Overview of Psoriasis

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Overview of Psoriasis

• Adam O. Goldstein, MD, MPH
• Associate Professor
• UNC Department of Family Medicine
• Email aog_at_med.unc.edu

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Objectives

• 1. Differentiate psoriasis types
• 2. Form differential dx
• 3. Review tx guidelines
• 4. Review new products
• 5. Learn 2 additional patient education pearls

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I am silvery, scaly. Puddles of flakes form
wherever I rest my flesh.... Lusty, though we are
loathsome to love. Keen-sighted, though we hate
to look upon ourselves. The name of the disease,
spiritually speaking, is.
Humiliation
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Psoriasis Incidence

• 2-3 U.S. (6.4 million)
• 200,000 new cases/year
• 300,000 have gt20 BSA
• Median age dx 30
• Two peaks 16-22, 57-60
• Costs 2 billion/year
• Mean per patient costs 3000

(Javitz, J Am Acad Dermatol, 2002)
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Psoriasis Quality of Life

• 50 seek treatment
• As debilitating as other chronic illnesses
• gt rates depression alcohol abuse
• (Sharma, J Dermatol, 2001)

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Case

• Bob- 34 yo insurance executive
• history of psoriasis for 8 years
• scalp, elbows, knees and trunk
• Got topical steroid (Psorcon E, 60 gms) from
  dermatologist 3 years ago
• helped with itching
• Wants a renewal and wonders if needs to see a
  dermatologist
• You estimate 5-10 involvement of skin with
  plaque psoriasis

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Case

• What is your treatment plan?
• Do you refer him to a dermatologist?

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Psoriasis

• Definition
• Chronic, remitting and relapsing
• Scaly and inflammatory
• Genetically influenced

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Psoriasis

• Morphology Circumscribed, thickened, plaques
  with secondary erythema and thick, silvery scales

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Psoriasis Pathogenesis

• Hyperproliferation of the epidermis
• Normal skin cell matures in 28-30 days
• Psoriatic skin cell matures in 3-6 days

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Psoriasis Types

• Plaque-typeLocalized or
  Generalized
• PustularLocalized or Generalized

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Psoriasis

• Arthritis associated (5-7)

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Psoriasis Distribution

• (From Pardasan AG, et al. Am Fam Physician 2000)

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Psoriasis Distribution

• Extensor

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Psoriasis Distribution

• Extensor

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Psoriasis Distribution

• Nails

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Psoriasis Distribution

• Genitalia

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Psoriasis Distribution

• Hands feet

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Psoriasis Distribution

• Pustular

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Psoriasis Distribution

• Intertriginous/inverse- armpits, groin, under
  breasts (less thick silveryscale)

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Psoriasis Distribution

• Guttate-small red dots (Gutta drops)
• Appears suddenly after a strep, URI, other
  infection, stress, medications

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Psoriasis Guttate

• Appears after strep, URI, stress,
  medica-tions

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Psoriasis Distribution

• Erythrodermic
• Widespread erythema, itching, pain, edema

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Psoriasis Distribution

• Sites of trauma (Koebners phenomenon)

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Psoriasis Diagnosis

• Early on, may look like other diseases
• Bx may be necessary

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Psoriasis Differential Diagnosis

• Drug eruption

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Psoriasis Differential Diagnosis

• secondary syphilis

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Psoriasis Differential Diagnosis

• Seborrhea Finer scale, central facial, scalp,
  central chest Greasier Sebopsoriasis

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Psoriasis Differential Diagnosis

• dermatophyte infections (Tinea)
• KOH negative
• scale not as thick or silvery

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Psoriasis Differential Dx

• intertriginous diaper dermatitis/candidiasis
• satellite pustules, beefy red, maceration KOH
  positive for yeast in candidiasis may coexist

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Psoriasis Differential Diagnosis

• Eczema
• Neuro-dermatitis/
  lichen simplex
  chronicus

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Psoriasis Differential Dx

• lichen planus

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Psoriasis Differential Diagnosis

• lupus erythematosus

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Psoriasis Differential Diagnosis

• pityriasis rosea

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Psoriasis Differential Diagnosis

• Cutaneous T-cell lymphoma

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Psoriasis Principals of Treatment

• Individualize treatment based on
• self-image, symptoms, interference with social
  interactions, expectations scientific evidence
• Patient education Control, not cure
• Pearl
• Combine products for better long-term control and
  fewer SEs

(Rees, J Am Acad Dermatol, 2003 )
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Psoriasis Treatment

• Flares
• skin injury (including dryness, scratching)
• sunburn
• infections (strep, HIV)
• psychological stress
• medications

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Psoriasis Treatment

• Medications linked to psoriatic flares
• Lithium
• Beta blockers
• ACE inhibitors
• Antimalarials
• Indomethacin

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Psoriasis Pearl

• Avoid systemic corticosteroids

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Psoriasis Treatment

• lt5 sunlight topical tx
• 5-20 sunlight topical tx /- systemic
• gt20 systemic tx /- light therapy

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Psoriasis Treatment

• Sunlight

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Evidence-based medicine

• No good evidence that non-drug txs work
• Topical txs effective in short-term (few
  comparative RCTs)
• RCTs show UVB and PUVA effective short/long term
  (long term risk PUVA-SCCa)
• Cyclosporin clears short term but toxic

(BMJ, Clinical Evidence 2001)
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Psoriasis lt 20 BSATopical Therapies

• 1. Emollients
• 2. Keratolytic agents
• 3. Topical steroids
• 4. Calcipotriene
• 5. Tazarotene gel
• 6. Topical calcineurin inhibitors
• 7. Anthralin
• 8. Coal tar
• ( BMJ 2001)

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1. Emollient cleansers and lotions/cream

• Mild cleansers
• Moisturizers

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2. Keratolytic Agents

• WHEN THE SCALE IS REALLY THICK
• Scalp P S liquid
• Body 2-10 salicylic
  acid qd- bid

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3. Topical Corticosteroids

• Never treated-
• start medium potency
• follow up in 2 weeks
• Previously treated
• start high potency
• 2-4 weeks, then taper
• Always use lower potencies on face and
  intertriginous areas

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3. Topical Corticosteroids

• Creams most body parts
• Lotions/mousse hairy areas
• Ultrapotent/potent BID 2-3 weeks to thick lesions
• Taper to weekend use only or
• Taper to Class III for maintenance to avoid
  atrophy/striae
• Educate on
• tolerance, signs of atrophy, tapering
  relapse
• If topical steroids insufficient
• Steroids occlusion (plastic wrap QHS- if no
  atrophy)
• Steroids calcipotriene cream/ointment or
  tazarotene gel
• Coal tar products and/or Anthralin
• (Tristani-Firouzi, Cutis, 1998)

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Intralesional injections

• Isolated recalcitrant lesions
• TAC 3-10mg/cc
• in NS to plaques lt 3 cm

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4. Calcipotriene 0.005 (cream, ointment,
solution)

• Calcipotriene (Dovonex)
• simulates differentiation
• inhibits proliferation
• gt effective as steroids, tar, anthralin
• gt irritation than steroids
• Use cautiously if renal or calcium-related
  conditions, especially (lt 60 gm/week)
• Use gt 4 wks to determine effectiveness

(BMJ 2001)
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4. Calcipotriene 0.005

• Use with potent topical corticosteroid
  (halobetasol) BID x 2-4 weeks
• less potent topical corticosteroids for facial or
  groin use
• may apply simultaneously
• Continue calcipotriene use BID and taper
  corticosteroid use to weekends only
• Helps prevent rebound flares
• Helps avoid atrophy
• Taper off steroid first, then calcipotriene
• (Koo, Skin Aging 2002)

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5. Tazarotene Topical Gel/ Cream

• Tazarotene (Tazorac)
• Mechanism of action not well defined
• Vitamin A derived
• Inhibits cornified envelope formation
• Suppresses inflammation in the epidermis

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5. Tazarotene Topical Gel (0.05-0.1 )

• Use with medium- high potency topical steroids
  QD-BID and Tazarotene gel QHS
• (63 post-treat flare with steroids alone
  vs 14 steroids tazarotene)
• After 2-4 weeks, gradually decrease potent
  topical steroids to weekend use only
• Continue or slowly taper tazarotene gel
• (Koo, J Am Acad Dermatol 2000)

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5. Tazarotene Topical Gel/Cream

• Educate
• apply very small amount to center of plaques
• initial increased erythema and scaling
• confine application to plaques
• do not chase erythema
• Pregnancy Do not use
• Use for gt 4-6 weeks before discontinuing

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6. Steroid Sparing

• Topical calcineurin inhibitors
• Tacrolimus ointment Pimecrolimus cream
• Facial and intertriginous areas
• (Freeman, J Am Acad Dermatol, 2003)

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Tacrolimus ointment Pimecrolimus cream

• Safety?
• In 2005, FDA warnings about possible link between
  topical calcineurin inhibitors and cancer (? inc
  risk of lymphoma and skin cancers)
• No definite causal relationship     
• FDA recommends these agents only as second-line
  therapy in patients unresponsive to or intolerant
  of other treatments
• Use for short periods of time and minimum amount
• Avoid continuous use

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7. Anthralin

• Antimitotic reducing agent
• Short-contact therapy
• Creams
• Drithocreme 0.1,0.25,0.5, 1
• Micanol 1
  
• Psoriatec 1
  
• Ointment
• Anthraderm 0.1,0.25,0.5, 1
• Micanol does not stain skin if rinsed with cool
  to lukewarm water
• Use daily until skin is smooth (2-4 weeks)
• (Koo, Skin Aging, 2002)

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8. Coal Tar

• Useful as an antimitotic agent
• Folliculitis, Staining, Photosensitizer, Smell
• Dozens of products

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Algorithm for Treatment of Localized Psoriasis
(From Pardasan AG, et al. Am Fam Physician 2000)
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Scalp Psoriasis

• Medicated shampoos 5-10 minutes daily
• keratolytics (salicylic acid)
• coal tar based
• Topical steroids in lotion or solution form
• Class I to II lotion or scalp
  application, tapering to
• Class III lotion, solution, oil
• Calcipotriene solution
• Use qhs in addition to topical corticosteroids

(Van der Vleuten, Drugs, 2001)
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Scalp Psoriasis

• Topical corticosteroids in mousse
• BMV foam (Luxiq)-may be used on nonfacial/genital
  areas
• Used qd-bid, less often with improvement
• Foam superior efficacy preferred by patients
  compared with lotion

(Franz, Int J Dermatol 1999)
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Genital Psoriasis

• Mid potency steroids can be use cautiously and
  for limited time
• short-term mometasone
• Reduce to low-potency creams asap
• desonide cream
• Consider compounding hydrocortisone 2.5 cream
  and ketoconazole (Nizoral) cream ,
• Cautious use of calcipotriene
• Cautious use of anthralin
• (Lebwoh, J Am Acad Dermatol 2001)

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Nail Psoriasis

• topical fluorouracil qhs
• tazarotene gel 0.1 qhs
• class I-II topical steroids
• posterior nailfold intralesional Kenalog 5-10
  mg/cc
• methotrexate

(Van Laborde, Dermatol Clin, 2000)
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Topical Treatments

• GIVE ENOUGH WITH REFILLS!
• BE AWARE OF !

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Generalized plaque-type psoriasis gt20 BSA

• Ultraviolet light UVB or PUVA (oxpsoralens
  photosensitizer UVA)
• Methotrexate
• Retinoids Acitretin/ Etretinate
• Sulfasalazine
• Cylclosporine

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Ultraviolet light UVB

• Indications
• guttate psoriasis
• gt20 BSA involved
• unresponsive to topical therapies
• Most effective wavelength of light for psoriasis
  (280-320 nm)
• narrow band UVB (new)
• not found in high enough concentrations in
  tanning salons
• natural sunlight

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Ultraviolet light UVB

• Risks burns, especially corneal, conjunctivitis
  (Face can be shielded)
• Very little toxicity involved
• Home light therapy
• Eximer laser

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Ultraviolet light PUVA

• Indications
• severe or incapacitating psoriasis
• previous failure of conventional topical therapy
• previous failure of UVB therapy
• rapid relapse after the above forms of therapy
• Must be administered in dermatologist office

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Ultraviolet light PUVA

• Contraindications
• photosensitive diseases
• photosensitive drugs
• previous or present skin cancers
• previous x-ray therapy to the skin
• cataracts
• pregnancy

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Ultraviolet light PUVA

• Increased risk of squamous cell carcinoma
• Possible increased risk of melanoma
  (controversial)
• Photoaging

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Methotrexate

• Indications
• psoriatic erythroderma
• acute pustular psoriasis
• localized pustular psoriasis
• psoriatic arthritis
• extensive psoriasis unresponsive to other, less
  toxic therapies
• psoriasis in areas preventing the individual from
  obtaining gainful employment
• psoriasis that is psychologically disabling

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Methotrexate

• Contraindications
• pregnancy
• history of significant liver disease
• excessive alcohol intake
• abnormal liver function
• poor renal function
• leukopenia
• active peptic ulcer
• active, severe infectious disease
• unreliable patient

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Methotrexate

• Test dose 2.5-5.0 mg once
• Dosage 10-25 mg 1X/Week
• Baseline labs (cbc w/platelets, urinalysis, BUN,
  creatinine, liver functions, CXR)
• Ongoing
• liver biopsy (0.5-1.5 grams)
• wbc and PLT q wk x 4 weeks 6 days after last
  dose
• Hct, liver functions, urinalysis, serum
  creatinine every 3 months, at least 6 days after
  last dose
• Folic Acid 1-5 mg/day for nausea

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Acitretin (Soriatane)

• New retinoid with shorter half-life than
  etretinate
• 10, 25 mg capsules
• Particularly useful in combination with light
  therapy
• Many potential side effects
• hepatotoxicity
• elevation of triglycerides
• dry eyes
• hyperostosis
• teratogenic

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Biologics

• Alefacet Amevive
• Efalizumab Raptiva
• Etanercept Enbrel
• Infliximab Remicade
• ximab chimeric monoclonal antibody
• zumab humized monoclonal antibody
• umab human monoclonal antibody
• cept receptor-antibody fusion protein

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Emerging Therapies

• Oral Pimecrolimus

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Alternative Therapies

• Fish oil
• Aloe vera
• Oral Vit. D
• Stress reduction

• Lifestyle change
• Antistrep tx
• Thermal bath
• Acupuncture

(Guyette, Clin Fam Pract, 2002)
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Alternative Therapies
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Alternative Therapies
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Case

• Treatment plan

• Use moisturizer cream sunlight daily
• SCALP
• Medicated shampoo
• BMV foam (Luxiq) BID for 7 days
• Calcipotriene solution qhs
• BODY- Flexural
• TAC 0.1 qd x seven days, followed by
  
• H/C 2.5 qd prn
• Calcipotriene cream qd
• BODY- rest
• 5 salicylic acid 1x/day thick areas 2 weeks
• Fluocinonide cream 0.05 BID
• See again in 2 weeks
• Tazarotene gel/cream if stubborn plaques
• or steroid dependent
  
• Anthralin perhaps stubborn areas

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Psoriasis Patient Education

• National Psoriasis Foundation, 6600 S. W. 92nd
  Avenue, Suite 300, Portland, OR 97223,
  503-244-7404, Fax. [phone]
• http//www.psoriasis.org/
• Patient ed brochure
• http//www.aafp.org/afp/20000201/20000201d.html
• Comprehensive WEB listing
• http//www.edae.gr/psoriasis.html

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Bibliography

• Bruner CR, et al. A systematic review of adverse
  effects associated with topical treatments for
  psoriasis. Dermatol Online J 2003 9(1) 2.
• Lebwohl MG, Tan MH, Meador SL, Singer G. Limited
  application of fluticasone proprionate ointment,
  0.005 in patients with psoriasis of the face and
  intertriginous area. J Am Acad Dermatol 2001
  44 77-82.
• Koo JY, Lowe NJ, Lew-Kaya DA, et al. Tazarotene
  plus UVB phototherapy in the treatment of
  psoriasis. J Am Acad Dermatol 2000 43 821-8.
• Tausk F, Whitmore SE. A pilot study of hypnosis
  in the treatment of patients with psoriasis.
  Psychotherapy Psychosomatics 1999 68 221-5.
• Tristani-Firouzi P, Krueger GG. Efficacy and
  safety of treatment modalities for psoriasis.
  Cutis 1998 61S 11-21.
• Jerner B, Skogh M, Vahlquist A. A controlled
  trial of acupuncture in psoriasis no convincing
  effect. Acta Dermato-Venereol 1997 77 154-6.
• Syed TA, Ahmad SA, Holt AH, et al. Management of
  psoriasis with Aloe vera extract in a hydrophilic
  cream a placebo-controlled, double-blind study.
  Trop Med Internat Health 1996 1 505-9.
• American Academy of Dermatology. Committee on
  Guidelines of Care, Task Force on Psoriasis.
  Guidelines of care for psoriasis. J Am Acad
  Dermatol 1993 28 632-7.

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• Gaston L, Crombez JC, Lassonde M,
  Bernier-Buzzanga J, Hodgins S. Psychological
  stress and psoriasis experimental and
  prospective correlational studies. Acta
  Dermato-Venereol 1991 156S 37-43.
• Fleischer AB Jr, Feldman SR, Rapp SR, et al.
  Alternative therapies commonly used within a
  population of patients with psoriasis. Cutis
  1996 58 216-20.
• Federman DG, Froelich CW, Kirsner RS. Topical
  psoriasis therapy. Amer Fam Physician 1999 59
  957-62, 964.
• Roenigk HH Jr, Auerbach R, Maibach H, Weinstein
  G, Lebwohl M. Methotrexate in psoriasis
  consensus conference. J Am Acad Dermatol 1998
  38 478-85.
• Owen CM, Chalmers RJG, O'Sullivan T, Griffiths
  CEM. Antistreptococcal interventions for guttate
  and chronicplaque psoriasis. Cochrane Database of
  Systematic Reviews. Issue 1, 2001.
• Pardasan AG, Feldman SR, Clark AR. Treatment of
  Psoriasis An Algorithm-Based Approach for
  Primary Care Physicians. Am Fam Physician 2000
  61725-733.
• Sharma N, Koranne RV, Singh RK. Psychiatric
  morbidity in psoriasis and vitiligo a
  comparative study. J Dermatol 2001 28 419-23.
• Koo JY, Nguyen KD. Treating psoriasis patients a
  topical therapy update. Skin and Aging 10 35-39.
• Van der Vleuten CJ. Management of scalp
  psoriasis guidelines for corticosteroid use in
  combination treatment. Drugs 2001 61(11)
  1593-8.
• Schon MP, Boehncke WH. Psoriasis. N Engl J Med
  2005 352 1899-912 .