia Tinio Department of Dermatology, Mount Sinai School ofMedicine, New York, New York, U.S.A

Jennifer Trepte Department of Dermatology, Wayne State University,Detroit, Michigan, U.S.A

Peter C M van de Kerkhof Department of Dermatology, RadboudUniversity Medical Center, Nijmegen, The Netherlands

Abby S van Voorhees Department of Dermatology, Hospital of theUniversity of Pennsylvania, Philadelphia, Pennsylvania, U.S.A

Gerald D Weinstein Department of Dermatology, University of

California, Irvine, California, U.S.A

Jashin J Wu Department of Dermatology, University of California,Irvine, California, U.S.A

Therapy of Mild-to-Moderate

Psoriasis—Introduction

Mark G Lebwohl

Department of Dermatology, Mount Sinai School of Medicine, New York,

New York, U.S.A

The therapy of mild-to-moderate psoriasis has come a long way from thedays of tar and anthralin, though the latter treatments are still occasionallyused The introduction of topical corticosteroids in the latter third of the20th century had a dramatic impact on the topical therapy of psoriasis,and topical corticosteroids remain one of the most important treatmentsavailable for mild to moderate disease Because superpotent corticosteroidsare associated with hypothalamic–pituitary–adrenal axis suppression, recentinnovations in topical corticosteroid development have emphasized morecosmetically elegant vehicles rather than more potent medications Mostrecently, the superpotent corticosteroid clobetasol propionate has beendeveloped in foam, spray, lotion, and shampoo vehicles Corticosteroidsare also available in creams, emollient creams, ointments, solutions, gels,and even tapes Therefore it should not be surprising that corticosteroids areextensively covered in this book and controversies such as tachyphylaxis aswell as issues such as compliance with therapy are raised by experts in the field

A major breakthrough in the treatment of mild to moderate psoriasisoccurred with the introduction of vitamin D analogs Calcipotriene, alsoknown as calcipotriol, was the first agent approved and it was followed

by additional vitamin D analogs including tacalcitol, calcitriol, and others

1

Tazarotene, a retinoid developed for psoriasis, was the next class of agent

to be developed for this disease Other topical agents include the topical nomodulators, pimecrolimus, and tacrolimus These agents are not veryeffective on thick plaques of the elbows and knees, but are highly effective

immu-on facial and intertriginous skin, precisely those areas where use of topicalcorticosteroids is associated with the development of cutaneous atrophy andformation of striae and telangiectasia All of the above agents are reviewedcomprehensively in chapters written by leading authorities

What can the clinician do when monotherapy with topical agents isnot sufficiently effective but the disease is not severe enough to justifysystemic therapy? Combination therapy has proven to be more effectivethan monotherapy with selected agents Moreover, combination therapyoften eliminates the side effects of monotherapy For example, the combina-tion of topical corticosteroids and tazarotene is not only more effective thaneither treatment alone, but tazarotene protects against the atrophy of thecorticosteroid while the corticosteroid minimizes the irritation caused bytazarotene Likewise, the combination of calcipotriene with topical cortico-steroids is more effective than either agent alone, allowing reduced use ofthe corticosteroid and less irritation caused by the calcipotriene The use

of combination therapy has led to the development of yet another new agentthat combines calcipotriene with betamethasone dipropionate

When combination therapy is not adequate, use of intralesionalcorticosteroids may be effective, and when the latter is not sufficient, photo-therapy may be warranted New forms of phototherapy including narrow-band ultraviolet B (UVB) and localized targeted high output phototherapysuch as that afforded by the excimer laser are often effective for localizedrefractory plaques of psoriasis

Finally, unique body sites such as the nails or scalp may require ent vehicles and approaches to achieve good results All of these challengesare addressed by experts in Therapy of Mild-to-Moderate Psoriasis with thehope that our patients will benefit from this book