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.
AAD Board Members:
The National Academy of Dermatology Nurse Practitioners (NADNP) has reviewed the announcement of the American Academy of Dermatology's (AAD) DermCare Team program. We do not support this initiative, which requires the direct supervision of NPs in order to belong to the "DermCare Team." This restriction of dermatology NPs' practice comes without any formal research or statistics that support their statements and initiative. NADNP would like to ask the AAD Board to review the American Association of Nurse Practitioner's position statement: "Quality of Nurse Practitioner Care" located on the AANP's website: http://www.aanp.org/publications/position-statements-papers. This link will provide AAD with research demonstrating the positive impact and contributions of NP care.
To restrict the scope of practice within one specialty demonstrates an unfair and an unrealistic approach to any healthcare "team." While NADNP is in favor of a dermatologist being a leader of a dermatology team, NADNP does not support the restriction of practice or trade of any non-physician provider.
This initiative negatively affects our profession and practice. The reality is that in today's healthcare crisis, dermatologists need NPs and PAs to survive just as much as NPs and PAs need dermatologists. It is evident in the multiple advertisement requests for job applications by dermatologists seeking help from NPs and PAs. It is a mutually beneficial relationship. We are opposed to making NPs "attest" to something that restricts our practice.
For years, NPs and PAs have practiced safely within their legally defined practice act. The AAD has never reached out to the NADNP in any manner to discuss developing true standards of practice that will ensure patient safety. As the only national dermatology NP organization with almost 2,000 members, AAD has not included NADNP in any discussions on a "team" initiative.
If the AAD attestation involves a collaborative practice statement that supports the current scope of practice for NPs, then NADNP would be willing to discuss the promotion of this initiative. NADNP would also like to refer AAD to AANP's position statement: "Nurse Practitioners and Team Based Care" as a reference for our expectation regarding this issue. It is the hope of the NADNP's Board Members, that one day we can all unite and truly respect each other's position on dermatology practice and education. We welcome any dialogue with AAD on this matter.
Respectfully Submitted on Behalf of NADNP Board Members,
Debra Shelby, PhD, DNP, FNP-BC, DNC