Are We Doing Enough for our Psoriasis Patients?
By Darrel Arthurs, ARNP, DCNP
Psoriasis is an autoimmune disease of chronic, recurrent, inflammatory plaques affecting the skin. Circumscribed, dry, scaling, erythematous plaques of various sizes characterize it with a fine white colored scale over the surface. The condition favors the scalp, nails, and extensor surfaces of the limbs, umbilical region and sacrum. The condition usually develops slowly but it can become exacerbated with a sudden flare encompassing much of the body. There is still much that is not known about the condition. A family tendency toward the condition is present but it appears to be multifactorial where the condition may or may not be passed to subsequent generations and outside sources can affect the occurrence.
Unfortunately, there are many associated complications and other conditions which are frequently associated with psoriasis. One of the more common is psoriatic arthritis which affects 10% to 30% of those affected by psoriasis. In addition, the economic burden is high with psoriatic arthritis requiring patients to have frequent physician appointments and a great deal of follow up care. Patients with psoriasis are also afflicted with increased cardiovascular risk. Arteriosclerotic vascular disease (ASVD) is characterized by inflammation in the artery wall as well as formation of plaques. It frequently is present prior to heart attacks many of which are lethal. In psoriatic patients this incidence is greatly increased. It is estimated that patients with psoriasis have a life span that is ten years shorter than their peers mostly due to the cardiac changes associated with the condition.
In recent years even more research has uncovered other associations which are harmful to the patient with psoriasis. The majority of the patients with extensive psoriasis are obese. In addition, many other risk factors that are commonly associated with obesity are observed in psoriatic patients. Some examples include arterial hypertension, dyslipidemia, increased insulin resistance as well as metabolic syndrome. All of these conditions have shortened life expectancies and all are have been found to be associated with psoriasis. Also, depression, anxiety, substance abuse, and even increased suicidal ideation are commonly listed as conditions that accompany psoriasis. Psoriasis is a disfiguring condition and with that comes issues with self-image. Many individuals report difficulty sleeping, low motivation levels and no interest in activities that once gave them pleasure. All of these are signs of depression and or anxiety and many of these individuals are noted to be treated with psychosomatic drugs.
The treatment of psoriasis should take a team approach consisting of dermatology, primary care, cardiology, rheumatology, and possibly psychiatry. These specialties are highly sought after and frequently difficult to get appoints scheduled. Often times there is a waiting period of months prior to getting in to see the provider.
The best central point of treatment for the severe psoriatic patient is dermatology. Frequently, psoriasis patients are seen on a three-month basis in the dermatology clinic. Sometimes, this is even more frequently than their primary care physicians see them. Therefore, the dermatology provider is in a unique position to better care for the psoriasis patient by closely monitoring their overall healthcare and not focusing solely on their skin integrity.
Coordination between the specialties should be conducted via letter (preferably), email or phone call with information pertaining to what needs the patient has to be addressed with follow up appointments. For instance, if it is noted that the patient's blood pressure has increased a letter will be sent to the primary care physician asking them to further evaluate the patient in this regard. If the patient is beginning to develop body aches it is up to the leader in the clinic first noting the issue to refer the patient to be seen by rheumatology.
A list of symptoms and critical parameters can easily be developed and a checklist created to monitor patients for changes in their health. These could all be easily done and monitored within the primary care and dermatology clinic. If one of the parameters is met then the patient is referred to the specialist where they need to have that parameter addressed.
It is up to the provider to be a strong advocate for their patients and proactive in their healthcare. This includes not only the chief complaint they arrive at our offices for, but also for the evaluation of parameters that could one day adversely affect the health and even life expectancies of our patients.
Arthurs' passion for dermatology developed while he was serving in active duty in the U.S. Navy. Since then he has accumulated over 11 years' experience in medical and surgical dermatology. Currently he works independently in a small city in northeastern Oklahoma.