Patients with psoriasis need assistance balancing a complicated treatment plan can include phototherapy, topical medications, systemic agents, and biological treatments.
Psoriasis is a chronic, relapsing disease with variable clinical features and triggers that are both environmental (eg, trauma, stress, infections, drugs) and genetic. Its hallmark symptoms— pruritic and erythematous lesions that exhibit well-demarcated papules and plaques with silvery white scales—result from excessive skin cell proliferation.1,2 Epidermal cell turnover occurs every 3 to 5 days in psoriatic skin (normal skin cells turn over every 23 days).3
Although the exact cause is unknown, evidence suggests psoriasis is a systemic autoimmune disease; its clinical features are explained by excess production of proinflammatory mediators (eg, tumor necrosis factor [TNF]-alpha, interferon-gamma, interleukin [IL]).3 Although several subtypes exist (Table 13,4 ), plaque psoriasis accounts for 80% of all cases.2
Psoriasis is classified as mild (<5% of the body affected), moderate (≥5% but <10%), and severe (≥10%). As a point of reference, the palm of the hand is approximately 1% of the skin’s surface.5 Psoriasis affects up to 2.6% of the population, making it the most common autoimmune disorder. Genders are equally affected, but prevalence is higher in Caucasians (2.5%) compared with African Americans (1.3%).5,6 Onset is bimodal, peaking between 20 and 30 years of age and again between 50 and 60 years of age.2 Up to 30% of cases occur within the first 2 decades of life, although children generally have lesions that are relatively thinner, softer, and less scaly. Guttate psoriasis is more common in children than adults.4,7
Severe psoriasis is associated with early mortality of 3.5 years for men and 4.4 years for women. 8 Up to 60% of psoriasis patients report that the condition negatively impacts their quality of life.1,5 Women report greater impact than men.5 Additionally, 20% to 30% will develop psoriatic arthritis, usually within 12 years of initial onset.9-11
Research suggests that psoriasis is systemic and not merely cosmetic. The systemic inflammation observed in psoriasis elevates C-reactive protein, homocysteine, and inflammatory cytokines such as TNF-a, IL-6, IL-17, IL-20, IL-22, and IL-23, which may contribute to overall morbidity and mortality.12 Psoriasis is associated with metabolic syndrome (hypertension, impaired fasting glucose, abdominal obesity, hypertriglyceridemia, and low high-density lipoprotein levels).13 Consequently, psoriasis patients have a higher incidence of diabetes, obesity, heart disease, and stroke. 12 Research demonstrates that psoriasis is an independent risk factor for cardiovascular disease.14
Psoriasis treatment options consist of topical agents, phototherapy, conventional systemic agents, and biologics. For mild cases, monotherapy may be sufficient, but moderate to severe cases may warrant a combination of agents coupled with phototherapy.
Phototherapy, or laser therapy, although effective, is used on treatment-resistant patches and can be time-consuming. Ultraviolet B (UVB) is often combined with systemic agents; the combination increases efficacy and allows for reduced systemic medication doses.15 Another form of ultraviolet therapy is PUVA, which is the combination of psoralen and ultraviolet A (UVA). Unlike UVB, UVA is ineffective without psoralen. Plaque psoriasis, guttate psoriasis, and psoriasis on the palms and feet are most responsive to PUVA.15
In 2011, the American Academy of Dermatology released the sixth of a 6-part series on treatment guidelines for psoriasis and psoriatic arthritis. Individualized treatment must consider psoriasis severity; agent efficacy, side effects, and ease of administration; comorbidities; and family history. Topical corticosteroids with or without phototherapy are first-line treatment for mild psoriasis. More intensive therapy should be used if affected areas include the face, genitals, hands or feet, scalp, or intertriginous areas.10 Ultraviolet therapy, systemic agents, and biologics should be used for patients with moderate and severe psoriasis (Table 21,3,4,11,16) . Clinicians should monitor all patients for psoriatic arthritis.11
Although biologics are effective, some agents may (rarely) reactivate latent tuberculosis13 The incidence of infections, including tuberculosis reactivation and opportunistic diseases, appears to be lower for etanercept than the monoclonal antibodies infliximab and adalimumab.11
Patients need to understand risks and benefits of prescribed agents. Although the prescribing physician or nurse should have reviewed treatment risks and benefits, pharmacists need to be prepared to discuss them. Additionally, patients may have questions regarding the proper use of topical agents. Patients who also receive UVB treatment from qualified dermatologists should be informed that symptoms may temporarily worsen before improving.15 Warn patients not to experiment with light therapy (eg, tanning salons).
Emphasize that best outcomes are achieved with early intervention; patients should never postpone treatment. Current symptom severity is not predictive of future symptoms. Psoriasis’s variable course is often triggered by external factors. Encourage patients to keep a log; this may help identify triggers. Daily application of moisturizing cream helps minimize itching and soreness. Remind patients that symptoms may improve in the summer and worsen in the winter.17
Research demonstrates that obesity increases psoriasis risk.13 Encourage patients to eat a healthy diet and, if necessary, to lose excess pounds. Also, because studies demonstrate that patients with psoriasis tend to drink more alcohol, counsel patients to drink within nationally recognized drinking guidelines, or to eliminate alcohol altogether if it helps their psoriasis.18,19
Given psoriasis’s psychological impact, encourage patients to seek professional help if they find themselves becoming depressed or avoiding social events because of embarrassment. Professional guidance can assist patients with coping skills.
Pregnancy affects psoriasis: 25% of women experience worsening symptoms, 25% experience an improvement, and 50% experience no change.13 Inform women of child-bearing age that they must discuss planned pregnancy with their providers, as they may have to temporarily discontinue medication. If the pregnancy is unplanned, they should call their provider immediately.
There is no cure for psoriasis. As a chronic condition, lifelong assessment and symptom management are the norm. PT
Dr. Zanni is a psychologist and health systems consultant based in Alexandria, Virginia.
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15. National Psoriasis Foundation. Phototherapy. www.psoriasis.org/netcommunity/learn/treating-psoriasis/phototherapy. Accessed April 2, 2011.
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18. National Psoriasis Foundation. Nutrition and psoriatic disease. http://www.psoriasis.org/NetCommunity/Page.aspx?pid=1910. Accessed March 20, 2011.
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