review articles

PSORIASIS AND ANESTHETIC CONSIDERATIONS

Amir Baluch*, Arushi Kak **, Omar Saleh**,
Lindsey Lonadier***, Alan D Kaye*****

Introduction
Psoriasis is an inflammatory skin disease. It is the most common chronic disease of the skin,
often a debilitating dermatological ailment that affects up to 3 percent of the world’s population.
The disease exhibits the characteristics of a high epidermal turnover rate accompanied with
epidermal hyperplasia and accumulation. The dermal papillae and epidermis undergo hypertrophy
and form cutaneous lesions that develop thick, loosely adherent scales (chronic plaque psoriasis).
The epidemiology is due to complex genetics and the disease is known to erupt due to many
environmental factors including infection, bone marrow transplantation, stress, and malignancy1.
Lesions usually appear on the scalp, elbows, knees and the sacral region. In some cases, psoriasis
can spread throughout the entire integument including the oral mucosa, palms, soles and even
finger nails. Symptoms are cyclical, peaking usually during young adulthood (16 to 22 years of
age) and during older ages (57 to 60 years of age)2.

Genetics
Psoriasis has strong genetic ties. One study of 3,717 families identified the relationship of
psoriasis among patients and siblings3. The lifetime risk for developing psoriasis is 4% for an
individual if the parents of the individual do not have psoriasis. However, the risk increases to 28%
if one of the parents is afflicted and to 65% if both parents have psoriasis.
It is believed that genomic imprinting of the psoriasis gene passes the disease from parent
to child. Penetrance of psoriasis can be variable according to the sex of the carrier, and is much
higher if the carrier is the father4,5. The genetics of psoriasis exhibit characteristics of autosomal
dominant and recessive gene traits, and it is therefore difficult to pinpoint the underlying cause. It
is most likely that psoriasis expresses traits by 3 to 4 autosomal dominant genes while one gene
acts in a recessive manner. If two of the predisposed genes are expressed, there is an increased
likelihood for the development of psoriasis6. In simplified terms, early-onset psoriasis with severe
progression is associated with human leukocyte antigen (HLA) factors whereas the milder, late-
onset counterpart is not.

* MD, Senior Anesthesia Resident, Jackson Memorial Hospital/University of Miami, Miami, Florida.
** Sophomore Medical student, Howard University College of Medicine, Washington, DC.
*** Radiology Resident, University Hospital, Jackson, MS.
**** Research Associate, Department of Anesthesiology, Louisiana State University Health Science Center, New Orleans,
Louisiana.
***** MD, PhD, Professor and Chairman, Department of Anesthesiology, Louisiana State University Health Science Center,
New Orleans, Louisiana.
Address Correspondence to: Alan D Kaye, MD, PhD, DABPM, Professor and Chairman. Department of Anesthesiology,
Professor, Department of Pharmacology, Louisiana State University School of Medicine, 1542 Tulane Ave, 6th floor-
Anesthesia, New Orleans, LA 70112. Tel: (504) 568-2319, Fax: (504) 568-2317, E-mail: [email protected]

621 M.E.J. ANESTH 20 (5), 2010

622 amir baluch et. al

Psoriasis has many patterns associated This examination can expose a wet surface which
with genetics which can best be appreciated by shows pinpoint bleeding, due to the upward growth of
understanding its relations to HLA factors. Different the dermal papillae with increased vasodilation. Some
HLA associations can determine many variant forms extracutaneous manifestations are exemplified in the
of psoriasis and also indicate other factors such as nails and include separation of the nail plate from the
time of onset and severity of the disease. For example, bed (onycholysis), dimpling, and pitting11.
pustular psoriasis has dissimilar HLA association from There are several risk factors associated with
psoriasis vulgaris. P. vulgaris is associated with HLA the onset of psoriasis. A recent study shows that there
A13 and A17, and this different association is one of is an association of psoriasis with smoking, obesity,
the factors that determine findings such as how pustular and infectious diseases. Clinical and immunological
psoriasis can arise at any age, even in childhood7, 8. HLA evidence supports streptococcal infection and the
associations can also be seen when examining PsA, subsequent development of psoriasis, mainly in young
which also shows evidence of heredity. Occurrence of people. There is an increased risk of psoriasis in
psoriasis increases by 8.3% for an individual if first patients with recent infectious disease, and the risk is
degree relatives have PsA9. Patients with PsA show greater within the first month after an upper respiratory
increased frequencies of HLA A26, B38, and DR410. tract infection, in particular among individuals aged 21
to 40 years12.
Clinical Presentation There is no specific diagnostic test for psoriasis,
Psoriasis is best observed as a disease that as it is partly genetic. A family history of predisposition
exhibits sharply demarcated erythematosquamous and knowledge of the presentation are important to the
lesions, which are in several forms and demonstrate diagnosis.
a variable cycle of growth and regression (Table 1).
Psoriatic lesions follow a distinct pattern, starting Pathogenesis
as small pinpoint papules, which in turn grow larger The pathogenesis includes a variety of
and develop into a polycyclic outline with sharp abnormalities that involve the epidermis, the stroma,
demarcations but with no change to the unaffected intracellular communication, the immune system, and
skin. Occasionally, psoriasis shows a white blanching numerous aspects of cutaneous inflammation. The
ring around the lesion. Macromorphical elements earliest stage begins with stromal changes. Later, an
include scaling, erythema and induration. The scaling inflammatory infiltrate is found. Finally, an increased
is silvery, and can be studied using a curette. Scratching recruitment of cycling epidermal cells is observable.
the scaling repetitively, removes the last membrane.

Table 1. Clinical Presentation of Psoriasis

• Chronic inflammation consisting of

erythematic papules and plaques

• Silver scaling

• Sharp demarcation of lesions

• Involvement of scalp, sacral areas, knees, elbows, fingers (psoriatic arthritis)

• Epidermal proliferation without differentiation

• Association with severe rheumatoid arthritis type lesions (psoriatic arthritis)

PSORIASIS AND ANESTHETIC CONSIDERATIONS
623

Systemic Factors based immunopathogenesis18. Experimental treatment

of psoriasis began in 1979, with a compound that acts
Direct evidence for involvement of systemic
on lymphocytes called cyclosporine19. The primary
factors in the development of psoriasis is provided by
action of CSA is to inhibit lymphokine release and
two observations: the response of the patient’s skin to
proliferation of T cells, which led many scientists to
injury and systemic factors that aggravate the condition.
believe that the T-cell is a key component of a psoriatic
The symptomless skin of a psoriatic patient responds
lesion. As aforementioned, the actual cause of psoriasis
with genesis of a new lesion at the site of trauma
still remains unknown, but an enhanced immune
known as the Koebner response. It is an all-or-none
response is now known to be an essential factor in the
phenomenon where either all or none of the injury sites
progression of the disease20.
on uninvolved skin will respond with psoriatic plaques.
The mechanism for this response can possibly be
explained via the release of proinflammatory cytokines, Variant Forms of Psoriasis
the unmasking of autontigens, or both13. In fact, some The term psoriasis encompasses a broad spectrum
treatments for psoriasis that have proinflammatory of diseases with different manifestations (see Table 2).
potential (e.g., anthralin and phototherapy) appear These diseases have many similarities, but must still
to trigger psoriasis if applied too aggressively - for be distinguished from each other given that they have
example, in high initial doses14. Aggravating factors different systemic effects and severities.
such as psychological stress, focal infections, and a
few medications also point to an underlying systemic Table 2
pathogenesis for psoriasis. Although many systemic Variant Forms Characteristics
abnormalities have been described, the extent to which of Psoriasis
Chronic Plaque Most common: scalp, sharp demarcations
the abnormalities determine the underlying cause of
the disease is unclear11. Other findings that show a Unstable Transition phase
systemic pathway include capillary abnormalities and Guttate Erythematosquamos papules, “droplets,”
involves trunk, spares palms and soles,
epidermal hyperplasia - two key features of psoriasis common in children
whose mechanisms are still unknown15. Pustular Macroscopic pustules, affects mucosal
membrane and oral cavity, general and
localized form
Abnormal intracellular communication
Erythrodermic Generalized erythema and scaling replaces
Abnormal intercellular communication is traditional plaques, systemic disregulation,
another identifying feature of psoriasis. Many of increased blood flow in plaques can lead to
high-output congestive heart failure
the molecules expressed in psoriatic plaques are
restricted or even absent in normal skin. SKALP
Differential Diagnosis
(skin-associated antileukoprotease) is expressed in
other hyperproliferative states and is also found in the There are several skin disorders that resemble
psoriatic patient16. The SKALP protein actually binds the clinical presentation of psoriasis based on
to proteases, especially elastase, the enzyme released macromorphology. One must be aware of the distinct
by neutrophils that enables penetration into the skin by traits of psoriasis that sets it apart from these other
collagen type IV degradation17. Other molecules have similar diseases, and that knowledge is usually
also been reported as increased in plaques, such as sufficient for an accurate diagnose (see Table 3).
TGF-α, calmodulin, epidermal growth factor receptor, Other diseases that resemble psoriasis and
IL-1α, IL-1β, IL-6, IL-8, GRO-α, -β, and -γ11. are best differentiated by the use of histopathology
include: Pityriasis lechenoides chronica, hypertrophic
Immunopathogenesis lichen planus and Bowen’s disease. In addition to using
While many of the factors that promote the histopathology, some conditions are best diagnosed
generation of psoriatic lesions still remain obscure, by obtaining cultures and using potassium hydroxide
compelling evidence suggests a primary T-lymphocyte (dermatophytic infections, candidiasis). Some diseases,
M.E.J. ANESTH 20 (5), 2010
624 amir baluch et. al

such as pre-malignancies, mycosis fungoides, and Treatment

premycotic eruptions are very difficult to differentiate The symptoms of psoriasis can be ameliorated
and may require multiple skin biopsies11. in a variety of ways that can include moderate doses
of UV light, tars, psoralen, anthralin, methotrexate,
Table 3
hydroxyurea and steroids27. There is no one standard
Differential Characteristics that differ from cure for psoriasis and treatments vary based on the
Diagnosis Psoriasis
Seborrheic - Erythema localizations on the scalp status of the disease. Both topical and systemic regimes
Dermatitis caused that can spread to the face are used. A wide array of antipsoriatic treatments is
by Pityrosporon - Yellowish scarring available that range from mild treatments with minimal
proliferation
side effects to drugs used to treat severe psoriasis
Pityriasis Rubra - “Islands” of unaffected skin
Pilaris surrounded by involved skin with severe adverse effects. Various combinations are
- Hyperkeratotic papules possible and the physician must individually design
- Yellowish scarring the treatment based on the patient’s individual case and
Eczema - Vesiculations
presentation of psoriasis.
Syphilis - Resembles guttate psoriasis (to
differentiate check serology) Table 4
Candidiasis - Combination of colarette scaling and
pustules Drugs that Common Examples
exacerbate
Psoriasis
Complicating Factors Antimalarials Chloroquine, Primaquine, Quinine,
Extended disease control of psoriasis is tough Sulfadoxine, Tetracyclines,
Mefloquine, Artemisinin,
to achieve due to difficulty in application of topical Halofantrine, Proguanil
medicines, hence leading to reduced compliance, as Non-Steroidal Indometacin, Aspirin, Ibuprofen,
well as a limit of the long-term use of many topical Anti-Inflammatory Naproxen
treatments due to safety issues21. The psoriatic condition Drugs

is further complicated by environmental, emotional, Lithium

and systemic factors. The underlying pathology can be Beta Adrenergic Acebutolol, Bisoprolol, Esmolol,
exacerbated by infections, alcohol, smoking, stress and Antagonists Propranolol, Atenolol, Labetalol,
Carvedilol, Metoprolol, and
various drugs. Nebivolol
It has been well documented that infections Systemic Prednisone, Prednisolone,
trigger psoriasis. For example, streptococcal infections Corticosteroids Methylprednisolone, Betamethasone,
Dexamethasone, Triamcinolone and
can trigger the disease and usually result in the guttate Hydrocortisone
form. Psoriasis can also be aggravated by upper
respiratory tract infections. A survey showed psoriasis
Topical Treatments
exacerbation in 50% of children with upper respiratory
While the severity of the psoriasis determines
tract infections22-24.
its treatment, approximately 70 to 80 percent of all
Other local triggering factors include: contact patients with psoriasis can be successfully treated
dermatitis and certain eczemas, irritant dermatitis, via topical treatments, while more severe cases
impetigo contagiosa, herpes zoster, mycotic infection, require a combination therapy of systemic drugs and
mechanical trauma and sunburn. There are many known phototherapy14. A variety of topical treatments have
drugs that can also aggravate the disease (see Table 4): been successful in the treatment of psoriasis. Patients
antimalarials, non-steroidal anti-inflammatory drugs, have responded favorably to the following topical
lithium, beta –adrenergic antagonists, and systemic treatments:
corticosteroids15,25,26. It has been reported that the skin Vitamin D3 analogues (calcipotriol and tacalcitol),
condition can even be triggered by emotional stress. corticosteroids, dithranol, phototherapy (UVB) and
PSORIASIS AND ANESTHETIC CONSIDERATIONS
625

photo (chemo) therapy (PUVA). biopsies. If methotrexate dosages are controlled and
Topical corticosteroids can be useful in managing patients are monitored properly, methotrexate is an
psoriasis, especially when used to soothe the irritation excellent drug where the benefits outweigh the risks
that psoriasis causes in the genital and flexure areas, an and it is still considered one of the most valuable
effect due to anti-inflammatory, immunosuppressive agents in psoriasis treatment.
and antimitogenic actions. Steroids regulate Topical and systemic retinoids can limit psoriasis
inflammation by binding to the DNA region called by enhancing retinoic acid cytoplasma levels. The
glucocorticoid responsive element (GRE)29. Another topical antipsoriatic retinoid, tazarotene, and the
effect of steroids is that they hamper the transcription systemic P-450 inhibitor liarazole both work in a similar
of cytokines30. Corticosteroids hinder inflammation fashion. Retinoids are classified as anti-inflammatory
by stopping vascular permeability, an effect that agents due to their influence on the arachidonic acid
can further inhibit problems such as dermal edema cascade and migration of PMNs. Acitretin is also used
and inflammatory cell movement within the skin. among these drugs, and is beneficial in hampering cell
Unfortunately, steroids must be given under close proliferation34.
observation because side effects may occur if the Cyclosporine A and S are cyclic peptides
corticosteroids bind to other steroid receptor sites and that are used to treat psoriasis by inhibiting certain
cause acne and hypertrichosis at the application site31. calcium dependent cellular processes such as the
Also, the side effects are proportional to the potency transcriptional activation of lymphokine genes (IL-2
of the application; high potency may be the source of in helper T cells that follows T cell receptor mediated
epidermal, dermal, vascular and systemic side effects11. signal transduction. Cyclosporine A is usually tried in
Phototherapy (UVB) and photo (chemo) therapy patients with severe psoriasis that have not responded
(PUVA) are long term treatment devices to manage to other treatments35. The medication is nephrotoxic
moderate to severe psoriasis. Psoriasis responds and can be detrimental to those with impaired kidney
favorably to photo chemotherapy that utilizes function and hypertension. Side effects are dose and
8-methoxypsoralen (8-MOP) plus UVA radiation duration related. It is advised that patients should not
(PUVA). UVB or PUVA are usually used in combination take the medication for more than 1 year. Although the
with other topical or systemic treatments11. drug is effective, its potency comes with adverse side
effects such as the aforementioned nephrotoxicity and
hypertension, malignancies, tumors and infections.
Systemic Treatments
A variety of systemic treatments are available
including methotrexate, retinoids and cyclosporine A New Drugs
and S. Some relatively new medications are available:
Methotrexate treats psoriasis and psoriatic efalizumab (Raptiva®), alefacept (Amevive®),
arthritis effectively. This folic acid antagonist is a etancercept (Enbrel®), and infliximab (Remicade®).
popular choice among patients and is one of the oldest Efalizumab is a humanized monoclonal antibody
systemic treatments for this ailment. In fact, this that inhibits T cell activation and is used to treat adults
drug improves psoriasis by 75% in 90% of patients. with moderate to severe chronic plaque psoriasis. Use
Up to 60% of psoriatic arthritis patients saw great and effectiveness can be seen based on the results
improvement while 30% experienced moderate of a clinical study involving 597 psoriatic patients.
improvement32. Even though methotrexate treats These patients were treated with efalizumab once a
psoriasis efficaciously, there has been a decline in its week and the trial resulted in a 75% improvement in
use due to its known liver toxicity and an increased the Psoriasis Area and Severity Index (PASI) over the
incidence of cirrhosis and fibrosis33. Even though the 12 week period. However, this improvement occurred
liver damage by methotrexate is not extremely severe, in only 22% of patients at 1 mg dosage, 28% with
patients using this drug should be followed by liver the 2 mg dosage and 5% in the placebo group. The
M.E.J. ANESTH 20 (5), 2010
626 amir baluch et. al

adverse side effects consist of initial reactions that are revealed an isomorphic all-or-none response, with
basically composed of mild constitutional symptoms approximately 25% of patients developing psoriatic
like headache, chills, fever, nausea and myalgia. The plaque at all injured sites40. It should also be noted that
psoriasis may worsen in 0.7% of patients, and can trauma to the dermis alone is not sufficient to elicit a
worsen when drug usage is discontinued. Moreover, response; the epidermis must also be injured41. Thus,
acute or chronic infection may develop. the anesthesiologist must protect the skin in the areas
In early 2003, the FDA approved alefacept, a of the psoriatic lesions. Tape should be used only in
drug that also inhibits T-cell activation and can reduce the most necessary cases, as even such a non-invasive
the count of memory T cells. Another treatment that step as tape-stripping has been reported to provoke a
may be approved soon for general psoriasis is the TNF- psoriatic lesion. An enhanced proliferative response
alpha inhibitor etanercept. This medication has been in the epidermis has been reported within 48 hours42
used to treat both rheumatoid and psoriatic arthritis and also in the late phase (6-9 hours)43. Intravenous
since 1998. Another TNF-alpha inhibitor is infliximab. catheters should be sutured in place or wrapped with
This drug was also a treatment for rheumatoid arthritis, web roll44.
similar to that of etanercept.
Pruritus induced by Neuraxial Opioids
Efalizumab (Raptiva), alefacept (Amevive) and
etancercept (Enbrel) are effective in about 30% of The onset of pruritus after the adminstration of
patients with moderate to severe psoriasis. Etanercept neuraxial opioids has been a longstanding adverse
has been widely used to treat rheumatoid arthritis effect with an incidence ranging from 0-100%45,46. This
and has a good safety rating. Currently, results of incidence of pruritus is lower in epidural opioids vs
comparative trials are not available36. spinal opioids (8% vs 46%), and the greatest incidence
has been shown when using neuraxial morphine47.
Opioid-induced pruritus is not only difficult to
Perioperative Anesthetic Considerations manage and extremely uncomfortable, but it also has
During the preoperative period, since chronic a poor response to histamine (H1) blockers and other
corticosteroid therapy is involved in the psoriatic conventional treatments. However, naloxone and
patient, stress-dose corticosteroids should be provided propofol are two drugs proven to be effective against
to those patients who are taking these agents. Physical opioid-induced pruritus48.
examination and laboratories should explore any
evidence of any acute infection or inflammation related Staph Aureus Complications
to psoriasis. Renal and liver function should be assessed Staphylococcus aureus is found in the lesions of
when immunosuppressants and/or methotrexate have 20 to 50 percent of patients with psoriasis49,50 although
been utilized in the psoriatic patient37. many may not exhibit any pyodermic symptoms. For
Intraoperatively, trauma, e.g. instrumentation comparative purposes, this bacterium is carried by
of any kind to psoriatic skin should be avoided. less than 10 percent of the normal population. Since
There are no specific agents that are contraindicated psoriatic lesions are commonly associated with S.
or indicated for this disease other than to protect the aureus, regional anesthesia or intravenous cannulae
skin. In addition, anesthesiologists must be aware of should not be directed at these sites. Doing so may lead
the high incidence of pruritus with neuraxial opioids, to septicemia and further complicate the case44.
especially when dealing with psoriatic patients - for
pruritus exacerbates their disease38. Methotrexate
Clinical observations of cancer patients that
Skin Trauma were placed on methotrexate after anesthesia later
It has been well documented that psoriatic showed unexpected signs of myelosuppression and
plaques can be elicited artificially by inducing trauma mucosal damage. This observation led to the discovery
to the skin39. Further investigation of this phenomenon that nitrous oxide, which inactivates the cobalamin
PSORIASIS AND ANESTHETIC CONSIDERATIONS
627

coenzyme of methionine synthase, and methotrexate, to limit the psoriatic lesions and impede recurrences.
which inhibits dihydrofolate reductase in folate Prednisolone is a popular choice used to treat psoriasis
metabolism, has a synergistic effect. Studies performed as well as other dermatologic diseases that exhibit
on Wistar rats demonstrated that no substantial kidney or lesions56. There are no serious problems of steroid
liver toxicity occurred in the rats with the combination; therapy causing complications reported during the
however, the lethal dose of methotrexate decreased by perioperative procedure57 and typically 100 mg of
83.3% when nitrous oxide was administered previously hydrocortisone is administered to prevent Addisonian
for 48 hours. Furthermore, the administration of crises.
5-formyl-tetrahydrofolate completely protected the Patients afflicted with psoriasis related
rats from the synergistic effect of the two drugs. It was psychological symptoms such as social phobias often
concluded that nitrous oxide potentiated the cytotoxic are given agents including tricyclic antidepressants
effects of methotrexate on proliferating cells and (TCAs) or the selective serotonin reuptake inhibitor
therefore the use of nitrous oxide before or even during (SSRI) antidepressants58. Neuromodulators including
methotrexate administration should be avoided51. antidepressants can alleviate inflammation. Psoriatic
inflammation can be due to an abnormal proliferation
Erythroderma Variant of neuropeptides such as Substance P and may be
Severe cases of erythroderma can present a used to treat depression as well as reduce psoriatic
challenging case for. In this inflammatory disorder, inflammation59-61.
generalized erythema and scaling occur. Furthermore,
this variant form may disturb the cardiovascular,
Summary
thermoregulatory, and metabolic systems52. Increased
incidence of vascular diseases such as thrombophlebitis, Psoriasis can be extremely debilitating for the
pulmonary embolism, cerebrovascular accidents, patient due to the fact that it can affect the whole
and myocardial infarction has been described53. It is integument, and, because of its chronic nature, can
recommended that the psoriatic patient undergo full afflict the individual for most of his/her life. In some
systemic management throughout the perioperative cases such as erythrodermic psoriasis, the disease can
period52. One of the most important preventative steps even be fatal due to complications such as high-output
in management includes evaluation for undiagnosed congestive heart failure. The anesthesiologist must take
high-output congestive heart failure45. many factors into consideration such as the severity
of the disease, where to place regional anesthesia, and
The presentation of systemic scales can cause
the anesthetic complications associated with certain
difficulty in placing ECG electrodes on the patient.
types of psoriatic medications. Although certain
Systemic scaling can also complicate endotracheal tube
mechanisms such as differentiating keratinocytes while
placement and may lead to postoperative dyspnea52.
impeding their proliferation, immunosuppressive
For example, pustular psoriasis can be accompanied
therapy, regulating transcription via steroids and the
by relapsing polychondritis; this phenomenon can
use of extra-cellular oxygen radicals have been used
complicate intubation due to reasons such as cartilage
to manage psoriasis, no “miracle” cure exists. Even
degeneration and a smaller glottis due to edema54,55.
though psoriasis is usually treated by dermatologists,
anesthesiologists must be careful and prepared because
Steroid and Antidepressant Treatment of the disease is chronic, variable, and patients must be
Psoriasis; Compatibility with Anesthesia carefully handled in the operating room.
Many patients are managed with steroid therapy

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628 amir baluch et. al

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