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Clinicians share clinical pearls at final day of AAD meeting


On the final day of the 72nd Annual Meeting of the American Academy of Dermatology, clinicians shared clinical pearls regarding psoriasis comorbidities, isotretinoin dosing for acne and how to treat patients with body dysmorphic disorder.


Denver - On the final day of the 72nd Annual Meeting of the American Academy of Dermatology, one expert shared clinical pearls regarding psoriasis comorbidities.

Addressing care for psoriasis patients, Abrar Qureshi, M.D., M.P.H., says that when he was a resident, “Our approach to psoriasis was very different. You saw the patient, asked how they were doing and typically gave them a systemic therapy - methotrexate, cyclosporine or acitretin - or put them on light therapy plus a topical regimen. We never asked about comorbidities.”

However, he says that based on recent data, “We should be thinking more about metabolic syndrome, diabetes, hypertension and hypercholesterolemia.” He is vice chairman, department of dermatology, and co-director, Center for Skin and Related Musculoskeletal Diseases, Brigham and Women’s Hospital, Boston.

Now, during patient visits, “We do a lot more thinking and talking,” taking thorough histories and, when appropriate, checking vital signs and weight, Dr. Qureshi says. “We will ask patients about morning stiffness lasting an hour or more. And we certainly ask about sudden arthritis flares, particularly in terms of gout.”

In a recent study he co-authored, patients with psoriasis had at least a 70 percent higher risk of subsequent gout than non-psoriatics (Merola JF, Wu S, Han J, Choi HK, Qureshi AA. Ann Rheum Dis. 2014 Mar 20. [Epub ahead of print]).

For overweight patients, “We talk about diet and weight loss and send them for physical therapy if needed, especially if they have inflammatory arthritis.” Dermatologists commonly see grossly obese patients with severe psoriasis who do “beautifully” after bariatric surgery, he added. Considering such connections is crucial, Dr. Qureshi says, because obesity tends to precede psoriasis onset.

Likewise, “Smoking cessation is an important question in our clinic. In fact, we are putting together a small manuscript on smoking cessation guidelines for the dermatology clinic,” he says.

Oral care is also a part of the discussion with psoriasis patients, Dr. Qureshi says.

“We are looking more in patients’ mouths - for dental problems and evidence of guttate psoriasis. We spend more time examining patients for inverse psoriasis as well,” he says.

Patients may not mention inverse psoriasis symptoms, but many of them live with horrible disease that has long gone untreated, he notes. Furthermore, “Inverse or intertriginous psoriasis may portend a worse prognosis or higher risk for psoriatic arthritis.”

Somewhat similarly, different psoriasis phenotypes can provide clues about comorbidities. For example, the presence of nail psoriasis raises the risk of psoriatic arthritis, Dr. Qureshi says.

Finally, “You cannot overestimate cardiovascular disease.” Although the frequency may not be high in absolute terms, he says, “The impact is so significant that it’s a very important aspect to consider.”

Additionally, biologic drugs taken for psoriasis have been shown to reduce the risk of some cardiovascular problems, he notes. Somewhat similarly, a study has shown that patients treated with tumor necrosis factor inhibitors or methotrexate for psoriasis or rheumatoid arthritis face a lower risk of developing type 2 diabetes (Solomon DH, Massarotti E, Garg R, et al. JAMA. 2011;305(24):2525-2531).

Going forward, Dr. Qureshi says, “The question is, when we’re treating psoriasis, are we modifying risk? It’s a question that's going to keep coming up,” particularly as healthcare moves toward quality-based metrics.

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