A 61-year-old male smoker with hypertension, fatty liver disease, and a history of cutaneous squamous cell carcinoma presents with slightly pruritic plaques over the abdomen, lower back, arms, and legs, for a total count of six lesions. Lesions have been present for 10 years, and he has never sought dermatologic therapy. At this stage in the disease process, which of the following is the best first-line treatment?
- Topical therapy
- Oral systemic therapies
- Biologic therapy
a. Topical therapy.
This patient has plaque psoriasis, a chronic inflammatory disease of the skin. The image (Figure 1) shows a characteristic lesion of a sharply defined, erythematous plaque with silvery-white scales, most commonly appearing on the trunk and extremities (Aldredge & Higham, 2018). Although there are several additional psoriatic variants (guttate, erythrodermic, palmoplantar, and pustular), plaque psoriasis is the most common, affecting up to 4.7% of the United States and Canada (Van de Kerkhof & O'Nestlè, 2012).
Although milder forms of psoriasis may be limited to cutaneous involvement, 20%–30% of patients will develop psoriatic arthritis (Van de Kerkhof & O'Nestlè, 2012). Additional comorbidities such as metabolic syndrome and atherosclerotic cardiovascular disease have been associated with psoriasis as well (Van de Kerkhof & O'Nestlè, 2012). As the spectrum of clinical severity is diverse, the lack of well-defined disease states can make treatment and management of psoriasis more complex.
Although this patient is considered to have mild disease based on limited body surface area (BSA) involvement, the lesions are still concerning (Adamski, Karczewski, Poniedzialek, & Rzymski, 2014). Lesions on the face, hands, feet, or genitals may be more symptomatic to a patient than those on the trunk. Furthermore, the BSA does not always reflect the severity of the individual lesions, which may complicate treatment decisions (Bos, Bossuyt, de Borgie, de Rie, Heydendael, & Spuls, 2004). Because this patient has mildly symptomatic lesions covering a limited BSA, an intense systemic therapy is not needed at this time. Topical treatment such as corticosteroids with or without a Vitamin D3 analogue should first be considered (Cather & Crowley, 2014). Additional options for mild lesions may include intralesional corticosteroid injections or EXTRAC laser therapy.
In more severe cases of psoriasis with systemic involvement, therapies such as methotrexate, acitretin, apremilast, and cyclosporine or biologics such as adalimumab, etanercept, infliximab, ustekinumab, secukinumab, and ixekizumab may be more appropriate (Cather & Crowley, 2014). At severe stages, combination therapies may be administered (Cather & Crowley, 2014). The patient's disease severity and preexisting comorbidities must always be considered; our patient is additionally a great candidate for topical therapy given the comorbidities of liver disease and prior skin cancer.
To ensure appropriate ongoing management, it is necessary for the dermatologic nurse to understand the various disease states of psoriasis. When appropriate, the potential for side effects with systemic and biologic therapies should be weighed against disease severity.
Adamski Z., Karczewski J., Poniedzialek B., & Rzymski P. (2014). Factors affecting response to biologic treatment in psoriasis. Dermatologic Therapy
, 27(6), 323–330. doi:10.1111/dth.12160
Aldredge L., & Higham R. (2018). Manifestations and management of difficult-to-treat psoriasis. Journal of the Dermatology Nurses' Association
, 10(4), 189–197. doi:10.1097/JDN.0000000000000418
Bos J. D., Bossuyt P. M., de Borgie C. A., de Rie M. A., Heydendael V. M., & Spuls P. I. (2004). The burden of psoriasis is not determined by disease severity only. Journal of Investigative Dermatology Symposium Proceedings
, 9(2), 131–135.
Cather J., & Crowley J. (2014). Use of biologic agents in combination with other therapies for the treatment of psoriasis. American Journal of Clinical Dermatology
, 15(6), 467–478. doi:10.1007/s40257-014-0097-1
Van de Kerkhof P., & O'Nestlè F. (2012). Psoriasis. In Bolognia J., Jorizzo J., Schaffer J., & Julie V. (Eds.), Dermatology
(pp. 135–156). Philadelphia, PA: Elsevier Saunders.