Improving standards of care in psoriasis

New guidance from NICE on the management of psoriasis is expected to be published next month (October) prompting a timely review of the condition and its common comorbidities, both physical and psychological

Psoriasis affects approximately 2-3% of the population,1 with men and women equally affected. Children may be affected, although uncommonly, and not usually before the age of 8 years. Adults have peaks of incidence between upper teens to 35 years and in the 50s-60s. Around 30% people will have a family history of the condition. The condition is a chronic one, for which there is no cure, and which is characterised by relapses (flares) and periods of remission.

So with the prevalence of the condition and its chronic nature, why is it that we see so little of our patients who suffer with psoriasis?

Perhaps, this is an illusion! As doctors and nurses we probably do see sufferers, but patients may choose not to present the problem: they may feel disillusioned with the chronicity of the condition, and the lack of success with treatment, but psoriasis can be associated with profound functional, psychological and social morbidity,1 and as such healthcare professionals need to be more aware of both the condition and its impact.

A further issue is whether primary care healthcare professionals have the necessary dermatology skills. For many of us, inadequate education may mean that we are just not very good at dermatology.

LIFE EFFECTS

The life effects of skin disease are now well recognised: many of us have experienced these first hand - the spot that appears at the most inappropriate moment, just before a job interview, or big night out. However, these events are often transient while the effects experienced by people with psoriasis are suffered long-term.

Measuring disability

The Dematology Life Quality Index (DLQI)² was developed in 1994 and contains 10 questions asking how the individual has been affected by their skin condition over the previous week. Each question has 4 possible answers ranging from unaffected to affected 'very much'. The latter grade scores 3. The scoring system then classifies the impact that their condition is having on their quality of life. So, for example, a score of 11-20 means that their skin problem is having a very large effect on their lives. The Children's Dermatology Life Quality Index (CDLQI) can be used for young psoriasis patients.

The Psoriasis Disability Index3 is a questionnaire looks back over the previous 4 weeks and reviews daily activities, work or school, alternative questions for those not at work or school, personal relationships and leisure. New patient checks represent a golden opportunity for the practice nurse or health care assistant to enquire how the patient is coping with their skin problem. Using these questionnaires should become as much a reflex as using the PHQ-9 in depression.

COMORBIDITIES

It has become more apparent that psoriasis has co-morbidities, one of the most common of which is depression. Reported prevalence rates vary depending on the study, but up to 60% may be affected. This mood disturbance may extend to the partners of those affected. Surprisingly, there isn't necessarily a direct correlation between the severity of the condition and the likelihood of depression.

Other co-morbidities include diabetes, hyperlipidaemia, hypertension, or obesity, for which people with psoriasis are at higher risk than the general population. NICE recommends that we discuss risk factors for these conditions, and provide appropriate advice on modification.

Here is an opportunity to assess the quality of our work. How many of our psoriasis sufferers have had their risk factors considered such as weight, fasting glucose and lipids along with their BP measured in the last 2 years? Perhaps the easiest way to find out is to identify your patients when they apply for a repeat prescription. If you have a prescription clerk, they can produce a blood form for the blood tests and attach a request to come into to have a blood pressure measurement and a weight check. An alternative approach is to carry out a computer search and invite the patients in by post asking them to complete their blood tests prior to consultation.

Psoriatic arthropathy is another comorbidity that may be under-recognised.⁴ The condition is more likely to occur if there is nail pitting, and it affects around 20% of patients. Review consultations should include this as part of the assessment, and detection can be helped by the Psoriasis Epidemiology Screening Tool (PEST). As soon as psoriatic arthritis is suspected, the patient should be referred to a rheumatologist for assessment.

TREATMENT

It is important that we understand the wide variety of treatments that are available for the condition, although some are expensive and can only be accessed in specialist care. A recent UK audit found wide variability in access to specialist treatments and support. The forthcoming NICE guideline aims to address this issue.

Topical treatments are first line: these include emollients, a combination of potent steroid and calcipotriol, and coal tar preparations. For sensitive areas such as the groins, face and genitals, a mild steroid such as 1% hydrocortisone should be used for up to 2 weeks. Patients should be provided with practical support and advice about the use and application of topical therapies, and adherence should be encouraged.

Those that do not respond may require referral to hospital for phototherapy (narrowband ultraviolet B). Those that still do not respond should be considered for systemic therapies. These may be non-biological with first choice being methotrexate, or biological with agents such as, adalimumab, etanercept and infliximab. Systemic treatments may be warranted where psoriasis is extensive, or associated with significant functional impairment or high levels of distress - and when other treatments have been unsuccessful.

REFERENCES

1. NICE. Psoriasis:the management of psoriasis. Draft for consultation; May 2012. www.nice.org.uk/nicemedia/live/12344/59183/59183.pdf

2. Finlay AY, Khan GK. Dermatology Life Quality Index. April 1992 www.dermatology.org.uk

3. Finlay AY, Kelly SE. Psoriasis - an index of disability. Clin Experiment Dermatol 1987;12:8-11

4. Burden AD, Hilton Boon M, Leman J, et al. Diagnosis and management of psoriasis and psoriatic arthritis in adults: summary of SIGN guidance. BMJ 2010;341:987-989

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