Longer consults may improve outcomes in psoriasis

Aug 31, 2018, 12:00am

Longer, more in-depth consultations with dermatologists, nursing staff, physician assistants could improve outcomes in psoriasis.

A recent article in Seminars in Cutaneous Medicine and Surgery addressing the mosaic of steps and strategies for optimizing the management of psoriasis confirms a complexity of considerations including patient adherence to prescribed therapies and the choice of appropriate medicine individualized to each case. Appropriate patient education is important with the overall goal of increasing the patient’s quality of life.

“We have to recognize as dermatologists that we are dealing with a systemic disease. Patients with moderate to severe psoriatic disease will likely also have multiple comorbidities including cardiovascular disease that need to be actively addressed alongside the typical skin signs and symptoms. As such, we need to spend more time with our psoriasis patients in clinical practice during the consultation to help improve symptoms, increase the quality of life and assess for comorbidities for a significant number of patients,” said Alan Menter, M.D., an author of the study.

Psoriasis is a common disease affecting approximately 7.5 million patients in the United States, 1.5 million (20%) of which have moderate to severe psoriasis (affecting more than 10% of their body surface area). Dr. Menter, chairman of dermatology, Baylor University Medical Center, Dallas, says that
less than 500,000 of 1.5 million patients with moderate to severe psoriasis are currently being treated with any form of systemic or biologic therapy. Therefore, over 1 million patients with moderate to severe psoriasis in the United States are not receiving appropriate therap. In addition to inappropriate drug selection, Dr. Menter said a patient’s adherence to prescribed therapies can also significantly contribute to inadequate disease control and suboptimal treatment outcomes.

ADHERENCE
Adherence in psoriasis has always been an issue particularly for patients with mild to moderate symptoms who are typically prescribed topical regimens. As psoriasis is a life-long disease without cure, many patients over time can become frustrated and indifferent towards a positive outcome for their disease and will not regularly apply therapy as advised by their doctor.

“People are very busy today and find it difficult to find the time or energy to commit and follow through with a long-term therapy, even though they are the ones making the appointment with the dermatologist to address their psoriasis symptoms. We use double the amounts of super potent topical steroids per patient per capita, more than anywhere else in the world because patients want to be over their symptoms as soon as possible. Everyone wants a quick fix but patients need to understand that psoriasis is a chronic life-long disease,” Dr. Menter said.  

Choosing the appropriate vehicle can be instrumental in improving treatment outcomes. Scalp psoriasis, for instance, is known to be very difficult to treat and can be recalcitrant to standard therapies. Here, it is paramount to consider the patient’s type of hairstyle when choosing among the different sprays, gels, and oil-based vehicles. According to Dr. Menter, the clinician needs to have understanding of the individual patient’s particular needs and aim to prescribe the appropriate therapy and vehicle for each individual case, facilitating treatment adherence by the patient.

“I’m not sure all dermatologists take or have the time to do this in their busy daily practices. Nursing staff or physician assistants following appropriate training could or should take the time and explain in greater detail to the patients how, when, and how often a prescribed therapy should be applied, as well as the importance of following through with the therapy. I believe that longer and more in-depth consultations with the dermatologist, nursing staff, or physician assistants could make a difference in improving outcomes,” Dr. Menter said.

QUALITY OF LIFE
Improving the quality of life of patients is one of the central goals in psoriasis therapy. Tracking disease severity is one way the clinician can have a better idea of the of the patient’s status. The Psoriasis Symptom Inventory (PSI) is comprised of eight usual symptoms seen in psoriasis (i.e., itching, scratching, burning, stinging, etc.) and patients rank their status on a 0 to 4-point score basis. According to Dr. Menter, the PSI is proving to be very useful in helping in categorizing where patients are in terms of their disease severity, which can often reflect their psychological state regarding their psoriasis. Clinicians can then perhaps more quickly adjust treatment to hopefully improve clinical treatment outcomes leading to a higher quality of life.  

“We have to be very aware to carefully assess the symptomatology of our patients and treat them appropriately. The PSI can give the physician some insight into some of the symptoms that patients experience but perhaps seldom talk about. I believe such assessment tools can help clinicians better understand what patients are going through and further help them choose an appropriate therapeutic plan for the typical complex mosaic of psoriasis symptoms,” Dr. Menter said.

REFERENCE
Wu JJ, Armstrong AW, Gordon KB, Menter MA. “Practical Strategies for Optimizing Management of Psoriasis,” Seminars in Cutaneous Medicine and Surgery. February 2018. DOI:10.12788/j.sder.2018.012

Hema N. Viswanathan, PhD; Alex Mutebi, PhD; Cassandra E. Milmont; et al. "Measurement Properties of the Psoriasis Symptom Inventory Electronic Daily Diary in Patients with Moderate to Severe Plaque Psoriasis," Value in Health Journal. September 2017. DOI: https://doi.org/10.1016/j.jval.2016.11.020