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Faculty Perspective

Faculty Perspectives


Comorbidities and the Central Role of the Dermatologist in the Care of Psoriasis Patients

RANGA REDDY
Alan Menter, MD

Psoriasis can no longer be considered a “mere skin disease” as it has been for centuries. It must now be taken more seriously by dermatologists, other specialists, primary care physicians, and allied health professionals.

Psoriasis care requires comprehensive collaboration among healthcare professionals (HCPs)

Psoriasis is a significant, chronic, inflammatory, immune-mediated, genetic disease with substantial comorbidities that requires comprehensive collaboration among HCPs. Of the approximately 120 million patients with psoriasis worldwide (7.4 million in the US), some are likely to develop comorbidities, such as psoriatic arthritis and metabolic syndrome (which includes three or more of: abdominal obesity, impaired glucose regulation, hypertriglyceridemia, low high-density lipoprotein cholesterol, and hypertension).1,2 The systemic nature of psoriasis is critical for HCPs outside dermatology to understand; and interaction with dermatologists and their allied health professionals is important because clinicians from all disciplines have essential roles in diagnosing the multiple phenotypes of psoriasis and its comorbid conditions.

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Consider that psoriatic joint disease, a primary comorbidity of psoriasis, classically presents up to 10 years post the initial onset of psoriasis. Which HCPs will a patient with psoriasis see, when he or she develops early-stage joint disease? Hopefully, we in the dermatology community can help accurately diagnose psoriatic arthritis in its earliest stage and minimize the potential progression with appropriate early intervention either ourselves or in collaboration with our rheumatology colleagues.

Appropriate time and consideration must be given to every patient

Dermatologists recognize the time required to complete a comprehensive medical evaluation of patients with psoriasis may be different than the time required to complete other dermatologic evaluations. However, it still remains incumbent on the dermatologists to play the central role to carefully evaluate and appropriately manage all psoriasis patients in their practices. No longer is the mere question, “How are you doing?” and a 5- to 7-minute session with a psoriasis patient considered “quality medicine.” For the dermatology community to continue to hold our heads up high and maintain respect in both the patient and medical communities, appropriate time and consideration must be given to each and every psoriasis patient at each and every visit.

Psoriasis can be considered analogous to lupus erythematosus (LE) in many ways. Before the subacute and systemic forms were understood, LE was considered a skin disease only. Now the disease is an essential therapeutic area for a new group of medical subspecialists and rheumatologists. Will psoriasis, with its equally broad range of cutaneous features and systemic associations, slowly fade from the practices of dermatology?

I sincerely hope that, with the significant current interest in psoriasis and its comorbidities, dermatologists will continue to lead the way as compassionate caring physicians who understand, recognize, and prescribe appropriate therapy for all forms of psoriasis. Our commitment to educating and collaborating with non-dermatology health care colleagues can help improve the care of the psoriasis population worldwide.

References

  1. Pietrzak A, Michalak-Stoma A, Chodorowska G, Szepietowski JC. Lipid disturbances in psoriasis: an update. Mediators Inflamm. 2010; doi:10.1155/2010/535612.
  2. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112(17):2735-2752.
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Optimizing Care for Patients With Moderate-to-Severe Psoriasis

Paolo Gisondi
Paolo Gisondi, MD

Optimizing care for patients’ moderate-to-severe psoriasis means providing a multidimensional approach that implements preventive and early therapeutic measures personalized according to an individual patient’s needs.

Moderate-to-severe psoriasis is associated with a broad range of comorbidities including inflammatory, metabolic, and psychiatric disorders. In particular, the most relevant comorbidities include psoriatic arthritis, inflammatory bowel diseases, obesity, diabetes, dyslipidemia, hypertension, nonalcoholic fatty liver disease, and anxiety-depression syndrome. A common genetic and inflammatory background as well as the presence of environmental risk factors (eg, heavy smoking and/or drinking habit, overeating, and sedentary lifestyle) is thought to link psoriasis to comorbidities. This association is clinically meaningful as moderate-to-severe psoriasis may predispose patients to an increased risk of cardiovascular morbidity and mortality.

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Moreover, psoriasis can lead to a substantial burden in terms of disability or psychosocial stigmatization. The impairment in health-related quality of life experienced by patients with psoriasis is comparable to that seen in other major conditions, such as cancer, diabetes, and depression. So the recognition of both clinical and psychological needs of psoriatic patients, in the context of their social or interpersonal relationships, daily activities, and their own family, is critical to optimize the management of the disease. Detection and appropriate management of comorbidities are crucial to optimize care.

Patients with psoriasis may not effectively portray the true burden of their disease with their physicians. They may be unaware that some symptoms (for example joint pain and fatigue) may be associated with their psoriasis. Patients should be regularly screened for metabolic disorders by measuring serum fasting glucose, lipids, creatinine, liver enzymes, blood pressure, and body mass index. From the physician’s perspective, understanding the patient in the context of these comorbidities is very important to ensure that treatment is tailored to be safe and meet individual patient needs.

Optimizing patients’ care also means using appropriate treatments when needed. Recent studies found that a significant proportion of patients with psoriasis are not receiving treatment at all, or they are undertreated.1 Most physicians still use a conservative approach in psoriasis treatment that can result in a delay for patients with severe psoriasis to achieve clearance. Therefore, patients are often dissatisfied with current treatment. Currently there is an ongoing debate among dermatologists whether an early treatment may modulate the future course of psoriasis.2

Several elements should be considered when selecting a treatment for psoriasis, including disease-, patient- and treatment-related factors. Comorbidity consideration in treatment decision is crucial. Treatment choice should be personalized according to the individual profile of the patient.

From the patient’s perspective, understanding of the course of psoriasis, potential for comorbidities, and benefits and potential side effects of therapy is important for them to be able to take an informed role in treatment decisions. Patients should be encouraged to monitor and report any changes in their health to their physician to help optimize care and treatment follow-up.

I believe that nonpharmacological interventions are relevant for long-term improved care of psoriatic patients. Psoriatic patients with comorbidities should be encouraged to address and work to correct their unhealthy life style and modifiable risk factors, because this could positively affect the course of their psoriasis. Hypo-caloric diet inducing a moderate weight loss (ie, 5% to 10% of body weight) can increase the responsiveness of obese patients to any systemic treatments. Smoking has been associated with increased disease severity and less response to certain treatments. Regular physical activity may lower the risk of incident psoriasis, with a beneficial effect on the natural course of the disease, influencing the severity as well as metabolic comorbidities.

In conclusion, optimizing care for patients’ moderate-to-severe psoriasis means providing a multidimensional approach that implements preventive and early therapeutic measures personalized according to an individual patient’s needs.

References

  1. Lebwohl MG, Bachelez H, Barker J, et al. Patient perspectives in the management of psoriasis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis Survey. J Am Acad Dermatol.#2014;70(5):871-881.
  2. Mrowietz U, Steinz KGerdes S. Psoriasis: to treat or to manage?. Exp Dermatol. 2014;23:10705-9.
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Psoriasis Patient Education: What Are the Essentials and Why Is It Important?

Lakshi Aldredge
Lakshi Aldredge, MSN, ANP-BC
April S. Abernethy
April S. Abernethy, ND

In the era of 10-15–minute appointments (if you’re lucky), the dermatology provider struggles with how best to meet the needs of the patient and have a successful visit that results in a mutually satisfying experience. For example, this can be accomplished relatively easily with the patient who presents with a skin cancer: both the patient and provider agree that a biopsy is needed, the procedure is done, the patient is out the door, and both await the results.

But with the psoriasis patient, many providers may hesitate, knowing that this patient may set back their schedules. Providers fundamentally understand that patients with psoriasis require more time, especially patients who are new to their practice. Why is that? Well, we know that these patients are often misdiagnosed and are usually under-educated regarding their disease and related risk factors. Many are told by other providers that it is simply a “dry skin” condition or “eczema” and that a topical therapy is the only treatment available. However, between the internet and direct-to-consumer advertising, patients are becoming more aware of their disease. Unfortunately, much of what the internet teaches is misleading (if not erroneous!). Therefore, it is more important than ever for dermatology providers to take the lead in educating psoriasis patients about their disease.

Fascinating data from the National Psoriasis Foundation (NPF) tell us that psoriasis patients see an average of 6 providers before finding one that they feel truly listens, empathizes, and provides the care that they are seeking. This is powerful information because it helps us to recognize that these patients are looking for much more than just a diagnosis and treatment option; they are looking for a “conversation” about their disease. Education, so that patients can have a voice in their treatment, is inherent in that conversation.

So what is it that psoriasis patients want to (and need to) hear? First and foremost, patients need to understand that their disease is chronic in nature, and that, currently, there is no cure. However, it is encouraging for them to also hear that this is a disease state in which there are a great number of treatment options and ongoing research. Secondly, there needs to be a strong emphasis that psoriasis is much more than just a skin disease. Discussing the comorbidities associated with psoriatic disease—including cardiovascular disease and psoriatic arthritis—helps to set the framework for discussion regarding treatment options and increases the likelihood of treatment adherence. Patients may be more willing to accept changes in their treatment management plan after understanding the potential link between their skin disease and comorbid conditions. It is also essential to help patients understand that while the skin will regenerate, bones do not: once joint destruction occurs, it is permanent. This is often new (and startling) information for our patients.

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Time must be allocated for educating patients about their treatment options. To help frame this discussion, it is essential that the provider have a complete and thorough understanding of patients’ comorbidities and current health status, along with an understanding of their lifestyle. Without this knowledge, disease management can be significantly complicated. For example, a patient with a history of hepatitis B may not be a candidate for certain treatments, and a teacher may have difficulty adhering to a three-times-a-week phototherapy schedule.

Patients want to hear about their treatment options. This discussion can truly occur in 5 minutes if dermatology providers are consistent and practiced in their scripts. (The PsO PACT website provides a wonderful resource for dermatology providers to gain this knowledge!) A review of available treatments must include the risks and benefits, the ease of use, and clear expectations of time to treatment response. It is also essential to include a discussion about the patients’ responsibilities with their treatment regimen: How often will the treatment need to be administered? What lab monitoring is required? How often will they need to follow up with their provider? How will it impact their lifestyle? If time is not devoted to this aspect of psoriasis patient education, there is a significantly greater chance that the patient will not adhere to the treatment regimen, or will possibly use the treatment incorrectly, resulting in poor outcomes.

Finally, time must be allocated to discuss the waxing and waning nature of psoriatic disease. With current therapies, patients can achieve near-clear states for the first time in their disease history. Many believe they are actually “cured”! It is important to educate patients that in order to maintain this level of response, it is essential that they remain on their therapy as prescribed. Furthermore, they need to understand that their disease may flare during emotionally stressful times, or when experiencing a physical illness. Without this understanding, patients may feel that the treatment is no longer effective and abandon therapy. Unfortunately, in some cases, stopping therapy may result in decreased response upon re-starting. This may seem like a minor point, but it is one that is often left out of the conversation. However, it is essential so that patients have a clear expectation of their disease course, to optimize adherence to treatment regimens, to ensure that patients do not lose response to effective therapy, and to mitigate risks associated with comorbidities.

In summary, have psoriasis patients ever said they wished their provider hadn’t spent quite so much time educating them about their disease? The greatest gift we can give our psoriasis patients is knowledge about their disease state, its comorbidities, and treatment options. It is equally important that patients are given the opportunity to educate us about their experience with psoriasis and the impact that it has on their lives. The successful dermatology provider is the one who takes that information and collaborates with the patient to formulate a therapeutic and mutually satisfying treatment plan. Isn’t it true that knowledge is meaningless unless it is shared? The more education psoriasis patients receive, the better equipped they are to successfully manage their disease.

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Enhancing Your Psoriasis Patients’ Satisfaction Through
Effective Dialog

Paolo Gisondi
Alexa Kimball, MD, MPH
Psoriasis PACT Faculty
2013-2014

As psoriasis is a life-long condition, it is best managed by taking a long-term approach to build rapport with patients and by having ongoing open and clear communication regarding treatment goals, quality of life issues, and therapeutic options.

Recent patient surveys have shown that many patients are dissatisfied with their psoriasis treatment.1 Some are frustrated by lack of efficacy and others are discouraged by fear of side effects, lack of clear instructions, or the time and expense of managing their disease. They also say that their physicians don’t always appear to listen or understand what they are trying to achieve with therapy. Collaborative goal-setting may improve treatment outcomes and patient satisfaction; thus a 2-way discussion early in the treatment process can help ensure that you and your patients have the same goals and expectations. Some people have termed this approach “shared decision making”2 and this patient-physician communication appears to not only help improve patient satisfaction but also adherence to therapy.

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A good first step is to acknowledge and show empathy for the psychosocial impact of the disease. Studies have clearly shown that demonstrations of empathy improve the patient’s encounter. Enhancing the physician-patient relationship appears to also have a small but statistically significant impact on outcomes.3 Second, ask what each patient’s goals are. In addition to goals for physical symptoms, patients may also have goals for their psychosocial well-being and quality of life. Next, find out where a patient thinks the major gaps in treatment may be. A discussion of current and potential therapies, including possible side effects, administration tradeoffs, and adherence, can be helpful. Don’t be afraid to assign patients homework and have them come back to talk about things again. It can often take patients, who are considering systemic therapy, for example, more than one visit to learn enough and to get comfortable with what often feels like a big step.

Once these conversations have occurred, managing the patient’s expectations of treatment outcomes may be easier to achieve. Additionally, agreement on practical and realistic goals, personalized for that patient, can be reached. We know that patients have very heterogeneous responses in coping skills. The degree to which the disease impacts their quality of life also varies greatly. So patients may be quite different in the efforts and approaches they are going to take to clear their disease, and their need for near or close to near clearance. Don’t underestimate the impact of age on these choices as well. Research is increasingly demonstrating that the decade of the 20s is crucial in social development4 and patients’ needs in the teens and early 20s might be very different as they face choices that will determine their ensuing careers and social structures. Similarly, patients may not always bring up the financial impact of treating their disease, nor how it affects their family, so these may also be topics of importance to address at some point in the therapeutic relationship.

Incorporating patient preferences into the process of treatment decision-making in psoriasis may result in better clinical outcomes and enhanced patient satisfaction. Psoriasis, unfortunately, is a lifelong disease, so viewing the therapeutic relationship as one that will develop with time can make implementing some of these strategies less daunting. You don’t have to do this all at once or even at the first visit. And it’s important to note that these strategies also appear to result in enhanced provider satisfaction. It turns out that it is more engaging and rewarding for providers as well to share in discussion about risks and benefits of current approaches, and celebrate successes with their patients.

References

  1. Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003-2011. JAMA Dermatol. 2014;150(3):337.
  2. Anstey A, Edwards A. Shared decision making in dermatology: asking patients, 'What is important to
    you?'. Br J Dermatol. 2014;170(4):759-760.
  3. Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(4):e94207.
  4. Jay, M. The Defining Decade: Why Your Twenties Matter─and How to Make the Most of Them Now. New York, NY:Hachette Book Group; 2013.
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Should We “Treat to Target” in Psoriasis?

Paolo Gisondi
Lluís Puig, MD, PhD

Treatment to target is an emerging concept in the management of psoriasis. Professional groups in Europe and North America have offered recommendations on this topic. My views on the current guidance and future directions are outlined below.

Psoriasis affects well-being as a consequence of the functional and psychological impairment that is partially reflected on health-related quality of life (HRQOL) measures. In chronic inflammatory diseases for which no cure can be provided, the goal of treatment should be to abrogate or minimize their impact on HRQOL. Treatment should be adjusted according to the degree of achievement of this predefined goal, which should be assessed by an adequate outcome measure.

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The use of treatment targets to improve outcomes has been implemented in clinical practice for the management of patients with various conditions such as hypertension, diabetes, and hyperlipidemia. In some cases, clinicians monitor blood pressure and use laboratory tests to define treatment targets associated with improved outcome, in terms of overall survival and HRQOL. Similarly, rheumatologists use composite disease activity measures to implement standardized treatment targets1 in managing patients with rheumatoid arthritis,2 spondyloarthritis, and psoriatic arthritis.3

Definition of treatment goals in psoriasis does not require biomarker surrogates. However, it should include the improvement in severity and extent of lesions as well as functional and subjective (itch, appearance, or emotional/sexual impact) impairment caused by the disease and their impact on patients’ perceived HRQOL, which is usually measured by the Dermatology Life Quality Index (DLQI).
Identifying treatment goals should include treatment targets for comorbidities, especially psoriatic arthritis, and cardiovascular risk factors that require close cooperation between rheumatologists and general practitioners to achieve therapeutic success.

True treatment targets in psoriasis have yet to be generally agreed upon. In the US, no targets have yet been currently identified. The ultimate goal of therapy is clearance of lesions and a Physician’s Global Assessment (PGA) of 0 (“clear”) has been proposed by Canadian expert dermatologists4 as the current therapeutic target in psoriasis.* A PGA of 0-1 (namely, “clear” or “almost clear”) with minimum body surface area (BSA) involvement was proposed in the Spanish guidelines on treatment of psoriasis with biologics.5 Using PGA alone misses important aspects such as the extent of the disease (BSA), visibility/location of lesions, and subjective symptoms such as itch, burning, or pain.

An improvement of at least 90% with respect to the baseline Psoriasis Area and Severity Index (PASI), namely a PASI90 or better response, is considered as treatment success by the European Medicines Agency, but PASI75 response has become accepted as a reasonable therapeutic goal.6 Absolute PASI values (with a cutoff of 5, 3, or 2) might provide a better benchmark, regardless of baseline PASI, which becomes less relevant with increasing duration of treatment.5 The lower value corresponds to a PASI90 or better response for patients with a baseline PASI ≥20. A PASI score of 5, often considered the threshold for therapeutic adjustment or switching, corresponds to a PASI75 or better response for them.

Treatment outcomes in psoriasis are clinically meaningful only if they correlate with significant improvement in HRQOL. If measured by DLQI, the achievement of a DLQI = 0-1 status, corresponds to lack of effect of the disease on patient’s HRQOL.5 DLQI does not take into account the psychological burden of disease and is subject to marked transcultural variability.7 A global question score anchor8 might be used as a substitute for DLQI in clinical practice. Similarly, Visual Analog Scales can be very convenient to assess both subjective symptoms and patient’s perception on the severity of disease and/or its impact on HRQOL.

The patient’s perspective and personal goals should also be taken into account when defining target outcomes. PASI75 response meets therapeutic expectations in most patients,9 but PASI90 response or better has a significantly higher impact on DLQI improvement and is associated with significantly higher DLQI = 0-1 response rates than PASI75.10,11 The European consensus proposal12 (in 2011) of PASI75 response as a treatment goal, irrespective of DLQI score, might fall a little bit short of current therapeutic expectations, and anything less than PASI75 response with DLQI ≥2 (which is considered a satisfactory outcome not requiring treatment modification in the consensus) might be unacceptable for patients who have achieved clearance at some time point during the induction or maintenance phase of biologic treatment.

Treatment to target is an iterative process, by which the effectiveness of the intervention must be assessed periodically and treatment must be adjusted accordingly to meet prespecified goals. Because of pharmacokinetic and pharmacodynamic reasons, biologic treatments (and conventional systemic agents) have different speeds of onset of action,13 and should therefore be assessed at the relevant time point. This can be defined as the end of the induction period, when assessment should be made in terms of effectiveness (achievement of the predefined goal) or failure (according to a predefined threshold).14 Future developments may eventually provide the means for accurate prediction of success or failure based on individual genetic markers15 and drug pharmacokinetics.16,17

During the maintenance period in a treat-to-target strategy, treatment should be adjusted with the aim of achieving and maintaining therapeutic goals that must be assessed at each visit. Decisions should be made taking into account trough serum concentrations of the drugs being used, combination treatment, adjustments of dose and administration intervals, and switching of biologics. Drug withdrawal for very responsive patients should also be considered. Perhaps this approach might be feasible for those who remain clear on minimal or even undetectable drug levels.

Footnote
*In clinical trials, based on approved products, PGA scales ranging from 5-7 have commonly been used.

References

  1. Smolen JS. Treat-to-target: rationale and strategies. Clin Exp Rheumatol. 2012;30(4 suppl 73):S2-S6.
  2. Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69(4):631-637.
  3. Smolen JS, Braun J, Dougados M, et al. Treating spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis, to target: recommendations of an international task force. Ann Rheum Dis. 2014;73(1):6-16.
  4. Gulliver W, Lynde C, Dutz JP, et al. Think beyond the Skin: 2014 Canadian Expert Opinion Paper on Treating to Target in Plaque Psoriasis. J Cutan Med Surg. 2015;19(1):22-27.
  5. Puig L, Carrascosa JM, Carretero G, et al. Spanish evidence-based guidelines on the treatment of psoriasis with biologic agents, 2013. Part 1: on efficacy and choice of treatment. Spanish Psoriasis Group of the Spanish Academy of Dermatology and Venereology. Actas Dermosifiliogr. 2013;104(8):694-709.
  6. European Medicines Agency. Guideline on clinical investigation of medicinal products indicated for the treatment of psoriasis. http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guidelin.... Accessed November 20, 2014.
  7. Bronsard V, Paul C, Prey S, et al. What are the best outcome measures for assessing quality of life in plaque type psoriasis? A systematic review of the literature. J Eur Acad Dermatol Venereol. 2010;24 (suppl 2):17-22.
  8. Hongbo Y, Thomas CL, Harrison MA, Salek MS, Finlay AY. Translating the science of quality of life into practice: What do dermatology life quality index scores mean? J Invest Dermatol. 2005;125(4):659-664.
  9. Schäfer I, Hacker J, Rustenbach SJ, Radtke M, Franzke N, Augustin M. Concordance of the Psoriasis Area and Severity Index (PASI) and patient-reported outcomes in psoriasis treatment. Eur J Dermatol. 2010;20(1):62-67.
  10. Revicki DA, Willian MK, Menter A, Saurat JH, Harnam N, Kaul M. Relationship between clinical response to therapy and health-related quality of life outcomes in patients with moderate to severe plaque psoriasis. Dermatology. 2008;216(3):260-270.
  11. Torii H, Sato N, Yoshinari T, Nakagawa H. Dramatic impact of a Psoriasis Area and Severity Index 90 response on the quality of life in patients with psoriasis: an analysis of Japanese clinical trials of infliximab. J Dermatol. 2012;39(3):253-259.
  12. Mrowietz U, Kragballe K, Reich K, et al. Definition of treatment goals for moderate to severe psoriasis: a European consensus. Arch Dermatol Res. 2011;303(1):1-10.
  13. Nast A, Sporbeck B, Rosumeck S, et al. Which antipsoriatic drug has the fastest onset of action? Systematic review on the rapidity of the onset of action. J Invest Dermatol. 2013;133(8):1963-1970.
  14. Puig L. Induction phase, primary endpoint, time to decide on primary failure, and therapeutic goals in biologic treatment of psoriasis. J Eur Acad Dermatol Venereol. 2013;27(2):e257-e260.
  15. Talamonti M, Botti E, Galluzzo M, et al. Pharmacogenetics of psoriasis: HLA-Cw6 but not LCE3B/3C deletion nor TNFAIP3 polymorphism predisposes to clinical response to interleukin 12/23 blocker ustekinumab. Br J Dermatol. 2013;169(2):458-463.
  16. Takahashi H, Tsuji H, Ishida-Yamamoto A, Iizuka H. Plasma trough levels of adalimumab and infliximab in terms of clinical efficacy during the treatment of psoriasis. J Dermatol. 2013;40(1):39-42.
  17. Mahil SK, Arkir Z, Richards G, Lewis CM, Barker JN, Smith CH. Predicting treatment response in psoriasis using serum levels of adalimumab and etanercept: a single-centre, cohort study. Br J Dermatol. 2013;169(2):306-313.
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Disease Control and Patient Expectations: A Balancing Act

Paolo Gisondi
Wayne Gulliver, MD

Despite great strides in psoriasis management over the years, the current approach is not one-size-fits-all. Treatment goals vary from person to person based on their life situation, disease course, and impact on their quality of life. As physicians, we need to be good listeners and incorporate patient preferences into treatment plans to optimize outcomes for our patients as well as us.

Over the past 25 years, we as dermatologists have witnessed many advances with respect to the management of psoriasis. Now, the expectation of the patient and physician is that psoriasis may be controlled for the long term, and that many patients can expect to have their psoriasis clear with proper treatment. This expectation of treat to the target of clear has recently been put forward as a realistic option by a panel of Canadian experts. In contrast, the European approach is to base success on a combination of psoriasis improvement and patient-reported outcome related to quality of life. The European consensus is that 75% improvement in psoriasis severity is an acceptable target or 50% improvement with reasonable quality of life, may also satisfy the target. Although these recommendations are a useful guide, we as clinicians understand that treatment goals need to be individualized and we must take into consideration the patient-desired outcome. This was more evident in 2 patients that I saw last week.

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Patient A, a 39-year-old gentleman whom I first saw in November of 1989, at that time had a BSA of 25 and a PASI of 16. He has undergone multiple therapies over the past 25 years and in 2010 had greater than 90% improvement in his psoriasis. Over the past 4 years, he had noted some recurrence and now has a BSA of 14 and a PASI of 7. Symptoms of pruritus and skin discomfort are “clear” and he is happy with the present management. We had discussed the option of optimizing his present therapy, but he is extremely pleased with his outcome and requests no further changes.

Patient A is a stark contrast to another patient, B, who is a 32-year-old gentleman whom I initially saw in November 2011. At that time, he had 21% of his BSA involved and a PASI of 16.8. With his current treatment, his BSA is less than 1% and PASI is 90% improved at 1.6. He still has some lesions on the lower legs. During his last visit he reported that he is not completely satisfied with the outcome and is requesting a change in therapy, as his present therapy has been optimized.

These are real-world situations that we as clinicians and patients face on a daily basis. The clinical scenario becomes even more daunting for both the patient and the clinician when the patient presents with not only psoriasis but psoriasis-related comorbidities such as arthritis, anxiety and depression, inflammatory bowel disease, or cardiovascular disease. At this point, the important question is how do we manage the psoriasis along with the psoriasis-related comorbidities. This question is extremely important as comorbidities such as hypertension, diabetes, and obesity may impact the therapies we choose, in light of potential toxicity. Additionally, comorbidities such as inflammatory bowel disease, ankylosing spondylitis, and cardiovascular disease may influence our choice of treatment and some therapies impact not only the psoriasis, but the psoriasis-related comorbidity.

Another important aspect of treatment relates to the ability of our therapies to improve nail, inverse, and scalp psoriasis. We know that psoriasis in these areas, along with psoriasis on the face and hands, can have a huge impact on quality of life, even though the disease may be considered mild when using measures such as BSA. So, all aspects of the cutaneous manifestations of psoriasis must be considered in developing a psoriasis management plan.

Considering the progress we have made in the past quarter century, we now have the knowledge that may allow us to set realistic treatment goals for both the patient and ourselves, the clinician. Taking into account patients’ perspectives and their unique personal experience, we are able to outline a treatment program that can potentially achieve the desired goals for both the patient and the clinician.

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Working With Primary Care Physicians and Cardiologists to
Manage Cardiovascular Risk in Patients With Psoriasis

Paolo Gisondi
Ehrin J. Armstrong,
MD, MSc, MAS, FACC

Patients with psoriasis tend to have lipoprotein alterations in levels and function, resulting in elevated cardiovascular risk. Collaboration among health care providers caring for these patients is critical to improving their overall health. The Psoriasis PACT developed a communication tool to facilitate this collaboration.

Over the last decade, we have increasingly begun to understand that psoriasis is more than skin deep. Multiple studies have now shown that patients with psoriasis, especially younger patients (below 40) with severe disease, have a significantly increased risk of developing heart attacks, stroke, and coronary artery disease. Much of my work centers on understanding why patients with psoriasis have a higher risk of cardiovascular disease, and communicating this risk to primary care physicians, dermatologists, and other cardiologists.

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Among the general public, there is still a lack of understanding that patients with psoriasis have an increased risk of cardiovascular disease. The first step is educating patients and physicians, while understanding that a multidisciplinary approach may be necessary. Many obstacles exist to cardiovascular risk screening, including lack of knowledge among both patients and health care providers, who may not think to screen patients with psoriasis more intensively. There is also limited time during a single physician visit to address multiple issues, and a lack of coordination among specialists. All these barriers may prevent patients with psoriasis from getting care focused on all their other medical problems that may be related to psoriasis.

In addition to the lack of general knowledge about cardiovascular disease in patients with psoriasis, there is also a number of emerging research findings that may help us better understand the relationship between psoriasis and cardiovascular risk. Patients with psoriasis often have elevated lipid levels, which are a major risk factor for cardiovascular disease. These lipid levels also modify risk in patients with the metabolic syndrome, which is common in patients with psoriasis. Recent studies have suggested that patients with psoriasis also have alterations in the function of lipoproteins that carry cholesterol in the bloodstream. Treatment of psoriasis with anti-inflammatory medications, such as statins, may alter the levels and function of these lipoproteins, suggesting that adequate treatment of the systemic inflammation could actually lower a patient’s risk of cardiovascular disease. Each of these emerging datasets may provide future insight into the best treatment strategies for managing cardiovascular risk in patients with psoriasis.

The Psoriasis PACT is a unique collaboration of physicians with expertise in psoriasis. One of the first projects of the Psoriasis PACT was to create a form known as the Psoriasis Management Report that can be shared with dermatologists and other health care professionals (available at www.PsoPACT.com). This report helps communicate cardiovascular risk to health care providers of patients with psoriasis, and can serve as the basis of a multidisciplinary treatment approach. By working together, I believe that we can effectively manage psoriasis and its associated comorbidities.

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Searching for Connection: Novel, technology-enabled delivery to increase healthcare access for psoriasis patients

Paolo Gisondi
April W. Armstrong,
MD, MPH

Skin diseases account for 30% of all physician office visits. Chronic skin diseases are associated with markedly decreased quality of life and financial consequences. While access issues vary across the globe, in countries such as the United States, there is lack of access to dermatologists especially among patients living in rural and underserved communities.

The average wait time for a new patient visit averages 6-8 months in these communities. Even after initial evaluation by dermatologists, patients in remote or underserved areas have difficulties maintaining regular access to dermatologists for follow-up care. Consequently, many patients with chronic skin diseases, such as psoriasis, lack regular specialty care and can experience worse clinical outcomes and reduced quality of life.

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Imagine that you are a patient with moderate to severe psoriasis who lives in a remote area without easy access to dermatologists. Or, even if you are able to find a dermatologist nearby, the dermatologist does not specialize in psoriasis and would like you to see his or her colleague who is several hours away. What are your options for getting good care for your psoriasis?

Health services researchers have studied this access problem for a while and have thought of innovative ways of connecting psoriasis patients with physicians specializing in their care. The term “connected health” refers to a model for healthcare delivery that uses technology to provide healthcare remotely. Teledermatology is a type of connected health where remote diagnosis and treatment of patients’ skin diseases occur by means of telecommunications technology.

What are the different models by which teledermatology can increase access to psoriasis patients? In the asynchronous consultative teledermatology model, a psoriasis patient presents to the primary care provider or the medical staff, who takes images of the patient’s psoriasis plaques and sends the images and the clinical history to a dermatologist online. The dermatologist serves as a consultant who provides recommendations to the primary care physician online, who then relays the dermatologist’s recommendations to the patient and implements the treatment plan.

Newer models of teledermatology delivery have focused on providing psoriasis patients with specialist care through more direct forms of communication. Specifically, research studies are currently under way to evaluate collaborative connected health (CCH) models, where online access to dermatologists is direct, versatile, and expedient. To be responsive to real-world workflow, the CCH model offers several ways that primary care physicians and patients can access dermatologists directly. Specifically, the primary care physician can access dermatologists online asynchronously for consultations or to request a dermatologist to assume care of patient’s psoriasis. Patients can upload clinical images and history online and obtain asynchronous evaluation and recommendations from dermatologists directly. Importantly, the model encourages active sharing of management plans and fosters multi-directional, informed communication among patients, primary care physicians, and dermatologists to increase engagement from all stakeholders.

As the communication technology advances, patients will have a greater number of options for connecting with specialists for their psoriasis care. This is not only beneficial for those living in geographically remote regions but also for individuals who may have difficulties coming to see the specialist face-to-face due to scheduling constraints. These newer models of healthcare delivery need to be carefully evaluated to see if clinical outcomes will be equivalent to the traditional face-to-face delivery model.

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Looking Out for Patients’ Psychological Well-Being – The Dermatologist’s Role, From a UK Perspective

Paolo Gisondi
Christopher Griffiths MD

Whether reflecting upon past consultations with patients, or reading the scientific literature, there is little doubt about the psychological impact of psoriasis on most patients’ lives. It can limit people’s life choices, make them feel alienated and isolated from society, and induce a sense of helplessness and hopelessness. This can lead to depression, anxiety, and even thoughts of suicide among a sizable minority of patients. Despite these feelings, patients often mask the distress they feel during consultations, begging the question why? Do patients feel it is futile to discuss their distress? Do they think it is inappropriate to discuss feelings within a medical consultation? Do they feel health care professionals don’t have the time to address their concerns and fears? Regardless of the reasons, it is well established that the distress patients with psoriasis experience is under-recognised and undertreated by health care professionals [1,2] and this needs to change. A poor sense of well-being not only has a direct impact upon the extent to which people enjoy their life, it is also likely to limit patients’ capacity for self-management, resulting in unhelpful coping behaviours including smoking, excessive alcohol use, lack of exercise, and over-eating. This continued stress may further contribute to increased levels of cutaneous inflammation.

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Being alert to signs of distress in consultations is a helpful start, but it is important to assess distress directly, preferably using validated tools where possible, and act upon what is found. At our institution, we recommend a comprehensive psychological assessment that has 3 parts: identifying key illness beliefs; measuring the impact of these beliefs on mood; and, identifying unhelpful behaviour or poor coping strategies. The Brief Illness Perception Questionnaire (BIPQ) [3] is an 8 item measure of important beliefs about the illness. The Hospital Anxiety and Depression Scale (HADS) [4], a 7-question measure of anxiety and 7 questions about depression, is a well-established measure of mood often used in patients with long-term conditions. Finally, asking patients about their lifestyle can provide useful information about how well they are coping. All patients are likely to have ideas, concerns, and expectations about their health, the medicines prescribed for them, and the health care they will receive, all of which will have an impact on stress and coping.

The Dermatology Life Quality Index (DLQI) [5] is a broad brush, cross-sectional measure of how psoriasis can negatively impact upon patients’ quality of life, and is commonly used. While DLQI is a useful indicator of the impact on living with a condition such as psoriasis, it does not give sufficient steer on where to intervene to manage the distress. Addressing patients’ beliefs and mood can, however, provide a focus for intervention. For example if a patient believes living with psoriasis is stressful and smoking relieves the stress (an example of a common ‘emotion-focused’ coping strategy), then helping him or her to find other healthier ways of coping may be more productive than simply recommending smoking cessation. These tools can also help to identify those patients who need more urgent referral for psychological support. They will also support the dermatologist in identifying what ways patients’ psychological well-being may be affecting their health.

Actively probing for the factors underlying patients’ distress may be important in unlocking self-management barriers, resolving difficult treatment decisions, improving adherence, and helping to optimise outcomes for patients. Once unhelpful beliefs, high levels of distress, or poor coping behaviour are identified using the assessment tool described above, the next step is to help patients set goals and action plans for addressing their underlying problems. This should be a collaborative discussion in which patients are asked what they want to change and what they could do toward that change before clinicians give their opinion. In the long-term, this approach may be time-saving as less time and fewer resources are used on failed interventions. Skills for this approach can be acquired with a brief one-day training session focused upon posing the appropriate questions and responses in a structured and supportive way.

Whilst it may appear to be challenging to actively address patients’ wellbeing in this way during the time-limited consultation, dermatologists are in a powerful position to challenge and correct any erroneous beliefs that patients may have about their condition, to provide a sense of hope and confidence in their futures, and to guide them to find appropriate support. Referrals may be necessary for some patients, but for all, simply being asked to consider what they could do to make helpful changes in their lives could be enough to instigate positive changes.

Most importantly, this approach demonstrates to patients that it is relevant and appropriate to talk to their health care professional about distress and wellbeing because these are issues that impact their health. Tackling psoriasis-related distress during consultations demonstrates to patients that their wellbeing is relevant to their skin health, and also increases the likelihood of uncovering hidden issues, which may be limiting existing management plans. Whilst the burden and consequences of living with psoriasis are clear to most dermatologists, it is helpful to remember we are in a unique position to support patients to help them optimise their health and their lives.

References

  1. Nelson PA, Chew-Graham CA, Griffiths CEM, Cordingley L. Recognition of need in health care consultations: a qualitative study of people with psoriasis. Br J Dermatol. 2013; 168(2):354-361.
  2. Richards HL, Fortune DG, Weidmann A, Sweeney SKT, Griffiths CEM. Detection of psychological distress in patients with psoriasis: low consensus between dermatologist and patient. Br J Dermatol. 2004;151(6):1227-1233.
  3. Broadbent E, Petrie KJ, Main J, Weinman, J. The Brief Illness Perception Questionnaire. J Psychosomat Res. 2006;60(6):631-637.
  4. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361-370.
  5. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use. Clin Exper Dermatol. 1994;19(3):210-216.
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Working With Rheumatologists to Diagnose and Manage Psoriatic Arthritis

Paolo Gisondi
Philip Helliwell, MD

Psoriatic arthritis occurs predominantly in people with psoriasis. In the UK, about 3% of the population has psoriasis and up to 30% of these people will develop the arthritis associated with psoriasis. Psoriasis precedes psoriatic arthritis in well over half the cases (70%), the average duration of psoriasis prior to development of the arthritis being around 8 years. As yet there is no way of knowing who, of those with psoriasis, will develop psoriatic arthritis but having psoriasis is clearly a risk factor. There are hints that phenotype of psoriasis matters; for example, people with nail psoriasis are more likely to develop psoriatic arthritis but the prediction is not strong.

Primary care physicians and dermatologists are in a good position to diagnose psoriatic arthritis early and should therefore be familiar with typical symptoms of psoriatic arthritis. Awareness is the key. In the UK, the National Institute for Care and Health Excellence recommends an annual psoriatic arthritis screen for patients with psoriasis, using the PEST screening questionnaire (PEST has 5 simple questions and performs equally with other screening questionnaires in identifying psoriatic arthritis). Undoubtedly, musculoskeletal disorders other than psoriatic arthritis will be identified but even cases of, for example, osteoarthritis that are severe enough to impact the screening questionnaires, should probably undergo a rheumatological evaluation.

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Should dermatologists be doing more than just handing out screening questionnaires? There are good arguments for enhancing the clinical skills of dermatologists so that they can identify key clinical features of psoriatic arthritis such as dactylitis and enthesitis. In a similar manner, rheumatologists should be given training in the evaluation of skin. Working together effectively will require an understanding of each of our specialties. How can each specialty treat the disease without knowledge of all the components of the disease, including the skin and the joints, both important components of disease, which can influence treatment choice? Delays in screening and treatment are unacceptable. A recent study found that more than 6 months delay in referral to a rheumatologist increased the risk of joint damage (erosions) by a factor of 2.4. And, unlike the skin disease, when inflammation of the joints is uncontrolled, damage persists and is unlikely to ‘heal’―that is the legacy of untreated joint inflammation.

The impact of psoriatic disease on function and health-related quality of life is important and often neglected. With every year of psoriatic arthritis, function declines. Importantly, we have shown that skin disease contributes to disability and poor quality of life, with a relationship between the effect and severity of skin disease. Early and effective collaborative treatment of skin and joints will help prevent this progression and help reduce the high psychosocial impact of the disease seen in this patient group.

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