Psoriasis Awareness Week runs from Thursday 29 October (World Psoriasis Day) until Wednesday 4 November 2020. Spend a few minutes with a psoriasis patient during the week, suggests pharmacist and dermatology expert Rod Tucker.
Psoriasis is a chronic inflammatory skin condition that is thought to affect up to 3% of the UK population, which amounts to nearly 2 million people. Though there are different forms of psoriasis, the most common form, which affects around 90% of patients, is chronic plaque psoriasis. Clinically, this is characterised by well-defined erythematous, silvery/white hyperkeratotic (raised) scaling plaques that classically occurs on extensor surfaces of the body, e.g. elbows, knees and the lower back, but for many patients, psoriasis also affects the scalp. In addition, some patients experience changes to their nails, including abnormal nail plate growth leading to characteristic pitting, a build-up of keratinous material underneath the nail (subungual hyperkeratosis) and onycholysis (detachment of the nail from its bed).
Although conditions such as atopic eczema are known to be highly pruritic, less attention has been paid to the fact that itch can affect the majority of patients with psoriasis. Furthermore, in itself, psoriasis is not life-threatening, but it is associated with a significant impairment of quality of life, including work, family, sexual relations as well as physical and emotional well-being. The visible nature of the condition has been reported as one of the most difficult aspects.
There is currently no cure. Psoriasis follows a relapsing-remitting pattern and so effective self-management is important. But psoriasis is not just a skin condition, and is best described as a complex, multifactorial and inflammatory disease. This broader definition is an acceptance that psoriasis is associated with several comorbidities, most commonly, psoriatic arthritis, a progressive and degenerative joint disease, which can be present in between 6 to 41% of those with psoriasis. In addition, psoriasis is positively associated with adverse lifestyle factors including obesity, alcohol consumption and physical inactivity. There are several known triggers for psoriasis, which include stress and injury to the skin, referred to as the Koebner phenomenon.
The precise cause the psoriasis is yet to be determined, though it is likely that a combination of genetic, environmental and immunological factors are responsible.
Prior to the 1980s, it was believed that psoriasis was solely due to keratinocyte dysregulation in the skin, leading to hyper proliferation of these cells, hence the raised plaques. Later work suggested that psoriasis was probably a T cell-mediated disease, and the important role of the pro-inflammatory cytokine, tumour necrosis factor in psoriasis was illustrated in a study using the anti-TNF- agent Etanercept in psoriatic arthritis, in which patients also saw improvements in their psoriasis. Subsequent work has shown the importance of a range of pro-inflammatory cytokines such as IL-17A in the development of the disease.
Key points in the management of psoriasis
The majority of patients in primary care have plaque psoriasis. Fortunately, most have mild to moderate disease that is amenable to treatment with topical therapies, usually potent topical steroids and vitamin D. In guidance from NICE is was recommended that these two treatments are applied separately, i.e., one in the morning and the other at night, but in practice patients are usually prescribed a combination product such as Dovobet or Enstilar.
Emollients are also effective adjunctive therapies in psoriasis and often under-prescribed. Ideally, an emollient should be applied to plaques around 30 minutes before any active treatments and applying emollients several times a day will help soften a plaque and prevent the skin from cracking which can be very painful.
Though very effective, the combination treatments Dovobet and Enstilar should not be used continuously for more than 8 weeks to avoid the development of adverse effects such as skin thinning. Patients might not be aware of this. One male patient once described how he used Dovobet continuously for at least 2 years and that his doctor never explained that he should stop. In fact, once a psoriatic plaque has flattened, patients can stop active therapy and just apply an emollient which should be continued long-term. If the disease starts to flare again, active therapies can be re-started in short bursts to bring it under control.
How pharmacists can support patients with psoriasis
Despite the effectiveness of topical therapy, studies have indicated how adherence to topical regimes is generally low. For instance, one study observed that nearly a third of patients with psoriasis did not redeem their initial prescription.
Moreover, qualitative research with those suffering from psoriasis has revealed an erratic and inconsistent use of topical therapies combined with a clearly recognised need for instruction on the correct use of treatments that was absent from consultations. Other work has found how patients perceived that healthcare professionals lacked knowledge and expertise in the management of their condition, empathy with the impact of the disease and failed to manage psoriasis as a long-term condition. These studies clearly illustrate the need for more effective community-based information, education and support.
As the experts in medicines, pharmacists have an important advisory and supportive role for patients with psoriasis. In my experience, some doctors minimise a patients’ psoriasis, reassuring patients that it is only a ‘minor’ skin problem that is not fatal and nothing to worry about. I once dealt with a psoriasis patient who informed me that his GP has told him that he should be lucky that he didn’t have something more serious like heart disease.
Relegating psoriasis to a minor condition often means that patients lack sufficient understanding of their treatments and how best to use them.
This was shown in a study I undertook exploring the educational impact of pharmacists’ advice to patients with psoriasis. In the study, community pharmacists held a consultation with patients and used a tool to assess their knowledge of psoriasis and provided individually tailored advice to improve both understanding and management of the condition. The patients themselves self-assessed the severity of their psoriasis and the impact on quality of life. A follow-up appointment was arranged after six weeks to re-assess patient’s understanding, as well as disease severity and the effect on quality of life.
The results showed significant improvements in understanding equally important was how disease severity had reduced as had the impact on quality of life. When patients were later interviewed, it was clear that what was of great importance was that somebody was prepared to take an interest in their skin condition and provide supportive advice. For instance, many did not use an emollient and were surprised by the improvements achieved from using one.
Perhaps most interesting was that the study did not specifically target those who were recently diagnosed. Most participants had lived with psoriasis for an average of 20 years, yet still managed to benefit. The pharmacists themselves felt that they now perceived themselves as members of the team caring for patients with psoriasis.
Time with psoriasis patients is well spent
Psoriasis Awareness Week runs from Thursday 29October until Wednesday 4 November 2020. The results from my research study clearly demonstrated a lack of understanding among those with psoriasis, and that pharmacists can make a valuable contribution to the care of these patients. So, during Psoriasis Awareness Week, please try and spend 10 minutes with a psoriasis patient and ensure that they understand how best to manage their condition. I am sure that both of you will benefit from this interaction.