Care of generalized psoriasis in the elderly beyond topical therapy: Areview and a proposed algorithm

(Poster reference number 4692)Matthew Matsunaga, UCSF Psoriasis Treatment Center, San Francisco, CA, UnitedStates; Eric Lee, UCSF Psoriasis Treatment Center, San Francisco, CA, UnitedStates; John Koo, MD, UCSF Psoriasis Treatment Center, San Francisco, CA,United States; Misha Heller, UCSF Psoriasis Treatment Center, San Francisco, CA,United States

Background: Treatment of generalized psoriasis in the elderly population canpresent many challenges for the clinician because of their sometimes frail health andpolypharmacy. Decisions regarding which systemic modality is appropriate can bedaunting at times.

Objective: An algorithm and optimal strategy is proposed for the treatment ofmoderate to severe psoriasis in this age group that goes beyond topical therapy.

Method: A search was conducted on PubMed. The articles reviewed covered 1969-2010. A total of 96 articles were found relevant to this subject.

Results: When choosing a therapy for generalized psoriasis in the elderly, UVBshould be attempted first due to its ease, efficacy and safety. Goeckerman should bea later treatment option because although safe and highly efficacious it requiresstamina over an extended duration which the elderly may not be able to tolerate.PUVA is next because of its concern with cutaneous malignancies as the number ofUVA exposures increases. In order of safety and efficacy of the systemic therapieswould be acitretin with or without phototherapy, etanercept, adalimumab,alefacept, ustekinumab, infliximab, methotrexate, cyclosporine then systemiccombinations. The justification for this algorithm will be presented.

Conclusion: While there are many treatment options for generalized psoriasis,selecting the appropriate therapy for an elderly patient presents certain challenges.The step-wise use of this algorithm can provide a practical guide to aid the clinicianin choosing an appropriate treatment for a given patient.

APRIL 20

cial support: None identified.

Commer

Case report: Psoriasis associated with chronic arsinicism

(Poster reference number 5200)Minh Van Hoang, MD, University of Medicine and Pharmacy of HCMC, Ho ChiMinh, Vietnam; Hoang Vu Nguyen, MD, Dermatology and Venereology Hospitalof HCMC, Ho Chi Minh, Vietnam; Huong Hoai Thi Tran, MD, Dermatology andVenereology Hospital, Ho Chi Minh, Vietnam; Phung Kim Thi Ngo, MD, PhD,University of Medicine and Pharmacy of HCMC, Ho Chi Minh, Vietnam; QuangMinh Nguyen, MD, Dermatology and Venereology Ha Noi Hospital, Ha Noi,Vietnam

Psoriasis is a chronic disorder with polygenic, predisposition and triggeringenvironmental factors. Because of the chronic course, psoriasis makes the patientsbecome worried and lose their patience with their diseases. They can take someChinese proprietary medicines that contain organic arsenic besides the prescrip-tion. Ingestion of inorganic arsenic has been reported to be associated with otherdiseases but psoriasis. We report a case of psoriasis associated with chronicarsinicism. A 39-year-old woman was hospitalized because of scaly, erythematouspatches and pruritus. She had suffered from psoriasis for 16 years and ingestedarsenic containing medications for 1 year. She was also treated with methotrexate,acitretin, and UVB. She had a history of ischemic heart disease for 1 year.Examination showed hyperpigmentation with superimposed guttate hypopigmen-tation, a raindrop figure on his trunk and multiple wart-like papules on her body,especially in hands and feet. There were demarcated, inflamed, erythematouspapules and patches covered by thinwhite scales and symmetric distribution. Levelsof arsenic in blood, hair and urine were 0.02 mg/L, 5.2 mg/kg, and 0.23 mg/Lrespectively. Histologic examination of papules and hyperpigmented macules andcancer screening for internal organs showed no malignancy. This is the first case inmy country.

cial support: None identified.

Commer

12

Clinical and patient-reported improvements of hand and/or foot psoriasiswith adalimumab: Subanalysis of REACH

(Poster reference number 5061)Alan Menter, MD, Baylor Research Institute, Dallas, TX, United States; Jerry Bagel,MD, Windsor Dermatology, East Windsor, NJ, United States; Kristina Unnebrink,PhD, Abbott GmbH & Co. KG, Ludwigshafen, Germany; Stephen Rozzo, PhD,Abbott, Abbott Park, IL, United States

Background: To examine the association between erythema, scaling, induration, andfissuring (ESIF) component scores with quality of life measures in adults withmoderate to severe hand and/or foot (h/f) psoriasis.

Methods: REACH was a 16-week randomized, double-blind, placebo (PBO)-con-trolled study of adalimumab (ADA) in h/f psoriasis patients. Patients were treatedwith ADA during a 12-week, open-label extension. ADAwas administered 80 mg SCat week (wk) 0, then 40 mg every other week from wk 1. Primary endpoint wasproportion of patients with Physician’s Global Assessment of the hands and/or feet(hfPGA) of ‘‘clear’’ or ‘‘almost clear’’ at wk 16. Post-hoc analyses evaluated percentchanges from baseline to wks 16 and 28 in ESIF component scores. Missing datawere imputed using last observation carried forward (LOCF). Percentage of patientsachieving change from baseline in Dermatology Life Quality Index (DLQI) scores[5and ESIF component scores[4.98 (0.5 SD) were calculated using NRI. Spearmancorrelation coefficients for changes from baseline in DLQI, Patient HealthQuestionnaire (PHQ-9), hfPGA, and Visual Analog Scale for Plaque Psoriasis andPsoriatic Arthritis Pain (VAS) scores vs changes in ESIF component scores werecalculated using LOCF data.

Results: Efficacy was analyzed in 72 patients (PBO, n ¼ 23; ADA, n ¼ 49). Percentchanges in ESIF component scores from baseline to wk 16 for PBO vs ADA-treatedpatients were: -19.2% vs -38.0% (erythema), -13.4% vs -36.9% (scaling), -17.2% vs-36.2% (induration), and -52.0% vs -52.3% (fissuring); changes from baseline to wk 28were -27.6% vs -43.7% (erythema), -17.0% vs -45.0% (scaling), -21.8% vs -43.1%(induration), and -49.1% vs -54.5% (fissuring). Percentages of PBO- vs ADA-treatedpatients achieving change in DLQI[5 was 30.4% vs 36.7% (wk 16) and 26.1% vs38.8% (wk 28). Significantly more ADA- vs PBO-treated patients achieved a changefrom baseline in ESIF score [4.98 at wk 28 (71.4% vs 30.4%), but not at wk 16.Moderate to strong correlations were observed between changes from baseline inPHQ-9, hfPGA, VAS, and DLQI scores with ESIF scores and its components at wks 16and 28.

Conclusion: ADA treatment for h/f psoriasis during a 16 week placebo-controlledstudy resulted in clinical improvements in ESIF component scores that are directlycorrelated with improvements in patients’ quality of life.

cial support: 100% sponsored by Abbott.

Commer

Clobetasol propionate 0.05% spray is efficacious for the treatment ofmoderate to severe plaque psoriasis

(Poster reference number 5257)Alan Menter, MD, Texas Dermatology Associates, Baylor Research Institute,Dallas, TX, United States

Clobetasol propionate (CP) is a class 1 topical corticosteroid available in severalformulations including a 0.05% spray formulation (CP spray) that is approved for useup to 4 weeks in patients with moderate to severe plaque psoriasis. In vehicle-controlled trials, significant improvement with CP spray was evident after 1 week,continued throughout 4 weeks of treatment, and was still evident in some patients 4weeks after completing treatment. In one study with patients of moderate to severeplaque psoriasis of the scalp (N ¼ 81), significantly more patients on CP sprayachieved a global severity scale rating of clear or almost clear compared to vehicle(85% vs 13%; P \ .001) at week 4. With CP spray twice daily for four weeks asmonotherapy (n ¼ 1254) or in combination with other topical or systemicantipsoriatic agents (add-on therapy, n ¼ 731) in a large observational trial,approximately 80% of patients experienced treatment success (global assessmentof improvement of clear [0], or almost clear [1] or improvement of $ 2 grades on a 7-point scale) with each therapy. Similarly, significantly more patients achieved anoverall disease severity rating of clear or almost clear with CP spray compared tocalcipotriene 0.005%/betamethasone dipropionate 0.064% ointment in a random-ized, open-label trial (N¼ 93) at week 4 (75% vs 45%; P¼.003). Collectively, resultsfrom these clinical trials indicate that CP spray is efficacious for the treatment ofmoderate to severe plaque psoriasis.

cial support: Galderma Laboratories, L.P.

Commer

J AM ACAD DERMATOL AB187