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Patient Case #3: 40-Year-Old Woman With a 10-Year History of Plaque Psoriasis


Experts in dermatological conditions review the case of a 40-year-old female with a long history of plaque psoriasis, highlighting the psychosocial impact of the disease and the importance of multidisciplinary care.

Alexa Hetzel, MS, PA-C: Let’s get into our next [case]. She’s a 40-year-old living with moderate to severe plaque psoriasis for over 10 years. She’s been treated previously with various topical treatments and phototherapy with very limited benefit. She continues to experience persistent, widespread plaques in her scalp, elbows, and knees. This is really affecting her quality of life because she feels really embarrassed. Now it’s starting to affect her clothing choice, and [she is] really shying away from social situations, which is really hard to see. Especially when you’re having that conversation, they won’t look you in the eye. You know they’re having a really hard time when they won’t look you in the eye. So Terry, what’s your initial impression of this case, and how would you approach it?

Terry Faleye, MPAS, PA-C: My first impression was that’s so sad, because you said 10-year history. And I think…that at times even a mosquito bite annoys the daylights out of me. I can’t imagine to have suffered with something for 10 years and not found any type of resolve. Obviously she’s come into the office, so in my mind, obviously she’s been on multiple topical therapies up until this point and is probably sick and tired of it and is looking for potential answers to what could be a good option.

So for me, I would discuss with her all the other treatment options within the algorithm that we have, whether it be oral therapies, just like deucravacitinib. Deucravacitinib could definitely be a great option for this patient, especially the significant amount of psoriasis that she has. But obviously, a systemic biologic could [also] be a great option for her. The one thing that comes to my mind is that this is a desperate patient. And so she’s come here, she wants help, and hey, I got you. So that’s it.

Alexa Hetzel, MS, PA-C: [I wonder] how many people has she seen before.How much money has she spent investing in the past 10 years on different therapies? And [how much] time with light therapy to not get much [in return].

Terry Faleye, MPAS, PA-C: How many buckets of triamcinolone does she have at her house? It’s just real tough.

Jennifer Conner, MPAS, PA-C: I think not only can we help her with her skin, but also having a discussion with her just about the psychosocial aspects of this. Clearly she’s got some depression, which we know goes hand-in-hand with psoriasis. [We can] help point her in the right direction and understand that this is part of this disease process. Let’s get [her] some help,because she’s suffering.

Alexa Hetzel, MS, PA-C: I think that’s so important. We talked about treating the patient as a whole, and the mind is part of the whole. Sometimes I feel like that gets left out, but we are always treating psychology all the time. I feel like that’s always a conversation. You already talked about it; Are there any other multidisciplinary [colleagues] you would bring in besides [psychology/psychiatry]?

Laura Bush, DMSc, PA-C: Well, first of all, I would empathize with her that, and I make a point with my patients to give them validation, that that was really tough what she went through for 10 years. I would point her in the right direction for as far as [psychology/psychiatry], either a psychologist, or if I felt she needed psychiatry, I would do that. And I would implore her primary care as well because she’s had this for 10 years, so maybe her overall general health needs a checkup. I would think if she’s had this for 10 years, has she even gone to a primary care? Has she even looked at her other health issues?

I do try to treat the whole patient, which Lakshi, you had said, NPs [nurse practitioners] and PAs [physician assistants] are really…top notch at that. We deal with a lot of medical dermatology and a lot of complex medical dermatology. We can collaborate with our physicians, at least I can. I think though that we have to make a point to look at the whole patient and plug her into her primary care too. If she needs rheumatology, plug her into the rheumatologist. Try to get her help as far as a psychologist. And since COVID-19, which is really nice that we have this now, there are a lot of online resources for patients to be able to reach out to a psychologist and have a visit and not miss work. Because it sounds like this lady has missed social events, she’s missed work, she’s missed a lot of her life, and you only get 1 life to live.

Transcript edited for clarity.

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