The patient’s perspective
is vital. The 2009 survey of Psoriasis Association members found that 19% of the respondents were given an incorrect initial diagnosis and, for some, obtaining the correct diagnosis took over one year. Better training of healthcare professionals in all aspects of dermatology is required in order for patients to receive consistent care of a good standard.5
Once a correct diagnosis of psoriasis has been received, most patients can be more than adequately treated and managed in a primary care setting, using topical treatments.6
● There is diagnostic uncertainty, or ● Any type of psoriasis is severe (as
defined on the static Physician’s Global Assessment) or extensive, for example, more than 10% of the body surface area is affected, or
● Any type of psoriasis cannot be controlled with topical therapy, or
● Acute guttate psoriasis requires phototherapy, or
● Nail disease has a major functional or cosmetic impact, or
However, referral to a
It is important to gather as much information from the patient as possible before prescribing a treatment; do they work long shifts/have long commutes that would make applying treatments throughout the day difficult, or do they have limited mobility restricting them from applying treatments to certain affected sites? It is also important to encourage patients to return for a follow-up appointment in order to have their skin and treatment re-assessed and to measure treatment response. Patients can quickly become demotivated by sometimes very demanding treatment regimes, and it can take a number of weeks before any benefit is seen. A healthcare provider who has encouraged them to return in 4–6 weeks’ time displays empathy and interest, which in turn helps the patient to feel valued and supported when treating this frustrating condition. It is of utmost importance to ask the patient if any intimate areas are affected by psoriasis – this information is not often freely given, and yet can have a profound impact on quality of life. Of equal importance when assessing the skin for psoriasis is to assess the impact the condition is having on the patient’s quality of life. Assessment tools such as the Dermatology Life Quality Index,8
specialist is needed at some point for 60% of people.7
ten-item questionnaire completed by the patient, give an indication of how severely a patient’s skin condition is impacting on their life. With approximately one-third of people with psoriasis experiencing depression and anxiety,9
and 85% of 32
dermatology patients indicating that the psychosocial aspects of their skin disease are a major component of their illness,10 psoriasis must be treated holistically and fully. Timely referral to specialist dermatology services is essential, and the National Institute for Health and Care Excellence (NICE) Guideline on Psoriasis recommends referral when:
● Any type of psoriasis is having a major impact on a person’s physical, psychological or social wellbeing Patients must be able to re-access specialist services in a timely way, when experiencing a flare-up of psoriasis – the delay in being able to re-access services causes unnecessary stress and distress, which in turn can exacerbate the condition.
What best practice psoriasis management looks like from a patient’s perspective
Best practice for psoriasis management sees interested and enthusiastic healthcare professionals working with their patients in order to set realistic targets for treating psoriasis. There should be regular and thorough assessments of the skin and joints as necessary, with referral to a rheumatologist if psoriatic arthritis is suspected. The assessments should be recorded in order for the patient and healthcare professional to look back and see how successful the treatments are. The assessment should not begin and end with the physical nature of psoriasis, but also include quality-of-life impact and screens for anxiety and depression. Patients should be encouraged to return to the healthcare provider following a new prescription being made, in order for the condition to be monitored, so as to avoid wasted months and years applying a treatment that is having no positive effect. If a treatment is not working, it should be changed and, if necessary a referral to a specialist made.
For patients with severe psoriasis, monitoring for signs of cardiovascular disease should be available, and education given on lifestyle risk factors. This must be carried out sensitively so as not to alarm the majority of people with psoriasis, who have a mild form of the condition, for whom the extra risk factors may not apply.11
Time must be taken to find out exactly what the patient would like the treatment outcome to be – this can be very different
to what the healthcare professional deems as successful treatment. It is important to both share the same end goal. Treating patients with psoriasis takes time and perseverance, for the patient, healthcare professional and the greater patient – the relationship can last for many years, owing to the unpredictable nature of this long-term condition. Take time early on in the treatment journey to get to know the individual patient: this will prove to be so valuable in the future.
Integrated services must not be seen to be solely between the GP and dermatologist, but between all healthcare professionals that a person with psoriasis may encounter: the GP, dermatologist, rheumatologist, psychologist, counsellor, nurse and pharmacist. The patient must feel listened to and valued. After all, they know their skin and their psoriasis far better than anyone, and so if they need to re-access services, this should be timely. ●
References 1. Raychaudhuri SB, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatric Dermatol 2000;17(3):174–8.
2. Henseler T, Christophers E. Psoriasis of early and late onset: characterization of two types of psoriasis vulgaris. J Am Acad Dermatol 1985;13(3):450–6.
3. Basra MKA, Finlay AY. The family impact of skin disease: the Greater Patient concept. B J Dermatol 2007;156:929–37.
4. Anstey A, McAteer H, Kamath N, Percival F. Extending psychosocial assessment of patients with psoriasis in the UK, using a self-rated, web-based survey. Clin Exper Dermatol 2012;37:735–40.
5. The Psoriasis Association The Patient Experience: A survey of members of the Psoriasis Association;2010 [unpublished].
6. Renton C. Psoriasis. National Association of Primary Care Review 2012; Autumn/Winter, 104–5.
7. National Institute for Health and Care Excellence (2012) [Psoriasis: The assessment and management of psoriasis]. [CG153]. London: National Institute for Health and Care Excellence.
8. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI): A simple practical measure for routine clinical use. Clin Exper Dermatol 1994;19:210–6.
9. Kimball AB et al. Psoriasis: Is the impairment to a patient’s life cumulative? J Eur Acad Dermatol and Venereol 2010;24:989–1004.
10. British Association of Dermatologists. Working party report on minimum standards for psycho- dermatology services 2012. London.
11. Samarasekera E et al. Incidence of cardiovascular disease in individuals with psoriasis: A Systematic Review and Meta-Analysis. J Invest Dermatol 2013; 10:2340–6.
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