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Translating the 2019 AAD-NPF Guidelines of Care for Psoriasis With Attention to Comorbidities

Cutis. 2021 August;108(2S): | doi:10.12788/cutis.0309
August 19, 2021|Cutis
Vipawee S. Chat, MD;Shelley K. Uppal, MD;Donovan G. Kearns, MD;George Han, MD, PhD;Jashin J. Wu, MD
Author and Disclosure Information

 

Dr. Chat is from Medical College of Georgia, Augusta University. Dr. Uppal is from Albany Medical College, New York. Dr. Kearns is from Loma Linda University School of Medicine, California. Dr. Han is from the Department of Dermatology, Zucker School of Medicine at Hofstra/Northwell,

New Hyde Park, New York. Dr. Wu is from Dermatology Research and Education Foundation, Irvine, California.

Drs. Chat, Uppal, and Kearns report no conflict of interest. Dr. Han is or has been an investigator, consultant/advisor, or speaker for AbbVie, Athenex, Boehringer Ingelheim, Bond Avillion, Bristol-Myers Squibb, Celgene Corporation, Dermavant, Eli Lilly, Janssen, LEO Pharma, MC2, Novartis, Ortho Dermatologics, PellePharm, Pfizer, Regeneron, Sanofi/Genzyme, SUN Pharmaceutical, and UCB. Dr. Wu is or has been an investigator, consultant, or speaker for AbbVie, Almirall, Amgen, Arcutis, Aristea Therapeutics, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Dr. Reddy’s Laboratories, Eli Lilly, Galderma, Janssen, LEO Pharma, Mindera, Novartis, Regeneron, Sanofi Genzyme, Solius, Sun Pharmaceutical, UCB, and Zerigo Health.

The eTable is available in the Appendix online at www.mdedge.com/dermatology.

Correspondence: Jashin J. Wu, MD (jashinwu@hotmail.com).

In April 2019, the American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF) released a set of guidelines regarding the management of psoriasis with a focus on its extracutaneous manifestations—comorbidities, mental health, psychosocial wellness, and quality of life (QOL). These guidelines provide the most up-to-date evidence on the screening and treatment recommendations for these disease comorbidities. The purpose of this review is to present the recommendations in a form that can be easily applied in clinical practice.

Practice Points

  • Educating patients about psoriasis and its extracutaneous manifestations, available treatment options, and the impact of lifestyle choices is advised to maximize their patient’s disease awareness and to promote a collaborative physician-patient partnership.
  • Physicians are strongly recommended to screen patients with psoriasis for the presence of disease comorbidities to ensure comprehensive management of their disease.
  • Managing psoriasis as a multisystem inflammatory disorder requires the combined effort of dermatologists and other specialists to prevent and treat disease comorbidities and enhance patients’ quality of life.

Malignancy

Psoriasis patients aged 0 to 79 years have a greater overall risk for malignancy compared with patients without psoriasis.32 Patients with psoriasis have an increased risk for respiratory tract cancer, upper aerodigestive tract cancer, urinary tract cancer, and non-Hodgkin lymphoma.33 A mild association exists between PsA and lymphoma, nonmelanoma skin cancer (NMSC), and lung cancer.34 More severe psoriasis is associated with greater risk for lymphoma and NMSC. Dermatologists are recommended to educate patients on their risk for certain malignancies and to refer patients to specialists upon suspicion of malignancy.

Risk for malignancy has been shown to be affected by psoriasis treatments. Patients treated with UVB have reduced overall cancer rates for all age groups (hazard ratio, 0.52; P=.3), while those treated with psoralen plus UVA have an increased incidence of squamous cell carcinoma.32,33 Adalimumab was correlated with increased risk for NMSC in patients with psoriasis but did not have an increased risk for all cancers collectively when used for various immune-mediated inflammatory diseases.35 In contrast, a meta-analysis of randomized clinical trials found no association with TNF inhibitor use and NMSC.36 Ustekinumab had no association with malignancy.37 Treatment history should be elucidated because of higher rates of squamous cell carcinoma in patients with prior psoralen plus UVA, cyclosporine, or methotrexate use.33 To address malignancy risk, patients with psoriasis should undergo regular screenings for skin cancer and follow national guidelines for age-appropriate cancer screenings.

Lifestyle Choices and QOL

A crucial aspect of successful psoriasis management is patient education. The strongest recommendations support lifestyle changes, such as smoking cessation and limitation of alcohol use. A tactful discussion regarding substance use, work productivity, interpersonal relationships, and sexual function can address substantial effects of psoriasis on QOL so that support and resources can be provided.

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Final Thoughts

Management of psoriasis is multifaceted and involves screening, education, monitoring, and collaboration with PCPs and specialists. Regular follow-up with a dermatologist and PCP is strongly recommended for patients with psoriasis given the systemic nature of the disease. The 2019 AAD-NPF recommendations provide important information for dermatologists to coordinate care for complicated psoriasis cases, but clinical judgment is paramount when making medical decisions. The consideration of comorbidities is critical for developing a comprehensive treatment approach, and this approach will lead to better health outcomes and improved QOL for patients with psoriasis.

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