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Papulosquamous and eczematous dermatoses SECTION 3

Peter CM van de Kerkhof and Frank O Nestlé


Key features
 Psoriasis is a chronic, immune-mediated disorder that results from a polygenic predisposition combined with environmental triggers, e.g. trauma, infections or medications  The underlying pathophysiology involves T cells and their interactions with dendritic cells and cells involved in innate immunity, including keratinocytes  Identification of susceptibility genes has pointed to a major role for both the innate and the adaptive immune systems  Sharply demarcated, scaly, erythematous plaques characterize the most common form of psoriasis; occasionally, sterile pustules are seen  The most common sites of involvement are the scalp, elbows and knees, followed by the nails, hands, feet and trunk (including the intergluteal fold)  Typical histologic findings include acanthosis with elongated rete ridges, hypogranulosis, hyper- and parakeratosis, dilated blood vessels and a perivascular infiltrate of lymphocytes with neutrophils singly or within aggregates in the epidermis  Psoriatic arthritis is the major associated systemic manifestation and the most common presentation is asymmetric oligoarthritis of the small joints of the hands and feet; other comorbidities include cardiovascular disease in patients with moderate to severe disease  Phototherapy, methotrexate, cyclosporine and “biologic” therapies that target key immune effector cells and cytokines lead to significant clinical improvement

It was not until the nineteenth century that psoriasis was recognized as an entity distinct from leprosy. Although Robert Willan (1809) was the first to give an accurate description of psoriasis, it would be another 30 years before Hebra (in 1841) definitively separated the clinical features of psoriasis from those of leprosy. In 1879, Heinrich Koebner described the development of psoriatic plaques at sites of skin injury. He designated this phenomenon as “artificial production of the psoriatic lesion”.

Epidemiology and genetics
In most reviews, the prevalence of psoriasis is said to be 2% of the world’s population. However, in the US and Canada, prevalences as high as 4.6% and 4.7% have been reported, respectively. This contrasts with frequencies in Africans, African-Americans, Norwegian Lapps, and Asians of between 0.4% and 0.7%2. Brandrup and Green3 reported that two-thirds of affected individuals were suffering from mild psoriasis, while one-third had more severe involvement. In one large group of patients with psoriasis (n = 1728), 79% had nail changes4. Psoriatic arthritis has been found to affect 5–30% of patients with cutaneous psoriasis in different series2. Psoriasis can first appear at any age, from infancy to the eighth decade of life. Two peaks in age of onset have been reported: one at 20–30 years of age and a second peak at 50–60 years. In approximately 75% of patients, the onset is before the age of 40 years5–7, and in 35–50%, it is before the age of 20 years. Although the age of onset is earlier in women than in men, the natural history is similar – chronic with intermittent remissions. In one epidemiologic study, 39% of the patients stated they had experienced remissions of 1–54 years7. In Europe, the overall prevalence rate for juvenile psoriasis was found to be ~0.7%8,9, with an increase from 0.37–0.55% in those 0 to 9 years of age to 1.01–1.37% in those 10-19 years of age8–10. Plaque psoriasis is the most frequent form of the disease in children, followed by guttate psoriasis11.

Psoriasis is an immune-mediated polygenic skin disorder. Various environmental triggering factors, e.g. trauma, infections or medications, may elicit disease in predisposed individuals1. The characteristic lesion is a sharply demarcated erythematous plaque with micaceous scale, and the plaques may be localized or widespread in distribution. Histologically, hyperkeratosis, parakeratosis, acanthosis of the epidermis, tortuous and dilated vessels, and an inflammatory infiltrate composed primarily of lymphocytes are observed. Psoriasis is a systemic disease process in which up to 20–30% of the patients have or will develop psoriatic arthritis. In addition, in patients with moderate to severe psoriasis, there is an increased relative risk for metabolic syndrome and atherosclerotic cardiovascular disease. Psoriasis also has a significant impact on patients’ quality of life2, and in surveys, patients feel that the current treatments, although often effective, do not provide a satisfactory long-term solution.

Genetic Factors
Depending upon the series, a positive family history has been reported by 35% to 90% of patients with psoriasis. Based on a large survey-based study in Germany, if both parents had psoriasis, the risk of their child developing psoriasis was 41%, whereas if only one parent were affected, the risk was 14%; the risk was 6% if just one sibling had psoriasis12. Analysis of concordance rates among monozygotic and dizygotic twins is another method for examining the influence of genetic factors on a disease. Farber and Nall13 reviewed the published data from twin pair studies in psoriasis. Of 141 monozygotic twin pairs, 82 were concordant for psoriasis and 59 were discordant; of 155 dizygotic twin pairs, only 31 were concordant and 124 were discordant for psoriasis. Thus, there is a two- to threefold increased risk of psoriasis in monozygotic twins as compared to dizygotic twins7, implying that genetic factors are important. The distribution of the lesions, the severity, and the age of onset were similar in the monozygotic twin pairs, whereas these features differed in the dizygotic twin pairs. This observation suggested that genetic factors also play a role in the clinical course of psoriasis.

Hippocrates and his school (460–377 BC) provided meticulous descriptions of many skin disorders. In their classification, dry scaly eruptions were grouped together under the heading “lopoi”. This group probably included psoriasis and leprosy. Between 129 and 99 BC, the word “psora” (meaning a desquamative condition) was first used by Galen to describe a skin disorder characterized by a scaliness of the eyelids, corners of the eyes, and scrotum. The condition was pruritic and excoriations were present. Although called psoriasis, this affliction was probably a type of eczema.

HLA studies
Histocompatibility antigens (HLA) are surface antigens on human cells, and the corresponding chromosomal region is called the major histocompatibility complex (MHC). It is situated on the short arm (p) of chromosome 6. Psoriasis is associated with HLA-Cw6, with the


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Papulosquamous and eczematous dermatoses

presence of HLA-Cw6 conferring a relative risk of 13 for developing psoriasis in the Caucasian population and 25 in the Japanese. HLA-Cw6 is strongly linked to the age of onset of psoriasis. In one series, HLA-Cw6 was expressed in 90% of the patients with early-onset psoriasis, in 50% of those with late-onset psoriasis, and only in 7% of a control population. A specific MHC class II antigen (DRB1*0701/2) also appeared to be associated with early-onset psoriasis, and the psoriasis-associated HLA alleles were often in an extended haplotype: Cw6-B57-DRB1*0701-DQA1*0201-DQB1*030314. Individuals carrying this haplotype were found to have a 26-fold increased risk of developing early-onset psoriasis. As a result, some clinicians have designated patients with early-onset psoriasis, a positive family history of psoriasis, and expression of HLA-Cw6 as having type I psoriasis and those with late-onset disease, no family history, and a lack of expression of HLA-Cw6 as having type II psoriasis15. Other HLA alleles may be associated with different psoriasis variants and related conditions. For example, the HLA-B27 allele is a marker for sacroiliitis-associated psoriasis and reactive arthritis (see below).

Several conclusions regarding the genetic factors in psoriasis can be drawn from recent GWAS18,19. First, most of the genes that have been implicated have immune-related functions, underscoring the importance of the innate and adaptive immune systems in the pathogenesis of psoriasis; in contrast, relatively few genes that encode skin-specific proteins have been associated with psoriasis. Second, thus far surprisingly few interactions among the genetic variants have been identified (with the exception of HLA-Cw6 and ERAP-1; see below). Third, associated genes encode proteins with roles in particular immunologic and signaling pathways, especially those involving tumor necrosis factor (TNF), NF-κB, interferons (IFN) and interleukin (IL)-23/Th17 cells (see Immunopathogenesis)19,20. Lastly, the ERAP1 gene encoding an aminopeptidase involved in MHC class I antigen processing is only associated with psoriasis risk in individuals carrying the HLA-Cw6 risk allele, providing evidence for the role of an MHC-restricted antigen and its presentation through HLA-C in the pathogenesis of psoriasis.

Genome-wide association studies
Classic genome-wide linkage analysis has identified at least nine psoriasis susceptibility regions (PSORS1–9) in different chromosomal locations16. By far the most important genetic region is PSORS1 (on chromosome 6p), which is estimated to account for up to 50% of psoriasis risk. PSORS1 contains genes such as HLA-C (with the HLACw6 risk allele; see above) and corneodesmosin (CDSN). Due to high linkage disequilibrium in PSORS1 (i.e. genes within this region are inherited as a block), it has been challenging to determine which gene(s) within PSORS1 contribute to psoriasis pathogenesis. Use of genomewide association studies (GWAS) has recently provided new insights into the genetic basis of psoriasis. In GWAS, hundreds of thousands of single nucleotide polymorphisms (SNPs) across the entire human genome are examined in thousands of patients17 (see Ch. 54). Genes that have been associated with psoriasis through utilization of this and other methods are summarized in Table 8.1.

Functional genomic studies
Microarray technology has been utilized to obtain a comprehensive picture of the genes expressed in psoriatic skin21. More than 1300 genes were found to be differentially expressed when compared to normal human skin. This group of genes included known markers of psoriasis in the skin, but it also contained numerous genes not known to be expressed in the skin. These analyses confirmed the known involvement, on a genomic scale, of T cells and dendritic cells (DCs), providing evidence for sustained chronic T-cell activation and persistence in psoriatic epidermis. Microarray-based comparison between the transcriptome of lesional skin from patients with psoriasis versus atopic dermatitis have revealed not only differences in expression of genes with immune function, but also differences in genes expressed by keratinocytes. For example, skin-derived antimicrobial proteins were expressed at high levels in psoriatic skin but at low levels in skin affected by atopic dermatitis22.

GENETIC LOCI LINKED TO PSORIASIS Gene/Locus PSORS1 PSORS2 IL12B IL23R ZNF313 (RNF114) CDKAL1 PTPN22 Chromosomal location 6p 17q 5q 1p 20q 6p 18p Odds ratio for psoriasis 6.4 – 1.4 2.0 1.25 1.26 1.3 Comments Contains HLA-Cw6 (putative immune function; major candidate gene) and CDSN Putative role in immune synapse formation T-cell differentiation T-cell differentiation Ubiquitin pathway Unknown T-cell signalling Other disease associations None None Crohn’s disease Crohn’s disease, ankylosing spondylitis, psoriatic arthritis None Crohn’s disease, type 2 diabetes mellitus Juvenile idiopathic arthritis, systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes mellitus, autoimmune thyroid disease Crohn’s disease (distinct variant)

IL4/IL13 cytokine gene cluster LCE3B/3C/3D IL23A ERAP1 TNFAIP3 TNIP1 TRAF3IP2 NFKBIA

5q 1q 12q 5q 6q 5q 6q 14q

1.27 1.31 1.68 1.27 1.28 1.72 1.36 1.19

T-cell differentiation Epidermal differentiation IL-23/Th17 axis MHC class I antigen processing NF-κB pathway NF-κB pathway NF-κB pathway/ IL-23/Th17 axis NF-κB pathway

Ankylosing spondylitis Rheumatoid arthritis Psoriatic arthritis



Table 8.1  Genetic loci linked to psoriasis18–20. In addition, polymorphisms in other genes, e.g. interferon induced with helicase C domain 1 (IFIH1), have been associated with a decreased risk of developing psoriasis. CDKAL1, cyclin-dependent kinase 5 regulatory protein subunit 1-like 1; CDSN, corneodesmosin; ERAP1, endoplasmic reticulum aminopeptidase 1; IL, interleukin; LCE, late cornified envelope; MHC, major histocompatibility complex; NFKBIA, nuclear factor of κ light chain gene enhancer in B cells inhibitor α ; PTPN22, protein tyrosine phosphatase non-receptor type 22; TNFAIP3, tumor necrosis factor-α-induced protein 3; TNIP1, TNFAIP-interacting protein 1; TRAF3IP2, TNF receptor-associated protein 3 interacting protein 2; ZNF313, zinc finger protein 313. Further references are available in the online content.

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especially acute or pustular forms. the pDC. A pDC-attracting chemokine. keratinocytes express TLRs and secrete signaling molecules such as IL-1.1). The presence of specific T-cell subsets within the epidermis and dermis of lesional skin is well documented (see below). psoriasis was long regarded as an epidermal disease in which the biochemical or cellular defect resided within the keratinocyte. In xenograft models in which uninvolved psoriatic skin was transplanted onto immunodeficient mice. NK T cells and neutrophils (see above). Animal models for psoriasis have also demonstrated the importance of T cells. chemerin. editor(s).1). and anti-VEGF therapy leads to improvement in mouse models of psoriatic inflammation39. culminating in the development of novel therapeutic approaches25. In addition. a major paradigm shift occurred when T-cell suppressive agents such as cyclosporine were found to result in significant improvement of psoriasis25. a number of biochemical mediators. Of note. but. and the increased presence of several chemokines and their cognate receptors in psoriatic lesions has been extensively documented. Although some regard psoriasis as an autoimmune disease. Neutrophils are typically prominent in active lesions and in the marginal zone of expanding plaques. 8. in contrast to T cells.30. to date no true autoantigen has been definitively identified. as well as epidermal keratinocytes. a human monoclonal antibody against the p40 subunit of IL-12 and IL-23. they are not a consistent feature of lesional skin. protein kinase C. Another argument supporting involvement of the adaptive immune system is the disappearance or development of psoriasis following hematopoietic stem cell transplantation26. the concerted action of these cytokines leads to proliferation of keratinocytes and dermal inflammation (see Fig. it is likely that 137 Psoriasis L1 Bolognia_Chapter 8_main. possibly triggered by exogenous microbial or viral antigens or cross-reacting autoantigens. circulating levels of IL-22 correlate with disease severity. CD2. by targeting the IL-2 receptor. Based upon studies in humans and a xenograft model.g. These experiments demonstrated that T cells can trigger psoriasis in a suitable patient-derived environment. they interact with CD1d on keratinocytes. including cyclic AMP . Based on animal studies and measurements in lesional skin. several cell types have been implicated in the initiation and maintenance of psoriatic lesions. which have direct antimicrobial activity against a broad spectrum of pathogens. CD11a and CD4) were found to result in clinical improvement of psoriasis25. provides additional evidence for the role of cytokines. keratinocytes can be stimulated to express a wide variety of other inducible antimicrobials such as hBD2. Chemokines are important mediators in the trafficking of leukocytes. and they have an enhanced ability to activate T cells when compared to DCs from normal skin33.37. various cell types are involved in innate (non-adaptive) immune response pathways. Induction of psoriatic lesions in these models was also shown to be dependent on TNF-α and on IFN-α derived from plasmacytoid DCs (pDCs)29. IFN-γ is released by activated T cells and NK T cells in the epidermis. e. DCs are present in both uninvolved and lesional psoriatic skin. This leads to a breaking of tolerance to self nucleic acids and potentially explains the start of the inflammatory cascade in psoriasis36.1)41. This proof copy is the copyright property of the publisher and is confidential until formal publication. either in spongiform pustules of Kogoj or in microabscesses of Munro. The role of lymphocyte subsets as well as cytokines involved in chemotaxis. The striking response of psoriasis to ustekinumab. Since most of these proteins are highly expressed in lesional psoriatic skin. 8. whereas the dermal infiltrate is a mixture of CD4+ and CD8+ cells. the cathelicidin LL37. is a typical histo­ pathologic feature of psoriasis. There is an increased number of dermal DCs in psoriatic skin. 8. Complexes of self DNA or RNA (from keratinocytes) plus antimicrobial peptide LL37 trigger IFN-α release by pDCs via a Toll-like receptor 9 (TLR9)-dependent mechanism (see Fig. such as HLA-Cw6. The IFN-γ-activated pathway is a key feature of psoriasis and explains several phenotypic alterations such as vasodilation (by the induction of iNOS) and accumulation of T cells (via the expression of various chemokines). In addition to these effector molecules. The innate immune cytokines IL-1. and because of their potent immunostimulatory capacity. psoriasis has been regarded as a T-cell-driven disease25. the antimicrobial effector protein hBD2 was also shown to have chemotactic activity via CCR6 and to bind to TLR-4. IL-23 and IL-15 are likely to contribute to the disease. The resulting production of IFN-γ could contribute to additional immune stimulation32. Chapter 8  Immunopathogenesis Role of T cells and dendritic cells The association of psoriasis with particular MHC alleles. which allows their interaction with basement membrane collagen IV . Interestingly. For the past two decades. Cytokines and chemokines Psoriasis is considered to be a disease with prominent involvement of helper T-cell subsets and their secreted cytokines40. Increased amounts of Th1 cytokines (IFN-γ and IL-2) are observed. DC phenotype and function are quite plastic. reviewer(s). Accordingly. In addition. qualifying them as Tc17 cells44. Innate immunity and role of keratinocytes In the skin. CCL17. phospholipase C.g. and (in individuals carrying such alleles) variants in the ERAP1 gene encoding an aminopeptidase involved in antigen processing strongly suggests a pathogenetic role for antigenpresenting cells and T cells (Fig. CXCL8 is thought to mediate the often-prominent infiltration by neutrophils. prior to the early 1980s23. IL-8 and TNF-α. was shown to initiate psoriasis via the production of IFN-α30. with the ability to differentiate into potent proinflammatory DCs that produce inducible nitric oxide synthase (iNOS) and TNF-α (referred to as TIP [TNF/iNOS-producing] DCs)34. 8. and SKALP/elafin46. they are not considered to be the primary cause of psoriasis. These include DCs (myeloid DCs and pDCs). eicosanoids.1)31. polyamines and transforming growth factor (TGF)-α. Pathogenesis Because it primarily affects the interfollicular epidermis. It has also been proposed that there is a distinct subset of IL-22-producing helper T cells (Th22 cells) that contribute to the pathogenesis of psoriasis42. In addition. which drive the expression of a large number of immune-related genes that have roles in psoriasis pathogenesis. keratinocytes constitutively express antimicrobial proteins such as β-defensin-1 (hBD1) and secretory leukocyte protease inhibitor (SLPI).indd 137 5/3/2012 8:50:01 PM . the skin homing receptor) and chemokine receptors such as CCR4. CCL20. homing and activation of inflammatory cells has been extensively investigated. they are likely to be involved in its pathogenesis. another type of DC. The majority of the cells in both locations are memory T cells that express cutaneous lymphocyte antigen (CLA. There is increased expression of vascular endothelial growth factor (VEGF)38. TNF-α is a particularly relevant cytokine and its importance is underscored by the therapeutic efficacy of TNF-α inhibitors (see Treatment). The IL-17-producing T cells in psoriatic epidermis might have a cytotoxic phenotype. IL-6. The presence of neutrophils in the epidermis. Elsevier and typesetter Toppan Best-set. keratins28. For example. donor immune cells (in particular resident T cells) were capable of expanding and inducing the complete lesional phenotype29. whereas levels of the anti-inflammatory cytokine IL-10 are reduced. enzymes and pathways involved in epidermal function were incriminated as being abnormal in psoriasis. Prominent angiogenesis is observed in plaques of psoriasis. The role of DCs in psoriasis has been validated by the presence of a prominent genomic DC signature and the decrease of DCs during effective targeted therapy35. is key for the entrance of these cells into psoriatic epidermis and establishment of the psoriatic epithelial phenotype (see Fig. IL-6 and TNF-α are upregulated in psoriatic skin.27. Although activated neutrophils could contribute to its pathogenesis. and it activates members of the STAT transcription factor family. Natural killer (NK) T cells represent another subset of T cells that are part of the innate immune system and are found in psoriatic skin lesions. a number of compounds that affect T-cell function (e. Expression of α1β1 integrin (VLA-1) on psoriatic T cells. Most of the epidermal T cells are CD8+.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). IL-12. CCL27 and CXCL9-11 are implicated in attracting T cells to the psoriatic plaque.43. analysis of lesional T cells has shown oligoclonality. indicating potential antigenspecific expansion of T-cell subpopulations. In humans. It is not allowed to publish this proof online or in print. It is thought that IL-23 (produced by DCs) stimulates Th17 cells to release IL-17 and IL-22. Although associated immunologic abnormalities were reported in the late 1970s24. is increased in psoriatic skin and might contribute to the early recruitment of pDCs into psoriatic lesions45.

proteoglycans). Courtesy. CXCL9–11 and CCL17. allowing entry into the epidermis and contributing to disease pathogenesis by releasing both Th1 and Th17 cytokines. while natural killer T (NKT) cells release TNF-α and IFN-γ. Elsevier and typesetter Toppan Best-set. Th22 cells secrete IL-22. editor(s). which induces further release of keratinocyte-derived T cell-recruiting chemokines. which form complexes with the cathelicidin LL37 that then induce interferon-α (IFN-α) production by plasmacytoid dendritic cells (pDCs. thereby activating dermal DCs (dDCs). Activated dDCs then migrate to the skin-draining lymph nodes to present an as-yet-unknown antigen (either of self or of microbial origin) to naive T cells and (via secretion of different types of cytokines by DCs) promote their differentiation into T helper 1 (Th1).g. Keratinocytes also release vascular endothelial growth factor (VEGF). S100A7/8/9 and the neutrophil-recruiting chemokines CXCL1. reviewer(s). 8. inflammatory DCs (iDCs) produce IL-23. collagen. This proof copy is the copyright property of the publisher and is confidential until formal publication. CXC-chemokine receptor 3 [CXCR3] and CC-chemokine receptor 4 [CCR4]). contribute to tissue reorganization and deposition of extracellular matrix (e. nitric oxide (NO) radicals and TNF-α. producing TNF-α. as well as CXCL8. Moreover. thereby promoting neoangiogenesis. acting on keratinocytes and dDCs. results in disease development. epidermal growth factor (EGF) and TGF-β. LC. CCR4 and CCR6) and Th22 cells (expressing CCR4 and CCR10) migrate via lymphatic and blood vessels into psoriatic dermis. L1 138 Bolognia_Chapter 8_main. memory CD8 + cytotoxic T cells (Tc1) expressing very-late antigen-1 (VLA-1) bind to collagen IV. stressed keratinocytes can release self DNA and RNA. which amplify the inflammatory cascade.indd 138 5/3/2012 8:50:03 PM . which in turn release keratinocyte growth factor (KGF). At the dermal–epidermal junction. and angiopoietin (Ang). basic fibroblast growth factor (bFGF). Dr Paola DiMeglio. The occurrence of triggering environmental factors in genetically predisposed individuals. CXCL5 and CXCL8. During the initiation phase. Keratinocyte-derived interleukin-1β (IL-1β). Macrophage (M)-derived chemokine CCL19 promotes clustering of Th cells expressing chemokine receptor CCR7 with DC in the proximity of blood vessels. this ultimately leads to the formation of a psoriatic plaque. Th17 and Th22 cells. and fibroblasts. with further T-cell activation. IL-6 and CCL20. Th1 cells (expressing cutaneous lymphocyte antigen [CLA]. CXCL3.1  Immunopathogenesis of psoriasis. which stimulate keratinocyte proliferation and the release of β-defensin 1/2. Th17 cells (expressing CLA. Langerhans cell. IL-6 and tumor necrosis factor-α (TNF-α) also contribute to the activation of dDCs. Th17 cells secrete IL-17A and IL-17F (and also IFN-γ and IL-22). It is not allowed to publish this proof online or in print. attracted by the keratinocyte-derived chemokines CCL20.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). Cross-talk between keratinocytes. recruited into the skin via fibroblastreleased chemerin). carrying susceptibility alleles of psoriasis-associated genes. Neutrophils (N) infiltrate the stratum corneum and produce reactive oxygen species (ROS) and α-defensin with antimicrobial activity. Th1 cells release IFN-γ and TNF-α. Section 3 IMMUNOPATHOGENESIS OF PSORIASIS Initiation phase Environment Imiquimod Microorganisms Drugs Trauma Plaque progression Papulosquamous and eczematous dermatoses Trigger N β-defensin 1/2 S100A7/8/9 LC CXCL1 CXCL3 CXCL5 CXCL8 ROS α-defensin CXCL8 CCL20 Collagen IV NKT Tc1 Stressed cells DNA RNA Th22 Th17 HLA-C IL23R Genotype LL37 FGFs NO IL-1β IL-6 IL-12 IL-17A/F IL-22 IL-23 IFN-α IFN-γ TGF-β TNF-α CLA CXCR3 CCR4 CCR6 CCR7 CCR10 VLA-1 CD45RO pDC dDC iDC dDC CCL20 CXCL9–11 VEGF bFGF Ang Th22 CCL19 M DC Chemerin Th22 Fibroblasts Lymph vessel E-selectin Th17 KGF EGF Naive T Th1 Th17 Th1 CCL17 CCL27 Th22 Collagen Proteoglycans Fig. and possibly Th22 cells releasing FGFs. IL-1β and transforming growth factor-β (TGF-β).

Provoking infections have been observed in up to 45% of psoriatic patients. Pregnancy may alter disease activity. sunburn. Keratinocytes within psoriatic plaques express STAT-3. oval or polycyclic (the latter indicating that the lesion is derived from several smaller units). sometimes in association with hypocalcemia. upper extremities. The configuration of psoriatic lesions due to the Koebner phenomenon reflects the etiology of the trauma. The scalp. e. then a wet surface is seen with characteristic pinpoint bleeding.indd 139 5/3/2012 8:50:03 PM . As STAT-3 is activated by a variety of cytokines including IL-22 as well as IL-6. the latter has been shown to stimulate proliferation of keratinocytes in psoriasis via an autocrine loop. the outline of the lesion is usually circular. morbilliform drug eruption. their precise roles remain to be determined. Elsevier and typesetter Toppan Best-set. Psychogenic stress is a well-established systemic triggering factor in psoriasis50. however. The cytokines and chemokines found in lesional skin are generally not mitogenic for keratinocytes. is observed in approximately 25% of patients with psoriasis. compared to those with type II psoriasis. reviewer(s). called Auspitz sign. However. see Ch. psoriatic lesions are sometimes surrounded by a pale blanching ring. If the superficial silvery white scales are removed via curettage (grattage method). For example. there are obvious macroscopic pustules. nearly all of the body surface is involved (“erythrodermic psoriasis”) or numerous. more widespread disease and frequent recurrences. is itself antiproliferative. The PASI is a cumbersome calculation and is more commonly utilized for clinical trials than for the routine management of patients with psoriasis. cognitive and behavioral patterns of worrying and scratching were both independently related to an increase in disease severity and pruritus 4 weeks later51. impetigo. Some studies have found that the prevalence of psoriasis in a population of individuals who stop smoking or who lose weight eventually reverts to background levels. Inflamed lesions may be slightly tender. In a transgenic animal model. in patients with chronic plaque psoriasis. the Psoriasis Area and Severity Index (PASI) was formulated (Table 8. Chapter 8  Clinical features Chronic plaque psoriasis. For example. trunk and lower extremities) and from the scores for erythema. such as those encoding ICAM-1 and TGF-α. IFNs. expanding psoriatic lesions are characterized by an active edge with a more intense erythema. In a prospective study.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). Plaques may persist for months to years at the same locations. e. also referred to as impetigo herpetiformis (see below). 73). IL-20 and IFN-γ. It is not allowed to publish this proof online or in print. this could represent a link between keratinocyte activation and immune cells in the development of the psoriatic lesion. may induce or aggravate psoriasis. In addition to their highly characteristic sharp demarcation.2 & 8. the elicitation of psoriatic lesions by injury to the skin. As noted in the section on Epidemiology and Genetics. from limited to extensive. erythematous. HIV HIV infection has also been shown to aggravate psoriasis (see Ch. The lag time between the trauma and the appearance of skin lesions is usually 2–6 weeks.5). β-blockers and antimalarials. psoriatic lesions often itch. Less often. Endocrine factors Chronic Plaque Psoriasis In chronic plaque psoriasis. smoking appeared to have a 139 Psoriasis L1 Bolognia_Chapter 8_main. whereas other studies have suggested that weight gain often proceeds the development of psoriasis. The degree of body surface area involvement can vary. there is also significant interindividual variability. Subsequently. a characteristic coherence is observed. elbows.3). but the skin lesions all share the same important hallmarks: erythema. can elicit psoriasis in genetically predisposed individuals. both external (directly interacting with the skin) and systemic. A particular patient may be “Koebner-negative” at one point in time and later become “Koebner-positive”. they are involved in the initiation or control of the inflammatory process. 78). This finding. Because the percentage of body surface area involved does not reflect the severity of the individual lesions with respect to erythema. thickening and scale. thickening and scale are reflections of the histologic findings of elongated dilated capillaries that are close to the skin surface. widely disseminated papules and plaques are seen (“guttate psoriasis”). This is a single score calculated from the body surface area involved (utilizing a seven-point score for involvement in each of four anatomic areas – head. as are the hands and feet (Figs 8. particularly bacterial infections. Although the size of a lesion may vary from a pinpoint papule to over 20 cm in diameter. especially pharyngitis. In one analysis.g. dental abscesses. suggesting that this transcription factor might be of pathogenetic importance. perianal cellulitis. e. A score for Psychogenic stress Drugs Several drugs have been incriminated as inducers of psoriasis. which is referred to as Woronoff ’s ring. Any model of the pathogenesis of psoriasis also has to account for the dramatically increased proliferation rate of keratinocytes. Systemic triggering factors Infections Infections.2). psoriasis can present with a spectrum of cutaneous manifestations. IFN-γ.6. The genitalia are involved in up to 45% of patients (Fig. In addition. scaly plaques (Figs 8. the most common variant of psoriasis vulgaris. increased alcohol consumption. is characterized by sharply demarcated and erythematous papulosquamous lesions. At any one point in time. is the clinical reflection of elongated vessels in the dermal papillae together with thinning of the suprapapillary epidermis.g. During exacerbations. as in generalized pustular psoriasis or pustulosis of the palms and soles. respectively. epidermal acanthosis plus cellular infiltrates. Occasionally. role in the onset of psoriasis. knees and presacrum are sites of predilection. editor(s). but it was found to be a crucial factor in supernatants of lesion-derived T-cell clones that could drive keratinocyte stem cell proliferation47. pregnant women may develop pustular psoriasis. in particular lithium. The involution of a lesion usually starts in its center. a prominent Th1 cytokine. STAT-3 induced the upregulation of a number of genes relevant for psoriasis. Although active vitamin D3 analogues improve psoriasis. and smoking have all been associated with psoriasis. are the most common offenders49. i. 8. induration and scaling (each scored using a five-point score from 0 to 4). different variants may coexist in a particular individual. External triggering factors The Koebner phenomenon.e. Triggering Factors Triggering factors. those with type I disease (HLA-Cw6+) have an earlier onset. periods of complete remission do occur and remissions of 5 years have been reported in approximately 15% of patients. there is a relatively symmetric distribution of sharply defined. Streptococcal infections.g. Hypocalcemia has been reported to be a triggering factor for generalized pustular psoriasis. smoking and obesity Obesity. The classic findings of erythema. resulting in annular psoriatic lesions. as if one has scratched on a wax candle (“signe de la tache de bougie”). epidermal expression of STAT-3 (in cooperation with T cells) was found to induce psoriasis-like lesions in mice48. a surface membrane is seen. and abnormal keratinization. Streptococci can also be isolated from other sites. From a clinical perspective.4 & 8. abnormal vitamin D3 levels have not been shown to induce psoriasis. This proof copy is the copyright property of the publisher and is confidential until formal publication. Rapid taper of systemic corticosteroids can induce pustular psoriasis as well as flares of plaque psoriasis Alcohol consumption. induration and scaling. which will also come off as a whole. while obesity appeared to be a consequence of psoriasis52. Psoriatic lesions can also be induced by other forms of cutaneous injury. 50% of the patients in one series reported improvement. Although the course of this disease is chronic. Pinpoint papules surrounding existing psoriatic plaques indicate that the patient is in an unstable phase of the disease. viral exanthem. The Koebner phenomenon suggests that psoriasis is a systemic disease that can be triggered locally in the skin. small. It has been associated with initial presentations of the disease as well as flares of pre-existing psoriasis. If the latter is removed.

8. Pustular Variants Generalized pustular psoriasis L1 140 In generalized pustular psoriasis. reviewer(s). and the patient has a fever and feels ill. and its onset can be gradual or acute. 10). hypo­ calcemia. 8. B Erythrodermic Psoriasis This variant of psoriasis is characterized by generalized erythema and scaling. 8. characteristic nail changes. biallelic mutations in the gene encoding the IL-36 receptor antagonist (leading to increased production of IL-8 and enhanced responses to IL-1β) have been identified in a subset of patients with generalized pustular psoriasis53. A. and triggering factors include pregnancy. known as the Nail Psoriasis Severity Index (NAPSI). This is a generalized eruption starting abruptly with erythema and pustulation (see Fig. MD. It is an unusual manifestation of psoriasis. antiDNase B or streptozyme titer is found. the pustules usually resolve and extensive scaling is observed. while erythema and the appearance of sterile pustules dominate the clinical picture (Fig. if Bolognia_Chapter 8_main. Four distinct patterns of generalized pustular psoriasis can be seen: ● von Zumbusch pattern. 8. 8. It is not allowed to publish this proof online or in print. Although there are many causes of erythroderma (see Ch. B Note the sharp demarcation and silvery scale.8). Elsevier and typesetter Toppan Best-set. Guttate Psoriasis Guttate psoriasis is more commonly seen in children and adolescents and is frequently preceded by an upper respiratory tract infection (Fig. Sometimes. Section 3 Papulosquamous and eczematous dermatoses Fig. Fig. Generalized pustular psoriasis during pregnancy is also referred to as impetigo herpetiformis. the infiltration of neutrophils dominates the histologic picture. infections. After several days.indd 140 5/3/2012 8:50:07 PM . and facial sparing. In over half of the patients. indicating a recent streptococcal infection (see previous section). The skin is painful during this phase. Recently. an elevated antistreptolysin O.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). chronic plaques of psoriasis. topical irritants. but it has not been widely utilized. B. and. in the case of the localized pattern.7).8). Courtesy Julie V Schaffer. B Both small and large plaques have a symmetric distribution pattern. rapid tapering of corticosteroids (or other systemic therapies).2  Psoriatic plaques.3  Symmetric distribution of psoriatic plaques. Note the active border at the proximal edge of the plaques on the calves. A. editor(s). clues to the diagnosis of psoriatic erythroderma include previous plaques in classic locations. A A B nail involvement has also been proposed. This proof copy is the copyright property of the publisher and is confidential until formal publication.

This can be seen during the unstable phase of chronic plaque psoriasis and following the application of irritants. This proof copy is the copyright property of the publisher and is confidential until formal publication. Elsevier and typesetter Toppan Best-set. It is not allowed to publish this proof online or in print. Erythematous plaques with scale on the penis and scrotum. Sometimes pustules appear within (Fig.g. nine episodes of pustulation occurred over a period of 10 years. consisting of erythema and scaling with pustulation at the advancing edge (Fig. ● “Localized” pattern.6  Psoriasis of the genitalia. see Ch. 8. Courtesy.4  Childhood psoriasis.g. reviewer(s). 8. can resolve. the pustules remain localized to the palmoplantar surfaces and the course of this disease is Fig. A The scalp is a common site of involvement and psoriasis is distinguished by its sharp demarcation. There is overlap between this form of pustular psoriasis and pustular drug eruptions.9). 21). ● Exanthematic type. The lesions enlarge by centrifugal expansion over a period of hours to days. Systemic symptoms usually do not occur. abruptly appearing and disappearing over a few days. e. ● Annular pattern. In the original case report by von Zumbusch (1910). A minority of patients have chronic plaque psoriasis elsewhere. 141 Psoriasis L1 Bolognia_Chapter 8_main. In contrast to the natural history of generalized pustular psoriasis. B Pustulosis of the palms and soles Pustulosis of the palms and soles is characterized by “sterile” pustules of the palmoplantar surfaces admixed with yellow–brown macules (Fig.5  Palmoplantar psoriasis. scaly erythematous plaques may also be seen. MD. The eruption is characterized by annular lesions. A. while healing occurs centrally. This is an acute eruption of small pustules. Erythematous scaling plaques of the palmar (A) and plantar surfaces (B). It usually follows an infection or may occur as a result of administration of specific medications. 8. B Annular and guttate lesions.10) or at the edge of existing psoriatic plaques. Chapter 8  A A Fig. also referred to as acute generalized exanthematous pustulosis (AGEP. 8. Julie V Schaffer.11). B.indd 141 5/3/2012 8:50:11 PM . B Fig. 8. tars. editor(s). present. 8. e. lithium.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s).

The lesions of L1 142 B Bolognia_Chapter 8_main. 50 to <70%. slight. The PASI ranges from 0 to 72. pustulosis. acne. severe. 2.40 A B A + B + C + D = total PASI C D Fig. editor(s). Courtesy. 4. very severe] Head Erythema Induration Scaling Total score = 1 0 to 4 0 to 4 0 to 4 Sum of the above Trunk 0 to 4 0 to 4 0 to 4 Sum of the above Upper limbs 0 to 4 0 to 4 0 to 4 Sum of the above Lower limbs 0 to 4 0 to 4 0 to 4 Sum of the above Table 8. moderate. 1. however.12) and sometimes the toes. pustulotic arthro-osteitis. MD. for which there are several names: chronic recurrent multifocal osteomyelitis. 4. 8. 2. in contrast to the less well-defined areas of involvement in seborrheic dermatitis. hyperostosis and osteitis. 8. chronic. Unless there is complete confluence. 26). Section 3 CALCULATION OF THE PSORIASIS AREA AND SEVERITY INDEX Severity of psoriatic lesions [0. none. and SAPHO syndrome. Clinically. At times.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). 3. Focal infections and stress have been reported as triggering factors and smoking may aggravate the condition. 5. and the two disorders may coexist. it is not possible to distinguish seborrheic dermatitis from psoriasis. reviewer(s). Acrodermatitis continua of Hallopeau This is a rare manifestation of psoriasis. Elsevier and typesetter Toppan Best-set. 70 to <90%. Special Locations Scalp psoriasis The scalp is one of the most common sites for psoriasis. Large areas of erythema with numerous pustules and the formation of lakes of pus. 30 to <50%. It is not allowed to publish this proof online or in print. <10%.7  Guttate psoriasis.30 0 to 6 1×2 0. Pustulation is often followed by scaling and crust formation.indd 142 5/3/2012 8:50:13 PM . B Numerous papules due to the Koebner phenomenon after a sunburn. 6. Transition into other forms of psoriasis can occur and acrodermatitis continua may be accompanied by annulus migrans of the tongue. B.2  Calculation of the Psoriasis Area and Severity Index (PASI).8  Generalized pustular psoriasis. 1. note the Koebner phenomenon. Papulosquamous and eczematous dermatoses Area of psoriatic involvement [0. This proof copy is the copyright property of the publisher and is confidential until formal publication. which consists of synovitis. Pustules may also form in the nail bed (beneath the nail plate). A Fig. A Small discrete papules and plaques of guttate psoriasis in an adolescent. pustules are seen on the distal portions of the fingers (Fig. Pustulosis of the palms and soles is one of the entities most commonly associated with sterile inflammatory bone lesions. Several neutrophilic dermatoses are associated with SAPHO (see Ch. the individual lesions are discrete.20 0 to 6 1×2 0. and there may be shedding of nail plates. 3. 8.10 0 to 6 1×2 0. 10 to <30%. none. 90–100%] Degree of involvement = 2 Multiply 1 × 2 Correction factor for area of involvement = 3 1×2×3 0 to 6 1×2 0. Ronald P Rapini.

When flexural areas are the only sites of involvement. 8. The pustules are limited to pre-existing plaques of psoriasis. Erythema and scale of the distal digit. 8. candidal or bacterial infections can be a trigger for flexural psoriasis. Fig. The most common sites of involvement are the axillae. This proof copy is the copyright property of the publisher and is confidential until formal publication. In addition. inguinal crease. reviewer(s). Oral mucosa Migratory annular erythematous lesions with hydrated white scale (annulus migrans) have been observed in patients with acrodermatitis continua of Hallopeau and generalized pustular psoriasis.9  Annular pustular psoriasis. pink to red.indd 143 5/3/2012 8:50:16 PM . and the clinical (and histologic) appearance is similar to geographic tongue. Often a central fissure is seen. Multiple sterile papules are admixed with yellow–brown macules on the palm.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). 69). pustules within the nail bed. 8. there can be central clearing. secondarily infected atopic dermatitis and tinea capitis. inframammary region and retroauricular folds. Multiple annular inflammatory plaques studded with pustules. the retroauricular areas and the upper neck. Chapter 8  Fig.11  Pustulosis of the palms and soles. Although pityriasis amiantacea can also be seen in patients with seborrheic dermatitis. psoriasis often advance onto the periphery of the face. The most common location is the tongue. dry desquamation (A) and/or moist desquamation that resembles wet cigarette paper (B).10  “Localized” pattern of pustular psoriasis. The scales sometimes have an asbestoslike appearance and can be attached for some distance to the scalp hairs (pityriasis amiantacea). Flexural psoriasis Flexural lesions are characterized by shiny. Fig. sharply demarcated thin plaques (Fig. patients with dermatomyositis involving the scalp may have lesions that resemble psoriasis. and partial shedding of the nail plate. 8. the term “inverse” psoriasis is sometimes used. There is much less scale than in untreated chronic plaque psoriasis.12  Acrodermatitis continua of Hallopeau. 8. 143 Psoriasis L1 Bolognia_Chapter 8_main. intergluteal cleft. editor(s). Elsevier and typesetter Toppan Best-set. It is not allowed to publish this proof online or in print. As the lesions enlarge.13). psoriasis is the most common cause. Localized dermatophyte. Alopecia occasionally develops within involved areas (see Ch. A B Fig.

rapidly progressive joint inflammation that results in destruction of the joints and permanent deformity. many patients also have peripheral joint involvement. The disorder is uncommon in children and occurs more frequently in men as compared to women. ILVEN is thought to be an entity separate from linear psoriasis. In a recent study from Germany involving 1511 patients with chronic plaque psoriasis. This variant may occur in conjunction with contiguous nail involvement. Psoriatic Arthritis Psoriatic arthritis occurs in 5–30% of patients with cutaneous psoriasis1.15). but an important hallmark is erosive change radiographically. Elsevier and typesetter Toppan Best-set. Disorders Related to Psoriasis A few disorders share important clinical and histologic features with psoriasis. in addition to psoriasiform skin lesions. Enthesitis and dactylitis have been reported in ~20% and 15–30%. there are no specific serologic tests for establishing the diagnosis of psoriatic arthritis. scaling and erythematous plaques) that follow the lines of Blaschko (see Ch. In some patients. and keratitis may also occur. Patients with psoriatic arthritis can have involvement of juxta-articular tendons and the sites where they insert into bone (entheses) as well as swelling of the fingers (dactylitis). Based upon its chronicity and resistance to therapy. with some clinical investigators suggesting that classic studies of psoriatic arthritis may have underestimated its prevalence.14) has been reported in 10–80% of psoriatic patients. Vigorous removal of distal subungual debris may be an exacerbating factor. female gender. Clinically. Psoriatic changes of the nail bed result in the “oil spot” or “oil drop” phenomenon. DIP involvement was observed in ~40% of the patients with arthritis. poorly adherent “nail” is seen. 8. In a survey from the Netherlands. Cutaneous lesions occur in approximately 5% of reactive arthritis patients. Fig. Patients have severe. wider and softer to palpation because of osteolysis and a telescoping phenomenon. Chlamydia trachomatis is a major cause of urethritis and may trigger the entire syndrome. ● Arthritis of the distal interphalangeal joints. ● Spondylitis and sacroiliitis. this variant is difficult to distinguish from rheumatoid arthritis. Small parakeratotic foci in the proximal portion of the nail matrix lead to pits in the nails (see Ch. ● Arthritis mutilans. as may other infections such as shigellosis. The digits become shorter. Papulosquamous and eczematous dermatoses Nail psoriasis Nail involvement (Fig. distal onycholysis. arthritis. epidemiologic or clinical features. polyarticular involvement. Individuals are often HLA-B27positive and may have associated inflammatory bowel disease and/ or uveitis. In contrast to rheumatoid arthritis. 79% of patients reported involvement of their nails. Exclusive involvement of the DIP joints is a classic but uncommon presentation of psoriatic arthritis. 62). as disease progression often results in loss of function. The clinical manifestations consist of a symmetric polyarthritis that involves small and medium-sized joints.16). Psoriatic arthritis is more prevalent among patients with relatively severe psoriasis. crumbly. but some have a positive rheumatoid factor.14  Nail psoriasis. In a minority of patients (10–15%). which reflects exocytosis of leukocytes beneath the nail plate. which may occur years after the presenting peri-articular inflammation. reviewer(s). the symptoms of psoriatic arthritis appear before involvement of the skin. Psoriasis affects the nail matrix. This variant can usually be distinguished from the arthritis mutilans that may accompany multicentric reticulohistiocytosis. ● Rheumatoid arthritis-like presentation. Patients are usually seronegative. The urethritis may be mild or severe with complications such as cervicitis. genetic Reactive arthritis (formerly Reiter’s disease) This syndrome features urethritis. depending upon the series. Risk factors for a more severe course of the arthritis include: initial presentation at an early age. but are distinct disease entities based upon genetic.e.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). with 52% experiencing associated pain and 14% major restrictions in daily life due to the nail changes. The fingernails are more often affected than the toenails. nail bed and hyponychium. 8. a whitish. Polyarthritis and sacroiliitis are the most frequent joint manifestations. 71). ankle and elbow. Currently.13  Inverse psoriasis. editor(s). predisposition.6% of the affected individuals had psoriatic arthritis56. and subungual hyperkeratosis and distal onycholysis are due to parakeratosis of the distal nail bed. Fortunately. in particular the PIP .and asymmetric oligoarthritis. with axial arthritis as well as involvement of the knees and sacroiliac joints. This proof copy is the copyright property of the publisher and is confidential until formal publication.The following classification has been outlined by Moll55. and radiographic signs of the disease early on54. Splinter hemorrhages are the result of increased capillary fragility. wrist. If the whole nail matrix is involved. 8. respectively. 8. MCP . these joints will become fixed in a flexed position. Whether seropositive patients have an overlap of the two disorders is debated. the metacarpophalangeal (MCP) joint is an unusual site for psoriatic arthritis. Inflammatory linear verrucous epidermal nevus (ILVEN) ILVEN is characterized by linear psoriasiform lesions (i. ● Mono. salpingitis and cystitis. with a predilection for the L1 144 Bolognia_Chapter 8_main. of patients with “probable” or definite psoriatic arthritis54. Leukonychia and loss of transparency (less common findings) are due to involvement of the mid portion of the matrix. Involvement of the PIP or both the DIP and PIP joints of a single digit can result in the classic “sausage” digit (Fig. ocular findings and oral ulcers. this is the least common variant of psoriatic arthritis. This form may be accompanied by inflammation of larger joints. Patients with nail involvement appear to have an increased incidence of psoriatic arthritis (see below). Shiny erythematous plaques of the inframammary folds that lack scale. red spotted lunula and subungual hyperkeratosis. 20. Conjunctivitis is a common eye finding in affected patients. Section 3 Fig. Changes include thickening and yellow discoloration of the nail plate.indd 144 5/3/2012 8:50:17 PM . and 5% suffered from arthritis mutilans56. Inflammation of the interphalangeal joints – both distal (DIP) and proximal (PIP) – of the hands and feet is the most common presentation of psoriatic arthritis (Fig. It is not allowed to publish this proof online or in print. The spondylitis resembles that seen in ankylosing spondylitis. pitting. uveitis with glaucoma. Early diagnosis of psoriatic arthritis is important. although iritis. 8.

HIV-infected patients can also develop this disorder and it may be severe. It is not allowed to publish this proof online or in print. There may be a gravity-induced demarcation in some vesicopustules. urticaria and allergic contact dermatitis have been found to be lower in psoriatic patients. An obvious explanation is the immunologic difference between these two conditions. New York: McGraw Hill. the possibility of allergic contact dermatitis as a triggering factor needs to be considered. asthma. 18th edn. The lesions on the plantar surface usually have thick yellow scale and are often pustular (keratoderma hagicum). fingers.15  Sites of psoriatic arthritis and reactive arthritis (formerly Reiter’s disease). immunofluorescence studies are required to distinguish the subcorneal pustular dermatosis type of IgA pemphigus from Sneddon-Wilkinson disease. This disease has a cyclic course. The combined picture is sometimes referred to as lichenified psoriasis or psoriasis neurodermiformis. Although the course is often self-limited. nails and scalp (Fig. Of note.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). Sneddon–Wilkinson disease (subcorneal pustular dermatosis) This disorder is characterized by annular or polycyclic lesions. i. SITES OF INVOLVEMENT IN PSORIATIC ARTHRITIS AND REACTIVE ARTHRITIS Fig. 8. penis. provide support for this condition being a disease entity distinct from pustular psoriasis.17). Fauci AS. The frequencies of atopic dermatitis. in patients with psoriasis in atypical locations and/or treatment-resistant lesions. Psoriatic plaques on the penis are referred to as blennorr­ balanitis circinata. Therapeutic regimens must address both disorders. Asymmetric involvement of the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints. Because the LSC itself is pruritic. Elsevier and typesetter Toppan Best-set. usually commencing in the flexures (Fig. et al. 8.18B. Its response to dapsone. with clear fluid superiorly and pus inferiorly. If a psoriatic lesion is pruritic.C) are the hallmark of Sneddon–Wilkinson There is a pronounced under-representation of allergic skin diseases in psoriatic patients as compared to age-matched controls without psoriasis. For example. in one study atopic dermatitis was seen approximately 50 times less often in psoriatic compared with non-psoriatic patients1. The patient then enters a vicious cycle. This proof copy is the copyright property of the publisher and is confidential until formal publication. although some authors have questioned the existence of Sneddon–Wilkinson disease as a distinct entity. Reactive arthritis has a strong association with HLA-B27. However. 2011. 8. In the authors’ experience. Associations between Psoriasis and Other Diseases Associations with skin diseases Fig.indd 145 5/3/2012 8:50:18 PM . reviewer(s). lasting weeks to months. some patients have disease that is chronic and disabling. extensor surfaces of the legs. with a predominantly Th1 response in psoriasis and a predominantly Th2 response in atopic dermatitis. A “sausage” digit (third digit bilaterally) results from involvement of both the DIP and PIP joints. editor(s). 8. Adapted from Longo DL. Chapter 8  Rheumatoid arthritis Gonococcal arthritis Juvenile arthritis Pseudogout Osteoarthritis Rheumatoid arthritis Pseudogout Psoriatic arthritis Reactive arthritis Osteoarthritis Psoriatic arthritis Reactive arthritis Osteoarthritis Systemic lupus erythematosus Rheumatoid arthritis disease. superimposed LSC may develop and the surface becomes shiny with increased skin markings. longstanding psoriatic lesions of the hands and external auditory canal are indications for patch testing. as the pustules resolve they are replaced by superficial scaling and then new pustules form again. 145 Psoriasis L1 Bolognia_Chapter 8_main.18A).16  Psoriatic arthritis. 8. Some patients with Sneddon–Wilkinson disease have an associated IgA paraproteinemia. Kasper D. combined with subcorneal pustules (in the absence of spongiform pustules). the resultant rubbing may worsen the psoriasis (Koebner phenomenon). Of note. hence its second name. dorsal aspects of the hands.e. A bi-directional relationship exists between lichen simplex chronicus (LSC) and psoriasis. soles. Very superficial (subcorneal) sterile pustules (Fig. Harrison’s Principles of Internal Medicine.

8. central face. B Plantar lesions of keratoderma blennorrhagicum.g. impetiginized). including lymphoma. Section 3 Papulosquamous and eczematous dermatoses C B A Fig. therapies. 8.g. e. there is controversy regarding whether PUVA-treated patients have an increased risk of cutaneous melanoma. The sites of predilection are the scalp.indd 146 5/3/2012 8:50:21 PM . ears. B Subcorneal pustules with scale and crusts as well as background erythema. but not dermatophytes. 13). Elsevier and typesetter Toppan Best-set. psoriatic lesions are seldomly secondarily infected by bacteria (i. Lastly. C Discrete subcorneal pustule with an erythematous rim.17  Reactive arthritis (formerly Reiter’s disease). Joyce Rico. are at increased risk for the development of skin cancers. Cancer L1 146 Patients with psoriasis may have an increased overall risk of cancer. This is largely due to an increased risk of obesity. 53)58–60. especially squamous cell carcinomas (SCCs).g. especially when diagnostic lesions of psoriasis are not present elsewhere. Association with internal diseases (including comorbidities) Cardiovascular diseases. Recently. C A B Fig. hypertension and diabetes mellitus (components of the metabolic syndrome. One explanation for this resistance to secondary bacterial infections is increased pro­ duction of skin-derived antimicrobial peptides (e. In flexural psoriasis. pulmonary emboli. It has also been shown that TNF-α and IL-6 can target adipocytes and induce dyslipidemia. editor(s). scales (see Ch. The relationship between psoriasis and mycotic infections is more complex. sometimes greasy. are more commonly found in psoriatic nails than in normal nails.5–4. concomitant Candida infections are frequently observed and have been incriminated as local triggering factors. myocardial infarctions.e. It is not allowed to publish this proof online or in print. Of note. >200 PUVA treatments. SKALP/Elafin. A. serum levels of C-reactive protein (CRP) have been reported to be elevated (as compared to healthy controls). In patients with psoriasis. Candida species. are more common in patients with severe psoriasis. Courtesy. e. see Pathogenesis). C Papulosquamous lesions of balanitis circinata on the penis. As the clinical features of psoriasis and seborrheic dermatitis can be seen in the same patient. see Ch.18  Sneddon–Wilkinson disease. Psoriatic patients who have had specific Bolognia_Chapter 8_main. defensins. A Annular and polycyclic plaques in the axilla.4year reduction in life expectancy.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). C. Severe psoriasis is associated with a threefold increased risk for myocardial infarction and a 3. the use of cyclosporine in patients previously treated with PUVA significantly increases the number and rate of appearance of SCCs. reviewer(s). some authors use the term “sebopsoriasis”. Infections In contrast to atopic dermatitis. and elevated CRP levels represent a risk factor for the development of cardiovascular disease. and treatment with immunosuppressive agents may increase this risk57. This proof copy is the copyright property of the publisher and is confidential until formal publication. evidence has been accumulating that treatment with methotrexate and/or TNF-α inhibitors may reduce the risk of atherosclerotic cardiovascular disease61. MD. presternal area and intertriginous zones. Seborrheic dermatitis is characterized by pink to red patches with yellowish. peripheral arterial disease and cerebrovascular accidents.

3  Differential diagnosis of subcorneal/intraepidermal neutrophilic pustules. When lesions are limited in number or have an annular configuration. tinea capitis is in the differential diagnosis of scalp psoriasis. Active lesion A fully developed guttate lesion or the marginal zone of an enlarging psoriatic plaque is designated as an “active lesion”. they may be misdiagnosed as hypertrophic lichen planus. Although the reason for this difference is not known. and a higher incidence of non-alcoholic fatty liver disease. it is important to remember that either can coexist with psoriasis. However. 9) and drug reactions (see Ch. ulcerative colitis and psoriasis share an association with sacroiliitis and HLA-B27 positivity63. IIF. The differential diagnosis of the annular form of pustular psoriasis includes Sneddon–Wilkinson disease and other causes of subcorneal pustules (Table 8. mast cell degranulation is a constant feature. hyperlipidemia. and when the upper trunk is the predominant site of involvement. The epidermis is acanthotic with focal accumulations of neutrophils and lymphocytes. In these patients. a biopsy is necessary to distinguish chronic plaque psoriasis from the mycosis fungoides variant of cutaneous T-cell lymphoma (CTCL). the possibility of a pustular drug eruption. This proof copy is the copyright property of the publisher and is confidential until formal publication. e. 9). The histologic findings of these conditions can be similar. the capillaries are increased in number and length and they have a tortuous appearance. eosinophils* Spongiform pustules* Subcorneal and intracorneal pustules Subcorneal and intracorneal pustules IgA pemphigus. In patients with pustulosis of the palms and soles and acrodermatitis continua. involvement of the scalp or intergluteal fold with psoriasis. 91) needs to be considered. as both may have scaling and fissures. direct immunofluorescence. anti-desmoglein 1 antibody DIF>IIF – intercellular IgA deposits. Although KOH examination of associated scale allows a narrowing of the differential diagnosis. Above these foci. Palmoplantar plaque psoriasis can be confused with keratotic eczema of the palms and soles.g. neutrophils are not yet detected in this early phase. Clinical features suggestive of the latter include wrinkling due to epidermal atrophy and progression to infiltrated plaques. there may also be scalp involvement with scaling and crusts. When there is a single or limited number of erythematous plaques. If eosinophils are also present. and it correlated with the presence of obesity. over time. Additional disorders that share susceptibility genes with psoriasis are listed in Table 8. the metabolic syndrome. chronic lesions of dermatitis may develop an appearance that is similar (clinically and histologically) to partially treated psoriasis and vice versa. 82) and pityriasis rosea (Ch. a pustular drug *Not all cases. including Sézary syndrome (see Ch. tinea incognito. It is not allowed to publish this proof online or in print. the possibility of tinea corporis is raised. When plaques of psoriasis involve the shins. 9). Bowen’s disease. Pathology Papulosquamous Lesions Initial lesion In the initial lesion. In a study of 142 adults with psoriasis. erythroplasia of Queyrat) needs to be excluded via histologic examination. needs to be considered in addition to generalized pustular psoriasis (see Ch. Occasionally. The lesions of guttate psoriasis rarely involve the palms or soles and are often more erythematous than those of parapsoriasis.3). periportal inflammation and focal necrosis. whereas similar methotrexate dosages in patients with rheumatoid arthritis do not pose such hepatotoxic potential. 120). IIF – intercellular IgG deposits. Elsevier and typesetter Toppan Best-set. as well as the hands. anti-desmocollin 1 antibody No spongiform pustules Spongiform pustules* Spongiform pustules. There are other causes of erythroderma (see Ch. 10). the possibility of Langerhans cell histiocytosis (Ch. especially at the tops of the papillae. Table 8. Reactive arthritis needs to be considered in any patient with the diagnosis of arthritis in the setting of psoriasiform skin lesions. The histopathologic findings in an active lesion are diagnostic for psoriasis. pemphigus foliaceus may be considered. There is a mixed perivascular infiltrate of lymphocytes. the possibility of SCC in situ (e. 21). When plaques of psoriasis develop pronounced hyperkeratosis. nonalcoholic fatty liver disease was detected in 59%. characteristic lesions often become apparent. macrophages and neutrophils. elbows and knees. Per a large body of evidence. Bowenoid papulosis and contact dermatitis. the histopathologic features are not yet diagnostic. necrolytic migratory erythema. 9).indd 147 5/3/2012 8:50:21 PM . In the dermis. extramammary Paget’s disease. Other etiologies include seborrheic dermatitis. pityriasis lichenoides chronica (Ch. editor(s). also referred to as AGEP . the possibility of concomitant hypothyroidism should be considered. Marked edema is seen. cutaneous candidiasis. psoriasis and candidiasis can coexist (see above). Psoriasis of the flexures is one cause of intertrigo. indirect immunofluorescence. Occasionally. In acute eruptive guttate lesions. is more commonly observed in patients with psoriasis. Dermatomyositis can involve the scalp. increased alcohol consumption by psoriasis patients. reviewer(s). the granular layer is absent and the stratum corneum 147 Psoriasis DIFFERENTIAL DIAGNOSIS OF SUBCORNEAL/INTRAEPIDERMAL NEUTROPHILIC PUSTULES 8  L1 Bolognia_Chapter 8_main. an AST:ALT ratio >1 and psoriatic arthritis62. secondary syphilis (Ch. but characteristic violaceous lesions elsewhere and mucosal involvement usually point to the correct diagnosis. including a genetic predisposition. In infants (more so than adults).g. i. Sharp margination of the lesions favors psoriasis and examination of the remainder of the skin surface can provide clues to the diagnosis. In the case of guttate psoriasis. Chronic administration of methotrexate is associated with a significant risk for hepatic damage in patients with psoriasis. characterized by fatty infiltration. the initial evaluation includes the exclusion of a dermatophyte infection or secondarily infected dermatitis. the epidermis is variably spongiotic.e.1. eruption is favored. several possible explanations have been put forward. Crohn’s disease. in addition to psoriasis. DIF. At these sites. Macrophages (detected by CD68 staining) and lymphocytes appear in the epidermis focally and some spongiosis of the epidermis is seen at these sites. Non-alcoholic steatohepatitis. When there are widespread pustules on a background of erythema. 21). DIF.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). Elsewhere. and lymphocytes and neutrophils have migrated into the epidermis. especially if they are treatmentresistant. a pinhead-sized papule. and initially may be diagnosed as psoriasis. There is mild epidermal acanthosis without parakeratosis and the keratinocytes have a swollen appearance. including spongiform pustules of Kogoj and microabscesses in the stratum corneum. pityriasis rubra pilaris (see Ch. Chapter Disorder Impetigo Superficial candidiasis Dermatophyte infection Superficial folliculitis Pemphigus foliaceus Histologic clues Gram-positive cocci in bulla cavity Yeast and pseudohyphae in stratum corneum Branching hyphae in stratum corneum Pustule at follicular orifice and infundibulum Acantholytic cells. the differential diagnosis may include small plaque parapsoriasis (Ch. A superficial perivascular infiltrate of lymphocytes and macrophages is seen in the dermis along with papillary edema and a dilation of capillaries. subcorneal pustular dermatosis type Sneddon–Wilkinson disease (subcorneal pustular dermatosis) Pustular psoriasis Acute generalized exanthematous pustulosis Amicrobial pustulosis of the folds Transient neonatal pustular melanosis Acropustulosis of infancy Differential diagnosis Although both seborrheic dermatitis (see above) and LSC are in the differential diagnosis of psoriasis.

Some rete ridges coalesce at the base. Spongiform pustules can be seen in palmoplantar lesions. Vitamin D3 analogues In the early 1990s. Lorenzo Cerroni. calcipotriene (calcipotriol) and other vitamin D3 analogues have become a first-line therapy for psoriasis65.indd 148 5/3/2012 8:50:23 PM . topical corticosteroids have become a mainstay in the treatment of psoriasis.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). A modest perivascular infiltrate is seen that consists primarily of lymphocytes and macrophages. elongation of the dermal papillae. As a result. editor(s). The horny layer has parakeratotic foci with an absence of the stratum granulosum. no treatment has been shown to cure this disease. In the stratum corneum. Table 8. For a detailed description of topical vitamin D3 analogues. hypogranulosis. Calcipotriene monotherapy has been shown to result in a ~60% reduction of PASI after 8 weeks of treatment. In Sneddon–Wilkinson disease. When calcipotriene and betamethasone dipropionate are combined. dilated superficial blood vessels. and it induces normal differentiation by enhancing cornified envelope formation and activating transglutaminase.19  Spongiform pustule of Kogoj. It is not allowed to publish this proof online or in print. are seen in pustular psoriasis (see Fig. Elsevier and typesetter Toppan Best-set. an ~70% reduction in PASI has been observed (ointment formulation)66 as has clearing/minimal disease in ~70% of patients with scalp psoriasis (gel formulation)67. Lorenzo Cerroni. vitamin D3 inhibits epidermal proliferation. The chronic nature of psoriasis necessitates adoption of a long-term approach with avoidance of dramatic short-term “fixes” that may actually produce a more reactive disease state (see below). 8. the histologic hallmarks of “active” psoriasis. The accumulation of neutrophils within a spongiotic pustule is referred to as a “spongiform pustule of Kogoj” (Fig. 8. Pustular Psoriasis In pustular psoriasis.5 describes their indications and contraindications. Numerous neutrophils accumulate between eosinophilic strands of keratinocytes. micropustules of Kogoj and microabscesses of Munro may be seen. so counseling of the patient and family members regarding its natural history and management strategies is recommended. They are often first-line therapy in mild to moderate psoriasis and in sites such as the flexures and genitalia. as a “microabscess of Munro”. MD. Hyperplasia of the epidermis with “squaredoff” rete ridges. These two findings are pathognomonic for psoriasis and AGEP. A collection of neutrophils is seen within the upper stratum spinosum. with consideration of the extent of the disease and its effects on the patient’s quality of life as well as the likely benefits and potential side effects of specific treatments. The management of psoriasis requires individualization of therapy. Fig. An appropriate treatment regimen for a particular patient is selected from available topical and systemic medications as well as phototherapies. 8. still contains flattened nuclei (parakeratosis). A brief description of each available treatment for psoriasis is provided below. vitamin D3 analogues became commercially available as a topical treatment for psoriasis. The rete ridges are elongated and have a squared-off appearance. the capillaries are elongated and tortuous. Other In reactive arthritis (formerly Reiter’s disease). the cutaneous histologic findings are similar to those described for psoriasis. 8.20). Due to their therapeutic efficacy and limited toxicity. Courtesy. The hyperproliferation of the epidermis now has reached its characteristic pattern (Fig. subcorneal pustules are the characteristic finding. only a small suprapapillary plate of epidermal cells covers the tip of these dermal papillae. When the epidermis is hyperproliferative. the reader is referred to Chapter 129. where other topical treatments can induce L1 Bolognia_Chapter 8_main. The psoriatic lesion is heterogeneous.19) and the accumulation of neutrophil remnants in the stratum corneum. single agents are usually evaluated. surrounded by parakeratosis. Treatment 148 Care of the psoriatic patient needs to focus not only on the skin. To date. In some lesions. Topical Treatments Guidelines of care for the treatment of psoriasis with topical therapies have been developed by the American Academy of Dermatology64. exaggerated spongiform pustules of Kogoj and microabscesses of Munro. Stable lesion In the dermis. and parakeratosis plus remnants of neutrophils (microabscess of Munro). This proof copy is the copyright property of the publisher and is confidential until formal publication. large accumulations of neutrophils are observed.19). reviewer(s). In Corticosteroids Since their introduction in the early 1950s. surrounded by parakeratosis. accumulation of neutrophils is the predominant feature. Section 3 Papulosquamous and eczematous dermatoses Fig. Courtesy. but practical use in psoriasis patients usually involves combination therapy with topical corticosteroids. extending upward into elongated club-shaped dermal papillae. 8.4 summarizes the major characteristics of commercially available vitamin D3 analogues and Table 8. but also on the comorbidities that exist or might develop. MD. but in practice most patients receive combination therapy. consisting of active areas (hot spots) and chronic nonspecific areas (cold spots). it also inhibits several neutrophil functions.20  Stable plaque psoriasis. clinical trials. This micromorphology explains the “Auspitz” phenomenon (see earlier).

hydrocolloid) Contraindications • Bacterial. At least 80% of patients treated with high-potency topical cortico­ steroids experience clearance. it is used most often in day-care centers and the inpatient moderate-strength corticosteroids. lotion BID. valerates or propionates. Once-daily application has been shown to be as effective as twice-daily application. 100 g/week of calcipotriene/calcipotriol (see Table 8. 125).4  Vitamin D analogues. lotion. Unfortunately. have the highest efficacy (see Ch. 1. Maximal quantities: 50 g/week of a superpotent corticosteroid.g. 4 mcg/g Ointment. As tachyphylaxis and/or rebound can occur fairly rapidly. Application under plastic or hydrocolloid occlusion also significantly enhances the penetration. cignolin. This proof copy is the copyright property of the publisher and is confidential until formal publication. because they may reduce UV penetration into the skin. compared with 21% of the patients receiving a placebo ointment69. the anti-inflammatory properties of topical corticosteroids have been improved by increasing their lipophilicity by masking the hydrophilic 16. solution BID 100 g 26. Table 8. reviewer(s). once every 2 or 3 days or on weekends) are advised for more prolonged treatment courses. vitamin D3 preparations need to be applied after UV irradiation or at least several hours prior. ointment formulations. sarcoidosis. 100 g/week of a potent corticosteroid. The indications and contraindications regarding the use of topical corticosteroids in the treatment of psoriasis are summarized in Table 8. intermittent treatment schedules (e.27-cyclo-vitamin D3 22. INDICATIONS AND CONTRAINDICATIONS FOR ANTHRALIN Indications • Mild to moderate or severe* psoriasis: second-line treatment as monotherapy or in combination Contraindications • Unstable plaque psoriasis in a phase of progression • Pustular psoriasis • Erythrodermic psoriasis *Severe psoriasis usually treated in day-care center or inpatient setting. i. in general. † Maximum weekly amount for 8 weeks of treatment.6  Indications and contraindications for topical corticosteroids. Anthralin Anthralin (dithranol. The indications and contraindications for the use of anthralin in the treatment of psoriasis are summarized in Table 8. BID. Elsevier and typesetter Toppan Best-set. daily 70 g. Table 8. 74% of patients remained in remission. 24-oxido-reductase Calcitriol 3 mcg/g Ointment BID 200 g 1α. 70 g† 1α. and long-term remissions may be maintained by applications on alternate days69. editor(s). although it was more commonly utilized in the past (see Ch. Combination topical therapy can take advantage of the rapid effect of topical corticosteroids as well as the prolonged benefits of topical vitamin D3 analogues. it is still used as a treatment for psoriasis. anthralin or retinoids.or 17-hydroxy groups or by introducing acetonides. Over the years. neither should be increased more often than once every 3 days. Chapter 125 provides detailed information on mechanisms of action. With maintenance therapy consisting of 12 weeks of intermittent applications of betamethasone dipropionate ointment (restricted to weekends). In the authors’ 149 Psoriasis L1 Bolognia_Chapter 8_main. a topical retinoid.7. It is not allowed to publish this proof online or in print.5  Indications and contraindications for vitamin D3 analogues.6. pharmacologic aspects and side effects of corticosteroid therapy. Corticosteroids are manufactured in various vehicles. Anthralin also inhibits mitogen-induced T-lymphocyte proliferation and neutrophil chemotaxis. irritation. In fact.indd 149 5/3/2012 8:50:23 PM . Table 8. *Can consider limited use of mild. INDICATIONS AND CONTRAINDICATIONS FOR VITAMIN D3 ANALOGUES Indications • Mild to moderate psoriasis: first-line treatment as monotherapy or in combination • Severe psoriasis: combination treatment Contraindications • Involvement requiring more than the maximally recommended quantity.23-reductase.g.24-dihydroxy vitamin D3 8  Inactivating enzymes 25-hydroxylase *To avoid hypercalcemia. no efficacy data are available on prolonged treatment for more than 3 months. from ointments. Table 8. To minimize irritation. It has marked epidermal effects. given that peak erythema is seen 3–4 days following application.e. If used in conjunction with phototherapy. anthralin or tar • Monotherapy for flexural and facial psoriasis (usually mild strength) • Recalcitrant plaques often require occlusion (plastic. cream.23 double bond Transposition of the 25-OH to the 24 position 22. foams and shampoos68. 129). e. creams and lotions to gels.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). Calcipotriene is the US Adopted Name (USAN) and calcipotriol is the International Nonproprietary Name (INN). within a few days to weeks. In Europe and other regions outside the US. twice daily.7  Indications and contraindications for anthralin. bone metastases. viral and mycotic infections • Atrophy of the skin • Allergic contact dermatitis due to corticosteroids or constituents of the formulation • Pregnancy or lactation* *For example. Chapter VITAMIN D ANALOGUES Calcipotriene/Calcipotriol Concentration Formulations Frequency Maximum weekly amount* Chemical structure 50 mcg/g Ointment.25-dihydroxy vitamin D (active natural vitamin D3) 24-hydroxylase Tacalcitol 2 mcg/g.4) • Abnormality in bone or calcium metabolism* • Renal insufficiency • Allergy to the vitamin D3 analogue or constituents of the preparation • Pregnancy or lactation INDICATIONS AND CONTRAINDICATIONS FOR TOPICAL CORTICOSTEROIDS Indications • Mild to moderate psoriasis: first-line treatment as monotherapy or in combination • Severe psoriasis: often in combination with a vitamin D3 analogue.8-dihydroxy-9-anthrone) has been available since 1916. including an anti-hyperproliferative effect. the maximum improvement is usually achieved within 2 weeks. concentration and application time are gradually escalated.

SCC. although effective in the treatment of acne. the efficacy is substantially less.8. total clearing of psoriasis in at least 80% of patients occurs with 3–5 weeks of treatment in an inpatient setting or day-care center. Calcineurin inhibitors are used to treat facial and flexural psoriasis. is a likely explanation for its antipsoriatic activity. If the anthralin treatment is performed at home. compared to 13% of the patients using a placebo gel71. Options include salt-water baths. Elsevier and typesetter Toppan Best-set. respectively.g. *Absolute contraindication † Need to adjust the dose and monitor closely. initial improvement is observed between 1 and 7 weeks and maximum improvement can be expected after 8–12 weeks of treatment. However. monotherapy with erythematogenic doses of broadband UVB proved to be an effective approach. Section 3 INDICATIONS AND CONTRAINDICATIONS FOR TOPICAL TAZAROTENE Indications • Mild to moderate psoriasis: second-line treatment as monotherapy or in combination Contraindications • Unstable plaque psoriasis in a phase of progression • Erythrodermic psoriasis • Allergic contact dermatitis to tazarotene or constituents of the formulation • Pregnancy or lactation INDICATIONS AND CONTRAINDICATIONS FOR PHOTO(CHEMO)THERAPY Indications • Moderate to severe psoriasis: first-line treatment as monotherapy or in combination Contraindications (absolute or relative) • Genetic disorders characterized by increased photosensitivity or an increased risk of skin cancer (UVB and PUVA)* • Skin type I (UVB and PUVA)† • Photosensitive dermatoses (UVB and PUVA)† • Unavoidable phototoxic systemic or topical medications (UVB and PUVA)† • Vitiligo (UVB and PUVA)† • Previous history of arsenic exposure. squamous cell carcinoma. MTX) was approved by the US Food and Drug Administration (FDA) as a treatment for psoriasis. experience. liquor carbonis detergens (LCD). especially in infants or those with reduced renal function. two to three times per week is preferred. 9% and 8% of patients. the maximum weekly dosage is usually 25 mg. pruritus. Topical retinoids All-trans-retinoic acid and 13-cis-retinoic acid. narrowband UVB (311–313 nm) was developed and is the optimal irradiation currently available. Guidelines for MTX usage vary depending on the country and disease state. editor(s). In view of its modest efficacy as monotherapy. usually as a single oral dose (but occasionally intramuscularly or subcutaneously) and less often every 12 hours for three doses per week. UVB and PUVA) • Poor compliance (UVB and PUVA) • Men and women in reproductive years without contraception (PUVA) • Pregnancy or lactation (PUVA)* • Impaired liver function or hepatotoxic medication (PUVA) • Cataracts (PUVA) Papulosquamous and eczematous dermatoses Table 8. UVB. topical tazarotene.11 summarize indications and contraindications as well as side effects of MTX. in the case of scalp psoriasis. In the late 1970s. Methotrexate In 1971. this needs to be reduced to enhance penetration of topical medications and ultraviolet (UV) light. The use of folic acid supplementation during MTX administration is controversial due to the concern that folic acid may decrease the efficacy of MTX. Photo(chemo)therapy and Systemic Medications L1 150 Evidence-based guidelines for the treatment of psoriasis with photo (chemo) therapy and classic systemic medications have been developed by various dermatologic organizations73–74a. After 6 weeks of treatment. at least 50% improvement (compared with baseline) was noted by 45% of the patients using twice-daily 0. placebo-controlled studies have demonstrated efficacy and safety for this indication71. Salicylic acid 5–10% has a substantial keratolytic effect and. but. However. i.9. Chapter 130 describes the mechanism of action. MTX is administered weekly. Coal tar has a range of anti-inflammatory actions and is effective as an antipruritic. 129). Phototherapy with broadband or narrowband ultraviolet B (UVB) and photochemotherapy with ultraviolet A (UVA) following ingestion of or topical application of a psoralen are classic treatment options. Tazarotene has been shown to decrease epidermal proliferation and it inhibits psoriasis-associated differentiation (e. * if current skin cancer. In chronic plaque psoriasis. amethopterin (methotrexate. it is usually prescribed as a second-line therapy. reviewer(s). a distilled product. It is manufactured in cream and gel formulations and is applied once or twice daily. In view of its mutagenic potential. This is to prevent systemic intoxication (see Ch.8  Indications and contraindications for topical tazarotene.indd 150 5/3/2012 8:50:23 PM . Table 8. It is not allowed to publish this proof online or in print. For this reason. guidelines on the use of tar products may differ between countries. Photo(chemo)therapy Photo(chemo)therapy represents a mainstay in the treatment of moderate to severe psoriasis. 129) may be the most effective tar available for the treatment of psoriasis. Although crude coal tar (see Ch. burning. an acetylene retinoid that selectively binds retinoic acid receptor (RAR)-β and RAR-γ. The maximal area that can be treated with tazarotene is 10–20% of the body surface. can be used to treat psoriasis. tar is contraindicated in pregnant or lactating women. MTX is a first-line systemic therapy for psoriasis as it is highly efficacious for severe disease and all clinical variants of psoriasis. Irritation of the skin can limit the use of tazarotene.9  Indications and contraindications for photo(chemo)therapy. topical salicylic acid and oral retinoids. and safety data are available for up to 1 year of treatment. PUVA.e. ionizing irradiation or excessive photo(chemo)therapy (UVB and PUVA) • High cumulative number of PUVA treatments. and the tables in this chapter are adapted from these recommendations. Tables 8. The efficacy and safety of tazarotene as monotherapy have been investigated in several studies. Bolognia_Chapter 8_main. combination therapy with topical corticosteroids is useful. Indications and contraindications of tazarotene for the treatment of psoriasis are summarized in Table 8. The 308 nm excimer laser can be used to treat a limited number of plaques in patients with localized disease.10 and 8. is also used. Application of salicylic acid to localized areas can be done daily. pharmacology and safety issues of MTX.05% tazarotene gel. This proof copy is the copyright property of the publisher and is confidential until formal publication. transglutaminase expression and keratin 16 expression). >150–200 individual treatments (PUVA)* • Treatment with cyclosporine (UVB and PUVA)* • Immunosuppressive medication (UVB and PUVA) • Previous history of skin cancer (UVB and PUVA. are not effective for psoriasis. and its indications and contraindications in psoriasis are summarized in Table 8. 18%. irritation and erythema have been observed in up to 23%. for more widespread areas. circulating and cutaneous.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). Randomized. especially SCC or melanoma) • Atypical melanocytic nevi (UVB and PUVA) • Seizure disorder (risk of fall/injury. Photo(chemo)therapy is discussed in detail in Chapter 134. ultraviolet B. salicylic acid can be formulated in an oil or ointment base. The effect of MTX on lymphocytes. Potential side effects restrict its use to moderate to severe disease resistant to topical treatments and photo(chemo)therapy and/or situations in which these are contraindicated. psoralen + ultraviolet A.72. Additional topical treatments If the psoriatic plaques have thick scale. later on.

the European multicenter dose-finding studies have shown that doses of 1. The indications and contraindications of cyclosporine are summarized in Table 8. Efficacy of cyclosporine has been demonstrated in all variants of psoriasis (including nail psoriasis). Because of possible mutagenic risk and teratogenicity. An important aspect is assessment of renal function. Based on large controlled studies.indd 151 5/3/2012 8:50:23 PM . but less so for psoriatic arthropathy78. provided that the guidelines are strictly followed. Cyclosporine can produce dramatic rapid improvement of psoriasis. The improvement is observed within a few weeks. In general. compression fractures) Ventricular cardiac arrhythmias Lowered seizure threshold *Same day or 2–3 days following MTX administration. In view of its nephrotoxic effects (e. given the need to ultimately stop cyclosporine therapy. the PASI numbers are not directly comparable. maximally 1 year. angioedema.11  Side effects of methotrexate (MTX). Up to 11% of patients on oral regimens. urticaria. squamous cell carcinoma. photo(chemo)therapy and/or systemic retinoids Contraindications (absolute or relative) • Impaired kidney function (creatinine clearance <60 ml/min)† • Severe anemia.25. Chapter INDICATIONS AND CONTRAINDICATIONS FOR METHOTREXATE Indications • Severe psoriasis – Chronic plaque psoriasis (>10–15% BSA or interference with employment or social functioning) – Pustular psoriasis (generalized or localized) – Erythrodermic psoriasis – Psoriatic arthritis (moderate to severe) – Severe nail psoriasis • Psoriasis not responding to topical treatments. This proof copy is the copyright property of the publisher and is confidential until formal publication. vertigo. psoralens + ultraviolet A. psoriatic patients who have been exposed to high cumulative doses of UV radiation are at risk for development of cutaneous malignancies. especially in those previously treated with PUVA. modifications of the vitamin A molecule resulted in the discovery of the so-called first generation of retinoids. although duration is still a matter of debate) and alternated with other therapies. May be reduced by folic acid (1–5 mg/day except on day MTX administered). reduced glomerular filtration rate. dyspnea) Carcinogenesis|| In rheumatoid arthritis patients. cyclosporine should be given for several-month courses (i. editor(s). and elevated cholesterol and triglycerides. it prevents T-lymphocyte activation from being translated into the release of effector cytokines such as IL-2. no increase in serious infections has been reported in patients treated with cyclosporine alone. 2. including all-trans-retinoic acid (tretinoin) and 13-cis-retinoic acid (isotretinoin). headache. tubular atrophy). hepatitis (active and/or recent). may respond to folic acid. 57% and 86%. Cyclosporine Cyclosporine is a cyclic undecapeptide that was isolated from the fungus Tolypocladium inflatum by Gams in 1970. and creatinine clearance should be estimated using the Cockrof-Gault formula: (140 − age in years) × (weight in kg) serum creatinine (mg/100 ml) × 72 In elderly patients and patients with a history of hypertension. As a calcineurin inhibitor. PUVA.12. continue contraception during these 3 months. Further research resulted in the 151 Psoriasis Mucocutaneous L1 Bolognia_Chapter 8_main. Of note. During longterm treatment.76.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). body surface area. || No increased risk of malignancy was observed in large series of psoriasis patients75. Although cyclosporine is an immunosuppressive agent. BSA. 52% and 88% of the patients. For example. excessive alcohol intake* • Concomitant hepatotoxic medications • Concomitant medications that increase MTX levels. respectively.10  Indications and contraindications for methotrexate (MTX). hypomagnesemia.g.† SIDE EFFECTS OF METHOTREXATE Hematopoietic† Leukopenia Thrombocytopenia Anemia ‡ 8  Oral erosions† Alopecia Delayed phototoxicity Tenderness and/or necrosis of plaques due to overdose Rarely. † ‡ Requires significant reduction in dosage. vitamin A deficiency was known to cause hyperkeratosis of the skin (phrynoderma). It is not allowed to publish this proof online or in print. Table 8. An alternative is an intermittent schedule using multiple short courses of a few weeks’ duration. SCC. Cyclosporine can be used safely. trimethoprim– sulfamethoxazole* • Significantly reduced pulmonary function* • Pregnancy or lactation* • Currently planning to have children (male and female patients)‡ • Immunodeficiency syndromes • Severe infections* • Active infections • Peptic ulcer (active)* • Gastritis • Concomitant radiation therapy • Pleural effusion or ascites† • Hypersensitivity to MTX* • Unreliable patient* Subjective symptoms Most frequent* Nausea Vomiting Abdominal pain Fatigue Headache Occasional Loss of libido Impaired memory Hepatic Hepatitis Cirrhosis§ † .e. § Up to 25% of patients receiving long-term therapy.5–3 and 5 mg/kg/day of cyclosporine resulted in reductions of the PASI of 35%. Table 8. The underlying mechanism is not mutagenesis but a decrease in immunosurveillance of the skin. leukopenia and/or thrombocytopenia* • Significant liver function abnormalities. cirrhosis. An improvement in the PASI of 75% was achieved in 24%. Other side effects include: gastrointestinal discomfort. gingival hyperplasia. Systemic retinoids By the 1930s. reviewer(s). osteoporosis. cyclosporine is a highly effective treatment for the severe manifestations of psoriasis. severe fibrosis. Thirty years later. hypertrichosis. but this must be balanced by the requirement for an appropriate replacement therapy. a reduction of the PASI of 60–70% can be reached within 4 weeks of treatment79. Guidelines for pre-cyclosporine screening and long-term evaluation during cyclosporine administration are outlined in Chapter 130. hyperuricemia (due to decreased clearance of uric acid). muscle cramps and tremor77. In particular. *Absolute contraindication. increased risk of lymphoma Risk factor for cutaneous SCC in PUVA-treated patients Opportunistic infections Pneumocystis jiroveci pneumonia Cryptococcosis Disseminated histoplasmosis Disseminated herpes zoster † ‡ Idiosyncratic reaction Early in course with full dosage Severe pneumonia Gastrointestinal hemorrhage Pancytopenia Additional/unusual Osteopathy (pain. there are no signs of tachyphylaxis. The efficacy of cyclosporine for psoriasis has been clearly shown in multiple controlled and uncontrolled studies. Cyclosporine treatment in psoriatic patients has been reported to increase the frequency of SCCs. because the criteria for these studies were different from those used for FDA approval of targeted immune modulators (“biologic” therapies). discontinue MTX 3 months prior to attempts to conceive. vasculitis Fetal development Birth defects: cranial and absence of digits Pulmonary Interstitial pneumonitis (acute-onset cough. Metabolic side effects include hyperkalemia. Elsevier and typesetter Toppan Best-set.g. e. dose reduction or antiemetic drug. paresthesias. the risks of renal impairment and hypertension are increased.

14 and 8. the dose should be maximized. Targeted immune modulators (“biologic” therapies) Beginning in 2000. cyclosporine is inactivated by the cytochrome P450 3A isoform.16 lists the biologic agents that are currently commercially available. gamma glutamyl transpeptidase. the mono-aromatic retinoids. which can be increased depending upon the clinical response and side effects. As monotherapy. and the recommended initial and ongoing evaluations are outlined in Tables 8. especially hypertriglyceridemia. Table 8.15. hyperkalemia • Hypersensitivity to cyclosporine* • Vaccination with live vaccines • Seizure disorder • Poorly controlled diabetes mellitus • Severe chronic organ dysfunction • Alcohol and drug abuse • Malabsorption • Unreliable patient* † INDICATIONS AND CONTRAINDICATIONS FOR ACITRETIN Indications • Severe psoriasis that cannot be managed by topical treatments or photo(chemo)therapy • Monotherapy is indicated for erythrodermic or pustular psoriasis • Combination therapy is indicated for chronic plaque psoriasis Contraindications • Severe liver dysfunction* • Severe kidney dysfunction (elimination reduced)* • Pregnancy or lactation* • Women of childbearing potential who cannot guarantee adequate contraception during and up to 3 years following discontinuation of acitretin* • Hyperlipidemia. a dose that causes a clinically apparent but tolerable cheilitis is an endpoint. 0. γ GT. phenytoin competes for plasma protein binding. A major problem with systemic retinoids is their teratogenicity. AST. For erythrodermic psoriasis.14  Pre-acitretin screening.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s).indd 152 5/3/2012 8:50:23 PM .g. and in pustular psoriasis. The efficacy of acitretin monotherapy in chronic plaque psoriasis is limited. This proof copy is the copyright property of the publisher and is confidential until formal publication. aspartate aminotransferase. whereas in patients with pustular psoriasis. Maximal therapeutic efficacy is reached after 2–3 months. Table 8. the initial dosage is 0. reviewer(s). Section 3 INDICATIONS AND CONTRAINDICATIONS FOR CYCLOSPORINE Indications • Severe psoriasis • Conventional therapies (topical treatments. Table 8.g. Their two major targets are T cells and cytokines. acitretin. methotrexate) ineffective or inappropriate Contraindications • Impaired renal function* • Uncontrolled hypertension* • Primary or secondary immunodeficiency • Concomitant immunosuppressive therapy • Past or present* malignancy • Concomitant drugs affecting cyclosporine pharmacokinetics† • History of arsenic exposure • History of excessive photo(chemo)therapy (>200 PUVA treatments). The recommended starting dose is 3 mg/kg/day in two divided doses.g. HDL • Glucose • Serum creatinine • Pregnancy test • Consider spinal X-ray (often initially performed during the first 3 months of therapy if long-term treatment is anticipated) Table 8. e. including TNF-α and IL-12/23. 23% of patients treated with 50 mg of acitretin daily for 8 weeks achieved ≥75% improvement in their PASI79.13  Indications and contraindications for acitretin.13. editor(s). dosage can be increased to a maximum of 5 mg/kg/day. doses up to 1 mg/kg/day.e. Acitretin is an effective treatment for psoriasis as well as disorders of keratinization and cutaneous lupus. bilirubin) • Serum triglycerides. pharmacologic aspects and side effects of these medications. methotrexate‡ • Poorly controlled diabetes mellitus • History of pancreatitis • Excessive alcohol intake* • Use of contact lenses • Unreliable patient* • Atherosclerosis † Papulosquamous and eczematous dermatoses *Absolute contraindications. PUVA. Although briakinumab (a human monoclonal antibody against the p40 subunit of IL-12 and IL-23) was found to have greater efficacy than methotrexate in patients with moderate to severe plaque psoriasis79a. γGT.12  Indications and contraindications for cyclosporine. alanine aminotransferase. Chapter 126 provides a description of the modes of action.25 mg/kg/day. ALT. *Absolute contraindications. In patients with chronic plaque psoriasis. Acitretin has been shown to be an effective maintenance therapy. Its efficacy in nail psoriasis and psoriatic arthritis is only modest. Requires dose adjustment and careful monitoring. biologic therapies were introduced for the treatment of psoriatic arthritis and moderate to severe psoriasis. once yearly in patients receiving long-term treatment) • Pregnancy test (throughout treatment) Table 8. alkaline phosphatase. Combination treatment with photo(chemo)-therapy and/or vitamin D3 analogues results in a substantial improvement in clinical response. respectively. L1 152 development of the second generation of retinoids. making contraception mandatory in women of childbearing age during treatment and (depending on the drug half-life) for a period of 2 months to 3 years after discontinuing therapy. etretinate and its free metabolite acitretin79. Blood donation is contraindicated in patients receiving acitretin. In one study. In patients with chronic plaque psoriasis. photo(chemo)therapy. cholesterol. at 2-week intervals. It is not allowed to publish this proof online or in print. Reserved for treatment-resistant patients. Elsevier and typesetter Toppan Best-set. that cannot be controlled* • Concomitant medications that interfere with retinoid bioavailability or whose metabolism is altered† • Concomitant hepatotoxic drugs. psoralens + ultraviolet A. i. HDL. high-density lipoproteins. ALT. The indications and contraindications for the use of acitretin in the treatment of psoriasis are summarized in Table 8. radiotherapy* • Concurrent photo(chemo)therapy* • Severe infections* • Active infections • Pregnancy or lactation • Concurrent methotrexate administration • Significant hepatic disease • Hyperuricemia. Bolognia_Chapter 8_main.5 mg/kg/day is the initial dosage. e. ‡ Requires dose adjustment and careful monitoring. with approximately 70% of patients achieving a moderate or better response. mild cheilitis (just perceived by the patient) is the goal. high-density lipoproteins EVALUATION DURING ACITRETIN TREATMENT • Monitor mucocutaneous side effects • Serum cholesterol/triglycerides/HDL and liver enzymes (every month for the first 2 months then every 2–3 months) • Serum creatinine (elderly patients or patients with mild to moderate renal dysfunction) • Monitor for development of hyperostosis by history (twice yearly) and by X-ray of spine (e. acitretin is highly effective in erythrodermic and pustular psoriasis.15  Evaluation during acitretin treatment. HDL. PRE-ACITRETIN SCREENING • History to exclude contraindications • Complete blood count • Liver function tests (AST.

guidelines. have been developed for the treatment of psoriasis patients with TNF-α inhibitors (adalimumab. Table 8. ‡ Soluble form and transmembrane TNF receptor. The relative efficacies of the various biologic agents are reviewed in Chapter 128. some listed below are relative. hypercalciuria Myelosuppression.9) is contraindicated in patients receiving biologic agents for psoriasis. etanercept and infliximab) and ustekinumab74.17  Indications and contraindications for commercially available targeted immune modulators (“biologic” agents). congestive heart failure (NYHA grade III or IV) or demyelinization disorders (the latter also in first-degree relatives)* • Selective for ustekinumab: BCG vaccination within the past 12 months (mode of action expected to increase susceptibility to mycobacterial infections) † Ustekinumab p40 subunit of IL-12/23 Human antibody *By registration authorities for the treatment of psoriasis. New York Heart Association. dosages.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). pustular. FDA. For research purposes. Dermatology Life Quality Index [DLQI].18  Additional systemic therapies for psoriasis. In general. European Medicines Agency. Individual patients report a wide variation with respect to their clinical response to various treatments. The visibility of the lesions and symptoms such as pruritus are relevant factors. It is not allowed to publish this proof online or in print. This proof copy is the copyright property of the publisher and is confidential until formal publication. Chapter 128 provides a description of the modes of action. Table 8. including European S3-Guidelines. Bacillus Calmette-Guérin. these aspects can be summarized as the PASI (see Table 8. ADDITIONAL SYSTEMIC THERAPIES FOR PSORIASIS Medication Fumarates85 Side effects Renal impairment. there is significant overlap between the efficacies of biologic agents (as assessed after 3 months of therapy) and those of photo(chemo)therapy and classic systemic medications such as MTX and cyclosporine. Both indications and contraindications for currently commercially available therapies are outlined in Table 8. Food and Drug Administration. some patients. they are used less often than the medications previously described in this chapter. eligible for a systemic treatment • Patients with psoriatic arthritis. although only a few studies directly comparing biologic agents with classic systemic medications are available.indd 153 5/3/2012 8:50:23 PM . bacterial or fungal infections* • Increased risk for developing sepsis* • Active tuberculosis* • Immunosuppressed patient • Past history of hepatitis B • Pregnancy (TNF-α inhibitors. in particular88: ● The area of involvement and the degree of erythema. particularly those who have failed other disease-modifying antirheumatic drugs (DMARDs) Restricted indication • Patients with moderate to severe psoriasis who are not candidates for topical treatments. may experience excellent improvement with a mild topical therapy. Aggravating factors such as focal infections. medications and psychological stress have been described above. Several guidelines restrict their use to “high-need patients” in whom all other existing treatments are contraindicated or have led to insufficient improvement. side effects and monitoring recommendations for biologic agents. it is important to exclude triggering factors. Production of alefacept in the US was discontinued in 2011. 130 87 Mycophenolate mofetil86 Oral calcitriol (0. TNF-α inhibitors and anti-IL-12/23 antibodies have substantial efficacy and enable long-term control of psoriasis84. tumor necrosis factor applications for approval by the FDA and European Medicines Agency (EMEA) were withdrawn due to safety concerns (including a possible increased risk of cardiovascular adverse events). gastrointestinal disturbances. Elsevier and typesetter Toppan Best-set. flushing. IL. 130 Hypercalcemia. TNF. BCG. 128]. Relative and absolute contraindications to the various treatment options have to be recognized.5–3 mcg/day) 6-thioguanine (40–160 mg/day) Hydroxyurea Other systemic therapies Additional systemic therapies have been reported as beneficial in the management of psoriasis (Table 8. blood dyscrasias. Table 8. while others are absolute [*]) • Guttate. editor(s). interleukin. photo(chemo)therapy or classic systemic treatments because of insufficient efficacy or contraindications Contraindications (The exact contraindications vary by agent [see Ch. In general. NYHA. For example. alefacept† and ustekinumab are category B) • Breastfeeding • Malignancy within the past 5 years (does not include adequately treated single cutaneous squamous or basal cell carcinoma) • Excessive chronic sun exposure or photo(chemo)therapy • Allergic reaction to the biologic agent* • Selective for alefacept†: CD4 counts <250 cells/mcl*. hepatotoxicity. ● The responsiveness to previous treatments. HIV infection* • Selective for TNF-α inhibitors: ANA+ (especially if high titer) or autoimmune connective tissue disease. EMA. whereas some investigators have voiced the opinion that biologic therapies should be an option for patients who have failed to respond adequately to one classic systemic treatment83. Impact of psoriasis on quality of life can be measured by questionnaires (e. **Production of alefacept in the US was discontinued in 2011. Therapeutic Management General considerations Before considering a specific treatment in an individual psoriatic patient.18). Biologic therapies are indicated for patients with moderate to severe psoriasis and/or psoriatic arthritis. ● The impairment of quality of life. even those with widespread disease. it is also crucial to assess the various aspects of disease severity. gastrointestinal disturbances See Ch. and psycho-emotional stress and the response of family and friends to the psoriasis should also be considered. reviewer(s).17. or erythrodermic psoriasis • Significant viral. Of note. Furthermore. fatigue See Ch. especially in the case of photo(chemo) 153 Psoriasis COMMERCIALLY AVAILABLE BIOLOGIC AGENTS USED FOR THE TREATMENT OF PSORIASIS INDICATIONS AND CONTRAINDICATIONS FOR COMMERCIALLY AVAILABLE TARGETED IMMUNE MODULATORS ("BIOLOGIC" AGENTS) 8  L1 Bolognia_Chapter 8_main.80–82. Skindex29).16  Commercially available biologic agents used for the treatment of psoriasis. and there are regional differences in their use. Administration of live vaccines (see Table 128.g. induration and desquamation of the cutaneous lesions. the latter recommendation has to be balanced against the high cost of these medications. With regard to the percentage of patients achieving PASI 75 improvement. Chapter Biologic agent Alefacept** Etanercept Infliximab Adalimumab Target CD2 TNF-α† TNF-α‡ TNF-α‡ Molecule Human fusion protein Human fusion protein Chimeric antibody Human antibody Approved* FDA FDA + EMA FDA + EMA FDA + EMA (psoriatic arthritis) FDA + EMA Indications General indications • Patients with moderate to severe psoriasis.2). headache. † Soluble form. whereas patients with localized disease may prove recalcitrant to even high-dose systemic treatments.

the combination of calcipotriene and a potent topical corticosteroid is applied for 4 weeks. stinging and irritation. a topical corticosteroid under hydrocolloid occlusion can be used for a few recalcitrant plaques. as the success of these topicals is highly dependent on the treatment setting. biologic agents are available exclusively for those patients with severe psoriasis who cannot be treated adequately with the classic treatments. it is not always practical to define a therapeutic ladder. editor(s). A day-care or inpatient setting is optimal. Management with topical agents It is important before instituting topical therapy that the patient understands that due to the Koebner phenomenon. For such patients. the existence of relative and absolute contraindications has to be considered. In ambulatory patients. For example. An important issue is whether a maintenance treatment is needed or desired. Because psoriasis is a chronic condition. If this regimen is not successful or if rapid clearing is required. For scalp psoriasis. especially in patients with longstanding disease and incomplete responses or fast relapses. as it allows the patient to more easily cope with the side effects of staining. some patients cannot accept a few coin-sized lesions in visible sites. Cyclosporine should not be used as a maintenance treatment. with lowdose cyclosporine (2 mg/kg/day) plus topical calcipotriene. For example. a possible impact on comorbidities (see above) may influence decisions in the future. patients should also be told that topical agents do not prevent new lesions from appearing at additional sites. resulting in a rapid improvement91. etanercept. the authors recommend the following: start with calcipotriene cream or ointment twice daily for a period of 8 weeks (except for sensitive skin areas and the scalp). patients have to cope not only with their disease.indd 154 5/3/2012 8:50:24 PM . treatment with photo(chemo)therapy or a systemic agent is indicated. whereas the combination of calcipotriene plus mediumstrength corticosteroids did not have a substantial additive effect compared with each as monotherapy. a fixed combination of calcipotriene and betamethasone dipropionate applied once daily proved to be superior to twice-daily calcipotriene or twice-daily betamethasone dipropionate monotherapy90. removal of scale with a formulation containing 10–20% salicylic acid is the initial step. intermittent application of a topical corticosteroid (once or twice weekly) is helpful. while for others this is less of a problem. Although it may seem obvious. Improved efficacy has also been observed with the combination of calcipotriene–cyclosporine and calcipotriene–acitretin. thereby increasing efficacy and reducing side effects. some general recommendations can be offered. However. but these same patients could be excellent candidates for retinoid therapy (considering its anticancer effects). These treatments often require a day-care or inpatient facility as their use in the ambulatory setting is disappointing. topical treatments are the first choice. Lastly. PUVA. Elsevier and typesetter Toppan Best-set. marked Beneficial combinations Management with photo(chemo)therapy and classic systemic medications L1 154 For patients with moderate to severe involvement. another vitamin D3 analogue or tazarotene may be tried as monotherapy or in combination with a topical corticosteroid. with prevention of permanent destructive changes. If topical therapies do not provide adequate improvement. Psoriasis of the face and flexures can be treated with a calcineurin inhibitor. from scratching or debriding lesions) can negate therapeutic interventions. Evidence for the efficacy of photo(chemo)therapy and classic systemic treatments has been reassessed in a meta-analysis92. individual circumstances may restrict the time available for intensive daily treatments. infliximab and ustekinumab. whereas methotrexate.9%) and cyclosporine (64%). treatment selection is a multivariable decision-making process and not a simple stepwise therapeutic ladder. tacalcitol and calcitriol tend to result in less irritation as compared to calcipotriene. Based on the above discussion. the other vitamin D3 analogues (tacalcitol and calcitriol) and the retinoid tazarotene89. For patients with mild to moderate involvement. methotrexate. Reduction of inflammation resulting from active psoriasis may also impact the development of metabolic syndrome and the cardiovascular diseases. For example. national health authorities and managed care insurance companies have adopted a restrictive approach. This proof copy is the copyright property of the publisher and is confidential until formal publication. How to combine treatments Enhanced clinical response and a possible reduction in side effects are the goals of combination therapy. however. followed by UVB (67. In addition. while cyclosporine is contraindicated in those with renal insufficiency or hypertension. Therefore. Section 3 Papulosquamous and eczematous dermatoses therapy and systemic medications. A trial of tar or anthralin may be tried. Therefore. lack of efficacy. If a few months of UVB therapy do not result in adequate improvement or a sufficient long-term remission is not achieved. for prolonged periods of time. With regard to maintenance therapy. Methotrexate is contraindicated in patients with excessive alcohol intake or active hepatitis. fumarates are only available in some European countries. However. However. for safety reasons. some combinations are contraindicated. with no indication to date of cumulative toxicity. In the case of an insufficient response or irritation.g. the use of ultrapotent corticosteroids should be avoided. treatments and become frustrated and non-compliant. patients with widespread disease often cannot manage their psoriasis with topical Bolognia_Chapter 8_main. Intermittent use of potent and ultrapotent topical corticosteroids (or corticosteroidcontaining shampoos) in combination with calcipotriene lotion is our preferred regimen for scalp psoriasis. in the selection of a systemic treatment for an individual patient. acitretin and fumarates can be employed for long-term control of psoriasis. For example. one of the other treatment modalities previously discussed should be selected (with a consideration of individualized risk factors).95. The concept of rotational therapies is valuable but complex. treatment with a biologic agent is indicated. Despite these considerations. If the therapeutic response is insufficient. the first treatment to be considered is typically narrowband UVB phototherapy. Daily use of a topical vitamin D3 analogue (below the maximum allowed weekly dosage) provides a safe long-term form of maintenance therapy. trauma (e. The efficacy of coal tar and anthralin are difficult to assess. Psoriasis in sensitive areas and on the scalp should be managed differently. compared with each as monotherapy94. On a chronic basis. If the response to topical therapies is unsatisfactory. reviewer(s). The combination of calcipotriene with superpotent topical corticosteroids has been shown to be more effective than either treatment as monotherapy. As a 1-year course of biologic therapy costs approximately $20 000 (~ c 15 000). The side-effect profiles are very different from those of photo(chemo)therapy and classic systemic medications. safety concerns. long-term use of these systemic treatments is restricted by their cumulative toxicity potential. in particular for long-term use93. Despite the availability of effective topical and classic systemic medications as well as phototherapy. coal tar. but also with their treatments. If neither photo(chemo)therapy nor classic systemic medications provide adequate improvement. From this analysis. Combination treatment is advised for the vast majority of patients. some patients prefer only intermittent clearing courses with no intervening therapy. it was concluded that only very potent topical corticosteroids tended to be more effective than monotherapy with the vitamin D3 analogue calcipotriene. It is not allowed to publish this proof online or in print. photo(chemo)therapy would not be chosen for patients with a history of excessive exposure to UV radiation. In these sensitive areas. calcipotriene was more effective than anthralin. Therefore. However. Targeted immune modulators (“biologic” therapies) Several biologic therapies are currently available worldwide for the treatment of psoriasis and/or psoriatic arthritis: adalimumab.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). in many countries. However. and inconveniences are important restrictions. while other patients want continuous treatment. topical therapies may be ineffective or impractical. a high degree of compliance is required and this can be difficult to achieve. Evidence for the efficacy of various topical treatments was reassessed in a recent meta-analysis89. Patients with more widespread involvement may also be treated with a topical agent. biologic agents can provide benefit for their skin disease as well as psoriatic arthritis (especially TNF-α inhibitors). the irritation caused by calcipotriene can be reduced by the addition of medium-strength corticosteroids. acitretin and then cyclosporine92. The investigators also developed practice guidelines and recommended the following sequence of therapies: UVB. PUVA had the highest percentage of patients with clearance (70%).

155:4078–83. 2010. 2005. 21.122:201–6.11:261–6. controlled studies are required to substantiate these claims. Coskun BK. improvement or clearing was seen in 90% of patients. Bonish B. Andressen C. The next step is to recommend treatment with narrowband UVB. 4. Inheritance of psoriasis.. 13. 2006. Ding J. 11. Turka LA. Gardembas-Pain M. Bowcock AM. Spontaneous development of psoriasis in a new animal model shows an essential role for resident T cells and tumor necrosis factor-alpha. Evidence for an antigen-specific cellular immune response in skin lesions of patients with psoriasis vulgaris. 22. J Clin Invest.202:135–43. et al. 2007. Gulinck MK. 2009. N Engl J Med. J Exp Med. et al. et al.193:300–3. de Jong EMGJ. As a result.141: 1537–41. Conrad C. 24. Brandt C. et al.165:4076–85. Nair RP. Dermatology. 1990. Vollmer S. 2002. therefore. Plasmacytoid predendritic cells initiate psoriasis through interferonalpha production. et al Psoriasis of the nails associated with disability in a large number of patients. The natural history of 5600 patients. 1982. New York: Marcel Dekker. Ifrah N. Lowes MA. Menssen A.106:711–4. Br J Dermatol. Analysis of 2035 family histories. methotrexate is regarded as the treatment of choice. Farber E.13:836–42. et al. Dissociated impairment of thymus-dependent lymphocytes. Nickoloff BJ. Nall L. Clot J.28:467–73. The combination of phototherapy with application of anthralin or tar is a time-honored therapy. 34. which focus on one key aspect of psoriasis pathogenesis. careful monitoring is mandatory. Nat Rev Immunol. 7. protein kinase C or p38 kinase. Epidemiology and prescribed treatments in childhood psoriasis: a survey among medical professionals. N Engl J Med. 33:214–7. severe hepatotoxicity has been reported. Psoriasis. in recalcitrant psoriasis. Semin Dermatol. In: Roenigk HH. A genome-wide association study indentifies new psoriasis susceptibility loci and an interaction between HLA-C and ERAP1. 19. However. J Invest Dermatol. Sequence variants in the genes for the interleukin-23 receptor (IL23R) and its ligand (IL12B) confer protection against psoriasis. et al. 1995. Nall ML. Dutronc Y. Henseler T. Overexpression of CD1d by keratinocytes in psoriasis and CD1ddependent IFN-gamma production by NK-T cells.133:768–73. Psoriasis after allogeneic bone marrow transplantation. 2000. 1981. Although increases in the duration of subsequent remission periods have been noted. and etanercept should be considered as a third-line drug for therapyresistant psoriasis100. Acta Derm Venereol. Spencer CC. et al. et al. Swanbeck G. Powles AV. Psoriasis type I and II as subtypes of nonpustular psoriasis. although remission periods following the combination of anthralin and optimized phototherapy are prolonged. 1976. Although this combination can be very effective. 31. Assessment of the psoriatic transcriptome in a large sample: additional regulated genes and comparisons with in vitro models. 2001. if phototherapy is optimized by using near-erythematogenic doses. Only two randomized controlled trials were identified. Nestlé FO. For treatment-resistant flexural and/or facial psoriasis. editor(s). 1986.95:295–301. Barker J. Br J Dermatol. 6. Jones FG. including oral inhibitors of kinases such as Janus kinase (JAK). Pediatr Dermatol. 2004. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Nestlé FO. The authors recommended topical calcipotriene as first-line therapy for mild to moderate juvenile psoriasis. Finding the missing heritability of complex diseases. Martinsson T. Epidemiology: natural history and genetics. Schmitt-Egenolf M. Manolio TA. Conrad C. 3. Cox NJ. The combination of calcipotriene and PUVA is characterized by a marked reduction in the cumulative dose of UVA required and enhanced efficacy. et al.94:202–9. 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Genome-wide scan reveals association of psoriasis with IL-23 and NF-kappaB pathways.indd 155 5/3/2012 8:50:24 PM . Topical corticosteroids are frequently combined with other antipsoriatic treatments. Kaplan DH. Anthralin is then considered if this treatment regimen is not effective or the psoriasis is moderate to severe. 1992. 16. Meynadier J. 30. 2007. 2010. Boehncke WH. Green A. Br J Dermatol. Seegers BAMPA. Immunological aspects of psoriasis.130:1829–40. the combination of acitretin and calcipotriene was more effective and permitted a lower dose of both acitretin and calcipotriene as compared to each as monotherapy. 2010. Maibach HI (eds). Nat Genet.126:1523. Of the systemic medications. Chamian F. Raychaudhuri SP. 12. Arch Dermatol. Inerot A. Jullien D.1% ointment can be added to the treatment regimen. Psoriasis—epidemiology and clinical spectrum. 33. 18. tacrolimus 0. 1996.and family-based study. used with success by rheumatologists. de Jong EMGJ. 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Augustin M.To protect the rights of the author(s) and publisher we inform you that this PDF is an uncorrected proof for internal business use only by the author(s). 2005. with attention to the number of treatments. et al. et al. The combination of acitretin and cyclosporine carries the risk of accumulation of cyclosporine. as well as inhibitors of STAT-3 (see Pathogenesis) such as topical STA-21/ochromycinone. combined with mild. Nat Genet. Seyhan M. Bridges JM. 2005. 20. van de Kerkhof PCM. Nat Med. It is not allowed to publish this proof online or in print. one examined topical calcipotriene and the other etanercept. Gudjonsson JE. Krueger JG. Burrows D. reviewer(s). Clearance of severe psoriasis after allogenic bone marrow transplantation. Saglam H. 10. An increased occurrence of SCCs has been observed in patients treated with the combination of cyclosporine and PUVA. Elsevier and typesetter Toppan Best-set. 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