What is the typical presentation of Plaque Psoriasis in a primary care setting?

From the Guidelines

Plaque psoriasis typically presents in primary care as well-demarcated, erythematous plaques covered with silvery scales, most commonly affecting the extensor surfaces of elbows and knees, scalp, and lumbosacral area, and initial management should focus on topical therapies tailored to individual patient needs and preferences, as outlined in the guidelines of care for the management of psoriasis 1. The presentation of plaque psoriasis in primary care can vary depending on the individual patient, but common characteristics include lesion thickness, degree of erythema, and amount of scaling.

• The choice of vehicle for topical agents can significantly alter the use and penetration of the medication, and therefore alter the efficacy, with different vehicles indicated for different body sites, such as solutions, foams, shampoos, sprays, oils, gels, or other vehicles for hair-bearing areas including the scalp 1.
• Treatment should be tailored to meet individual patients’ needs, taking into account body location, characteristics of the psoriasis being treated, and patient preferences, with the goal of matching patient expectations with practical considerations 1.
• Topical agents, such as corticosteroids and vitamin D analogs, are generally effective and safe for mild to moderate disease, but may not be sufficient for extensive disease or recalcitrant lesions, and may require adjunctive therapy with ultraviolet light or systemic medications 1.
• Patient education is crucial, emphasizing the chronic, relapsing nature of psoriasis, and identifying triggers such as stress, skin trauma, and certain medications, to help patients manage their condition and improve their quality of life 1.

From the FDA Drug Label

The safety and efficacy of Enbrel were assessed in two randomized, double-blind, placebo-controlled studies in adults with chronic stable PsO involving ≥ 10% of the body surface area, a minimum Psoriasis Area and Severity Index (PASI) score of 10 and who had received or were candidates for systemic antipsoriatic therapy or phototherapy Patients with guttate, erythrodermic, or pustular psoriasis and patients with severe infections within 4 weeks of screening were excluded from study. The PASI is a composite score that takes into consideration both the fraction of body surface area affected and the nature and severity of psoriatic changes within the affected regions (induration, erythema and scaling) The sPGA is a 6-category scale ranging from "5 = severe" to "0 = none" indicating the physician's overall assessment of the PsO severity focusing on induration, erythema and scaling.

The presentation of Plaque Psoriasis in primary care can be assessed using the Psoriasis Area and Severity Index (PASI) score and the Static Physician Global Assessment (sPGA).

• The PASI score is a composite score that considers the fraction of body surface area affected and the nature and severity of psoriatic changes.
• The sPGA is a 6-category scale that assesses the physician's overall evaluation of PsO severity, focusing on induration, erythema, and scaling. Key points to consider in primary care include:
• Body surface area involvement: ≥ 10% of the body surface area
• PASI score: a minimum score of 10
• sPGA classification: ranging from "5 = severe" to "0 = none"
• Types of psoriasis: plaque psoriasis, excluding guttate, erythrodermic, or pustular psoriasis 2

From the Research

Presentation of Plaque Psoriasis in Primary Care

The presentation of plaque psoriasis in primary care involves the use of various topical treatments, including corticosteroids, vitamin D analogues, topical retinoids, and calcineurin inhibitors 3.

Topical Treatments

• Corticosteroids are commonly used to treat mild-to-moderate plaque psoriasis, with potent and superpotent corticosteroids providing significant improvement within 2 weeks 3.
• Vitamin D analogues, such as calcipotriol, are also effective in treating plaque psoriasis, particularly when combined with corticosteroids 4, 5.
• The fixed combination of calcipotriol and betamethasone dipropionate is a popular treatment option, offering improved efficacy and safety compared to monotherapies 4, 5, 6.

Treatment Modalities

• Topical corticosteroids can be used as a maintenance treatment to prolong remission in plaque psoriasis 7.
• The use of occlusion dressing can provide additional benefit in treating plaque psoriasis 7.
• The choice of formulation, potency, and application frequency can vary, but expert opinion recommends a once-daily regimen for optimal patient adherence 6.

Clinical Evidence

• Numerous studies have demonstrated the efficacy and safety of topical treatments for plaque psoriasis, including randomized controlled trials and systematic reviews 3, 4, 5, 7, 6.
• American and European guidelines recommend the calcipotriol/betamethasone dipropionate fixed combination as a first-line topical treatment for mild to moderate plaque psoriasis of the body and scalp 6.