Pre-Treatment Workup for Severe Psoriasis in a 35-Year-Old Healthy Patient
Before initiating systemic therapy for severe psoriasis in a 35-year-old healthy patient, a comprehensive laboratory and clinical assessment must be performed based on the specific treatment being considered. 1, 2
General Pre-Treatment Assessment
- Complete history and physical examination, with special attention to skin lesions not typical for psoriasis (which should be biopsied before starting treatment) 1
- Assessment of disease severity using objective measures (body surface area, PASI) and subjective impact (DLQI) 2, 3
- Screening for comorbidities including psoriatic arthritis, cardiovascular risk factors, and mental health disorders 4
Treatment-Specific Workup
For PUVA (First-line systemic therapy)
- Liver function tests 1
- Eye examination to rule out cataracts 1
- Assessment for history of skin cancer or previous UV/radiation therapy 1
- Minimum phototoxic dose determination 1
For Methotrexate
- Full blood count 1
- Liver function tests 1
- Serum creatinine measurement 1
- Liver biopsy consideration before starting therapy 1
- Eye examination for cataracts 1
- Assessment of pregnancy status/contraception needs 1
- Screening for drug interactions (alcohol, NSAIDs, salicylates, etc.) 1
For Etretinate/Retinoids
- Full blood count 1
- Serum lipids 1
- Liver function tests 1
- Pregnancy test and contraception counseling (especially important due to 2-year teratogenic potential after discontinuation) 1
For Cyclosporine
- Blood pressure measurements (on at least two occasions) 5
- Serum creatinine (on two occasions) 5
- BUN 5
- CBC 5
- Serum magnesium, potassium, uric acid, and lipids 5
- Evaluation for occult infection 5
- Assessment for history of malignancy 5
- Biopsy of skin lesions not typical for psoriasis 5
For Biologics (newer options)
- Tuberculosis screening 4
- Hepatitis B and C serology 4
- HIV testing 4
- Complete blood count 4
- Liver function tests 4
- Assessment for active infections 4
Important Considerations and Pitfalls
- All systemic agents are absolutely contraindicated in pregnancy - strict contraception counseling is essential 1
- Avoid combination of systemic agents due to additive toxicity unless absolutely necessary 1, 6
- Systemic corticosteroids should generally be avoided as they can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or unstable psoriasis upon discontinuation 6
- Patients should be informed about potential drug interactions specific to their treatment 1, 5
- For patients receiving methotrexate or cyclosporine, written instructions about potential drug interactions should be provided to both the patient and their primary care physician 1, 5
Follow-up Monitoring
- For methotrexate: Weekly monitoring of full blood count, liver function tests, and serum creatinine initially, then every 1-2 months if stable 1
- For cyclosporine: Blood pressure and serum creatinine every 2 weeks for first 3 months, then monthly if stable 5
- Adjust monitoring frequency based on clinical response and side effects 5