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Why patients with psoriasis need a holistic approach

Dr Angelika Razzaque highlights the physical and psychological comorbidities associated with psoriasis and the role GPs can play in identifying and limiting the long-term burden of these serious health conditions.

GPs play a unique role in assessing the whole patient (Photo: iStock.com/sturti)
GPs play a unique role in assessing the whole patient (Photo: iStock.com/sturti)

Research shows that nearly a quarter of the population have sought a GP consultation on skin matters in England and Wales, making dermatology appointments common in our surgeries.1,2 Yet the debilitating impact of psoriasis on the emotional, mental and physical wellbeing of the 2m people living with the condition in the UK is still under-recognised.3,4,5

More than skin deep

Psoriasis is a chronic immune-mediated condition and there is a large body of evidence showing an association between psoriasis and developing serious comorbidities,6 for which there is no cure. These include an increased risk of developing potentially serious psoriatic arthritis,6 stroke,7 heart attack,8 metabolic syndrome,9 anxiety and depression,10 Crohn’s disease,11 complications with vision12 and some cancers.1

PSO What?

The PSO What? initiative is a partnership programme led by the Patients Association and LEO Pharma, in collaboration with the expert PSO What? Taskforce. The PSO What? report challenges misconceptions about psoriasis and highlights the debilitating effect the condition can have on an individual’s wellbeing and the burden of its comorbidities. For more information download a factsheet and consultation guide developed by LEO Pharma.

LEO Pharma has initiated, funded and provided editorial input to support the development of this article for GP Connect

GPs play a unique role in assessing the whole patient, and are ideally placed to anticipate, identify and manage the comorbidities associated with psoriasis. As identified by the PSO What? report, regular holistic reviews, at least annually, offer the opportunity to identify and address physical and psychological comorbidities early. They are essential for the overall physical and mental health of patients living with psoriasis.3

However, research carried out as part of the report shows that a third of patients with psoriasis do not visit their GP at least once a year to review their condition.3 As a result, opportunities for early diagnosis are being missed, and serious health conditions that could shorten the lives of people with psoriasis are often left unnoticed.3

Experts together with LEO Pharma have developed a consultation guide for GPs, based on the current NICE guidelines for the assessment and management of psoriasis (CG153). The guide highlights seven key questions to help you make the most of your consultation.

Uncovering the ‘PSO-morbidities’

As an example, a patient of mine was experiencing a difficult time in her life and she began to notice the physical symptoms of her psoriasis worsen, which ultimately led to social isolation and depression. When her small finger joints started to become affected by arthralgia, she was referred to a rheumatologist and was later diagnosed with psoriatic arthropathy.

Without fully understanding the comorbidities associated with psoriasis, it was some time before she was given an accurate diagnosis, and the delay in accessing much needed treatment lowered her mood even further. As a consequence of social withdrawal and depression, she became obese which further impaired her mobility and led to increased isolation.

Now in her late 50s, she is being reviewed at the practice on a six-month basis for chronic disease management and receives an annual Qrisk assessment due to her increased risk of developing cardiovascular disease and other serious health conditions.

This case truly demonstrates the difficulties that patients with psoriasis experience in terms of emotional and physical implications.6 Closer alliances between primary and secondary care, as well as between dermatology and rheumatology, are much needed in order to improve patient experience and satisfaction.

The importance of GPs

While the physical and psychological impact of the condition can range from mild to severe, most people with psoriasis can be managed effectively in primary care.14 As with other chronic conditions, it is important that GPs take the opportunity to fully assess the broader impact of psoriasis and offer a holistic approach.

Whilst recognising that as GPs we are often time poor, I support the need to invest sufficient time to get the best outcomes from our consultations. I would recommend booking a double appointment to fully understand an individual’s personal goals and the impact psoriasis has on their quality of life, assess the physical appearance of psoriasis, explore its broader burden (physical and psychological) and review their treatment plan.

For help with physical checks, a nurse-led service can allow individuals to be assessed over time, as well as screened for any risks of comorbidities. It is also important to remember that at some point in their life, 60% of people with psoriasis will need specialist referral,14 meaning that GPs also have a crucial role in recognising when this is required.

Referral should be made when psoriasis is severe (e.g. more than 10% of the body surface area is affected), nail disease has a major functional or cosmetic impact, or if the symptoms cannot be controlled with topical therapy.15 Additionally, if there is diagnostic uncertainty, or psoriasis is having a major impact on a person’s physical, psychological and social wellbeing, it is important that they are given the opportunity to see a specialist.15

  • Dr Razzaque is salaried GP and trainer and an associate specialist in dermatology

References

  1. The King’s Fund. How can dermatology services meet current and future patient needs while ensuring that quality of care is not compromised and that access is equitable across the UK? Source report, 7 March 2014.
  2. Schofield JK, Grindlay D, Williams HC. Skin conditions in the UK: a health needs assessment. Centre for Evidence Based Dermatology, University of Nottingham, 2009.
  3. PSO? What Report. 2016.
  4. Irish Skin Foundation. The burden of psoriasis.Epidemiology, quality of life, comorbidities and treatment goals. 2015.
  5. Mental Health Foundation, Psoriasis Association. See psoriasis: look deeper. Recognising the life impact of psoriasis. 2012.
  6. World Health Organization. Global report on psoriasis, 2016.
  7. Ahlehoff O, Gislason GH, Jorgenson CH, et al. Eur Heart J 2012; 33: 2054-64.
  8. Gelfand JM, Niemann AL, Shin DB et al. JAMA 2016; 296: 1735-41.
  9. Langan SM, Seminara NM, Shin DB, et al. J Invest Dermatol 2012; 132 (Pt 1): 556-62.
  10. Dalgard F, et al. J Invest Dermatol 2015; 135(4): 984-91.
  11. Skroza N, Proletti I, Pampena R, et al. Biomed Med Int. 2013: article ID 983902. doi: 10.1155/2013/983902.
  12. Fraga NA, Oliveira MF, Follador I, et al. An Bras Dermatol. 2012; 87: 877-83.
  13. Pouplard C, Brenaut E, Horreau C, et al. J Eur Acad Dermatol Venereol 2013; 27(Suppl 3): 36-46.
  14. NICE. Psoriasis: assessment and management. CG155. Updated September 2017.
  15. NICE. Psoriasis: assessment and management. CG155. Algorithm. Updated September 2017.

Initiated, funded and reviewed by LEO Pharma
UK/IE/MAT-19537
October 2020

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