Ms. S, aged 37 years, presented to an outpatient clinic with an 18-year history of plaque psoriasis and psoriatic arthritis. She complained about a severely painful, itchy rash on her trunk and extremities, and joint pain.
The patient stated she was using fluocinonide cream with minimal relief of symptoms. Ms. S had been admitted into the hospital several times for conditions related to alcohol abuse. Each time she was admitted, she had not been using her prescribed psoriasis medications.
The patient has tried multiple biologic and systemic therapies including alefacept (Amevieve) and cyclosporine. Most recently in 2012, Ms. S took subcutaneous injections of adalimumab (Humira) every other week.
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Ms. S stated the medication resolved most of her plaques but she discontinued the medication due to injection site pain. Ms. S denied fever and/or chills, muscle weakness, headaches, diabetes, heart disease, or history of skin cancer. She admitted to a history of elevated liver enzymes and alcohol abuse.
Physical exam
The skin exam revealed diffuse thick silver scaled plaques covering more than than 60% of her body surface area (BSA). Some plaques were fissured and scaling. Some plaques had been avulsed and several plaques showed signs of excoriation on the trunk and extremities.
Image 1: Ms. S’s plaque psoriasis at presentation
Treatment
The patient was started on the topical corticosteroid clobetasol propionate ointment 0.05% twice daily (Class I), emollients as needed, and phototherapy with narrow band ultra violet B (NB-UVB) therapy with application of petrolatum twice weekly.
The systemic therapies available to Ms. S included methotrexate and acitretin (Soriatane). Niether of these systemic therapies were considered due to Ms. S’s alcohol abuse and her status as a woman of child-bearing age.
Ms. S and her providers discussed starting a new injectable biologic, ustekinumab (Stelara), to address the psoriasis and psoriatic arthritis. The treatment requires fewer injections throughout the year. Screening labs were ordered: complete blood count (CBC), comprehensive metabolic panel (CMP), HIV, hepatitis profile, and tuberculosis assay.
Follow-up
New photos were obtained, three weeks after the start of therapy, prior to one of her phototherapy treatments. The patient’s only therapy at this time was topical clobetasol propionate ointment 0.05% applied twice daily and NB-UVB twice weekly.
Ms. S reached a PASI score of >75% with the topical and NB-UVB therapies. The patient’s insurance approval for the injectable biologic, ustekinumab was still pending.
Image 2: Ms. S’ plaque psoriasis three weeks after initiating topical corticosteroids and ultraviolet therapies.
Discussion
Psoriasis is a chronic auto-immune, auto-inflammatory disease that can also be associated with many systemic morbidities such as hyperlipidemia, diabetes, and heart disease, as well as the more common skin manifestations.
Less than 4% of the United States adult population is affected, with the highest incidence in the Caucasian population. The onset of psoriasis can occur at any age, but the peak ages of affected individuals are 30 to 39 years.
The most common type of psoriasis diagnosed in the U.S. is plaque psoriasis. The immunoinflammatory pathway — through the activation of various cytokines, which causes rapid division of the skin cells, a decrease in the skin cell cycle, and increases the rate of which the epidermis thickens — can result in very thick and scaly plaque structures, such as with Ms. S.
Topical corticoidsteroids are commonly used alone or as adjunctive therapy because of their anti-inflammatory effect and local immunomodulation. The classes are classified and numbered as very potent, Class I, high potency, Class II and III, to mid-potent, Class IV and V, all the way down to low potency, Class VI and VII. Topical steroids are classified based on their vasoconstriction ability. Long-term, continuous use of topical corticosteroids can cause adverse events such as systemic immunosuppression when applying to large body surface areas with very potent to mid-potent classes in adults and even low potent classes in young children and infants.
UV therapy has also been a long-standing therapeutic option beginning with psoralen and UVA (P-UVA), which decreases inflammation of the skin in its deeper levels (mid to deep dermis) as well as in the blood vessels, and now the more commonly used NB-UVB, which has a greater anti-inflammatory effect in the epidermis and superficial dermis.
Ultraviolet light, when absorbed by the skin, causes immune suppression by stimulating the synthesis of prostaglandins and cytokines that can disrupt the inflammatory cascade, thus arresting the rapid skin cell cycle.
UV therapy is often suggested as adjunctive therapy my practice because it can assist in speeding the recovery process during treatment. Patients can start with both topical (once or twice daily) and NB-UVB treatments (as often as every 48 hours) until lesions are resolved.
Summary
Although the treatments for psoriasis are rapidly evolving, with the addition of new biologics and systemic medications, clinicians should not discount the tried and true therapies that have been used for decades.
Topical corticosteroids and ultraviolet therapies are still proving to be strong competitors in today’s medical arena. Not only are they effective, they are also cost-effective.
B. Jang Mi Johnson, PA-C, is the senior physician assistant at Illinois Dermatology Institute, specializing in surgical and general dermatology.
References
- Uva L et al. International Journal of Endocrinology. 2012; doi: http://dx.doi.org/10.1155/2012/56101
- Feldman SR et al. “Epidemiology, clinical manifestations, and diagnosis of psoriasis.” UpToDate. Retrieved from http://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-psoriasis.
- Bulat V et al. “The mechanisms of action of phototherapy in the treatment of the most common dermatoses.” Coll Antropol. 2011; 35 Suppl 2:147-51.
All electronic accessed on February 9, 2015.
