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Sun 21 Oct 2007 05:20 PM

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Dealing with psoriasis

Optimal treatment of the chronic skin disease depends less on extent of the disease than its impact.

Optimal treatment of the chronic skin disease depends less on extent of the disease than its impact.

Psoriasis is a chronic skin disease that affects millions of people worldwide. Patients with plaque psoriasis (by far the most common form) usually have patches of thick, red, inflamed skin covered with dry flaky scales.

The patches may be itchy and sore and commonly are found on the elbows, palms, legs, soles of feet, lower back, scalp, and face - though they can be found on other parts of the body as well.

Half of patients with psoriasis don’t adhere to their prescribed treatment plan.

Psoriasis is not life threatening, but it can be debilitating. Many patients with the disease report feelings of embarrassment, unattractiveness, and depression. The disease may affect their social relationships, job performance, and even their ability to hold onto a job.

There is no cure for psoriasis. There are, however, many treatments which used alone or in combination can be effective - provided the patient uses them as directed. The trouble is that half of patients with psoriasis don't adhere to their prescribed treatment plan. Consequently, you will often encounter patients who are not only frustrated by their disease and its symptoms, are but also discouraged from having tried complicated and messy regimens only to see their condition remain or return.

In this In Practice, we offer advice for general physicians on when to treat vs. when to refer and Steven R. Feldman, MD, PhD, a Professor of Dermatology, Pathology & Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, North Carolina offers tips for increasing patient compliance.

Whom to Treat

When it comes to patients with psoriasis, the first challenge for the general physician is deciding whether to manage the person or seek consultation. The key in making that decision is assessing the impact of the disease on the individual.

If the patient has pain in the joints they likely have psoriatic arthritis. This autoimmune disease affects 15% of people with psoriasis and is more frequent in those with severe cutaneous disease.

Patients with severe joint pain should be referred to a rheumatologist to see whether they are a good candidate for phototherapy (light therapy), or systemic treatment such as methotrexate, biologic agents, or some combination.

If no joint inflammation is present, the decision whether to treat or refer should be based less on the extent of the disease but its impact on the patient's quality of life.

Even if an individual has fairly extensive disease but it is confined to the skin and it doesn't rate highly as a daily concern, it is often something a general physician can care for with topical treatments. The main topical treatments are corticosteroids (cortisone-like creams, gels, liquids, sprays, or ointments), vitamin D-3 derivatives, coal, tar, anthralin, or retinoids.

Each drug has specific adverse effects or loses potency over time, so it's common to rotate them or sometimes combine them. Note that there is no best drug for every patient, so lifestyle factors come into play as well as medical history, age and gender, the location of disease, how the disease comes and goes, its extent, type, and the patient's response to treatments in the past.

These treatments often are effective in reducing the symptoms of psoriasis, but they will not make them disappear completely. So, in a person with moderate psoriasis, medications will turn red, scaly, raised patches to pink, flat, non-scaly, lesions, but they still don't look like regular skin.

Treatment can become challenging at times. Patients may become frustrated when treatments fail to improve their condition to the degree they'd hoped for. So physicians need to learn to manage patient expectations. In addition, not only do the symptoms wax and wane, but so do patients' response to the symptoms.

Sometimes a person for whom the disease has been manageable will suddenly become so bothered by it that it becomes worth making a referral to a dermatologist for phototherapy or systemic treatment, or to a psychologist for counselling, or both.

Communication and follow-up

Many patients with psoriasis have given up hope after trying topical treatments and watching them fail. But Feldman says that the problem is not that the treatments are ineffective, it's that few patients use the medications consistently and as often as directed.

To increase the number of psoriasis patients who improve, Feldman has devised several techniques for getting them to be more diligent.

First, he says, he sits close to them and puts his hand on their psoriasis and comments on it. He might say something like, "that's a really thick plaque psoriasis you have there."

He says he does this not because it's part of the physical exam but rather to establish trust and help patients overcome the feeling that their disease prevents them from having contact with other people. "The sense of isolation is one of the worst things about psoriasis," he says.

He further establishes this connection by acknowledging the patients' frustration with previous treatments. The next important step, he says, is to discuss the patients' lifestyle and find a treatment option that fits it.

Besides asking about how much the disease bothers them, it is important to understand what is realistic for them to fit in your daily routine (an hour to apply topical medications, or a three-times-a-week drive to phototherapy treatments?) and their ability to pay for treatment (which can be expensive and is needed over a long period of time).

For some people, a topical ointment is fine, but others may fare better with treatments that come in other forms, such as spray, foam, gel, or liquid. "They are not breakthrough science, but they give people something they are willing to use," Feldman explains.

But perhaps the ‘ultimate trick' in getting patients to comply, says Feldman, is to schedule a return appointment in 3-7 days. This follow-up visit often gets patients to adhere to their treatment regimen in the early days, see results, and thus become more motivated to continue.

This article is provided courtesy of Harvard Medical International. © 2007 President and Fellows of Harvard College.

When to treat vs. referTreat

Mild to moderate plaque psoriasis - without joint pain - that is not bothersome to the patient at this time.

Refer to a dermatologist

Moderate to severe disease - without joint pain - that is not responding to topical treatment or that is very bothersome to the patient.

Refer to a rheumatologist

Any patient in whom the problem is primarily with their joints and their skin is not very bothersome.

Note: the prevalence of psoriatic arthritis is about 15% and more frequent in those with more severe cutaneous disease.

Refer to a psychiatrist or psychologist

Patients with mild to moderate psoriasis for whom the disease is very bothersome; psoriasis patients who show symptoms of depression or anxiety.

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