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LEARNING OBJECTIVES

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After completing this case study, students should be able to:

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  • Describe the pathophysiology and clinical presentation of plaque psoriasis.

  • Discuss the appropriate use of topical, photochemical, and systemic treatment modalities including biologic response modifiers (BRMs) for psoriasis, based on disease severity.

  • Compare the efficacy and adverse effects of systemic therapies for psoriasis, including first-line standard therapies (methotrexate, acitretin, cyclosporine), second-line therapies (azathioprine, hydroxyurea, sulfasalazine), and the BRMs (alefacept, adalimumab, etanercept, infliximab, and ustekinumab).

  • Select appropriate therapeutic regimens for patients with plaque psoriasis based on disease severity and patient-specific considerations such as organ dysfunction.

  • Educate patients with psoriasis about proper use of pharmacotherapeutic treatments, potential adverse effects, and necessary precautions.

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PATIENT PRESENTATION

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Chief Complaint

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“Nothing is helping my psoriasis.”

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HPI

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Gerald Kent is a 50-year-old man with a 25+ year history of psoriasis who presented to the outpatient dermatology clinic 2 days ago with another flare-up of his psoriasis. He was admitted to the inpatient dermatology service for a severe flare-up of plaque psoriasis involving his arms, legs, elbows, knees, palms, abdomen, back, and scalp (Fig. 111-1).

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FIGURE 111-1.

Example of severe plaque psoriasis involving the lower extremities in a male patient. (Photo courtesy of Wayne P. Gulliver, MD.)

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He was diagnosed with plaque psoriasis at age 23. He initially responded to topical therapy with medium-potency topical corticosteroids, later to calcipotriol. He subsequently required photo-chemotherapy using psoralens with UVA phototherapy (PUVA) to control his condition. PUVA eventually became ineffective, and about 10 years ago, he was started on oral methotrexate 5 mg once weekly. Dosage escalations kept his condition under fairly good control for about 5 years. Flare-ups during that period were initially managed with SCAT (short-contact anthralin therapy), but they eventually became more frequent and lesions were more widespread despite increasing the methotrexate dose. A liver biopsy performed about 5 years ago showed no evidence of fibrosis, hepatitis, or cirrhosis.

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After requiring two SCAT treatments in a 4-month period, along with methotrexate 25 mg once weekly orally (given as two doses of 12.5 mg 12 hours apart), a change in therapy was considered necessary at that time. Because he was receiving maximum recommended methotrexate doses and had already reached a lifetime cumulative methotrexate dose of 2.2 grams, he was changed to a cyclic regimen of cyclosporine microemulsion (Neoral) 75 mg twice daily for 3 months, followed by acitretin (Soriatane) 25 mg once daily with dinner for 3 months, and repeat. He found the acitretin drying, so after 6 months he was changed to his current regimen of only cyclosporine microemulsion 75 mg twice daily. Flare-ups had become infrequent and were again successfully managed by SCAT for over a year. However, in the last 6 months, he has already ...

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