Primary care and psoriatic disease
Screening for PsA
Up to 30 percent of people with psoriasis will also develop psoriatic arthritis (PsA). Early diagnosis of PsA leads to better long-term health. Download a free tool to help you recognize signs of PsA in your psoriasis patients.Download the tool
Psoriasis is a chronic, inflammatory disease that affects over 8 million Americans. Psoriasis can profoundly decrease quality of life without appropriate treatment. Additionally, psoriasis is associated with comorbidities including cardiovascular disease, inflammatory arthritis, depression and others.
Primary care providers play an important role in both managing overall health and screening for comorbidities in psoriasis patients.
Psoriasis impact and comorbidities
Quality of life
Despite scientific advancements and a better understanding of psoriatic disease, non-treatment and under-treatment of psoriasis patients continue to persist and adversely affect patient quality of life. In addition to common physical symptoms of itch, irritation and pain, psoriasis can negatively affect lifestyle, emotional well-being, social life and ability to work.
In patient surveys conducted between 2001 and 2008 by the National Psoriasis Foundation (NPF), 33 percent of patients with mild and 60 percent of patients with moderate-to-severe psoriasis reported that it was a significant problem in their everyday life.
Psoriasis patients, especially those with more severe disease, may be at increased risk for comorbidities.
Not only can psoriatic arthritis cause swelling, stiffness and pain in and around the joints, nail changes and overall fatigue, studies show that delaying treatment for psoriatic arthritis as little as six months can result in permanent joint damage.
Additionally, complications of psoriatic arthritis can include arthritis mutilans, conjunctivitis and uveitis. We encourage you to give the Psoriasis Epidemiology Screening Tool (PEST) to your psoriasis patients that allows them to answer questions about their symptoms. If patients check “Yes” to three or more of the five questions, they may have psoriatic arthritis. You should speak with them about their symptoms and possibly refer them to a rheumatologist.
Patients should be fully educated about all aspects of their disease, including all potential systemic comorbidities. Each patient should also receive a specific, personalized treatment plan that is appropriate for their severity level.
In 2016, the NPF developed treatment target recommendations for psoriasis. These goals stipulate that at the 3 month assessment after treatment is initiated, the body surface area (BSA) should be less than or equal to 1 percent. (An acceptable response is a BSA improvement of 75 percent from the patient’s baseline level or a BSA of 3 percent or less.)
At 6 months, it is expected that a BSA of 1 percent or less should be achieved. With defined treatment targets, providers and patients can regularly evaluate treatment responses and perform benefit-risk assessments of therapeutic options individualized to the patient’s level of disease severity, comorbidities, access to medical care and patient treatment preferences.
Currently, providers treating psoriasis patients have many therapeutic options available, including biologics, oral treatments, phototherapy and prescription topicals. The treatment targets do not exclude any treatment. The benefits and risks of all accessible therapies, as either monotherapy or combination therapy, should be considered in the patient-provider dialogue to achieve the patient’s treatment goals. For more information on treatment algorithms and management options, please refer to The Psoriasis and Psoriatic Arthritis Pocket Guide.
Frequently asked questions
1. What are the different major types of psoriasis?
There are 5 main types of psoriasis. Each type has different symptoms and characteristics, and a psoriasis patient may present with more than one type, which may also change over time.
Plaque psoriasis is the most common type, characterized by sharply defined red-to-purple, scaly plaques that are distributed somewhat symmetrically. For some patients, the skin may be red with silvery white scales; however, for patients with skin of color, this may look more violaceous. Although most commonly seen on the scalp, knees, elbows and in or around the umbilicus and lower back, plaque psoriasis can affect any area of the body. Plaque psoriasis may also present with nail involvement, such as pitting, onycholysis, subungual hyperkeratosis and “oil spots.”
Erythrodermic psoriasis (also called exfoliative psoriasis) consists of widespread inflammation of the skin characterized by generalized erythema, scaling and exfoliation. Patients may be ill and have hypo- or hyperthermia, electrolyte disturbances, protein loss, dehydration, renal failure and cardiac abnormalities. Severe nail involvement is also characteristic of erythrodermic psoriasis.
Pustular psoriasis is characterized by individual or coalescing sterile pustules. Pustular psoriasis may present as either generalized (von Zumbusch psoriasis) or localized pustules, most often on the palms of the hands or soles of the feet (palmoplantar pustular psoriasis).
Guttate psoriasis is characterized by mostly small, red, scaly papules. “Droplet” lesions may occur over the entire body surface, with the trunk being most commonly affected. This type of psoriasis tends to occur in younger patients, and often follows a strep infection (most commonly strep pharyngitis).
Inverse psoriasis (also called flexural or intertriginous psoriasis) is a seborrheic-dermatitis-like form that occurs in the body folds such as underarms, under breasts, in the genital area and the gluteal cleft.
2. How is psoriasis diagnosed?
The clinical manifestations of psoriasis are well-known and usually recognized easily. A complete skin examination, including the nails and scalp, should be performed. Additionally, a skin biopsy may also be done for further confirmation.
3. How is psoriasis severity measured?
The severity of psoriasis is determined by measuring BSA affected and by the effect of psoriasis on the patient’s quality of life and ability to function. Psoriasis affecting less than 3 percent BSA may be considered mild, 3 to 10 percent as moderate and more than 10 percent as severe.
However, a patient may have psoriasis that covers only a small area, but if it is highly visible or debilitating, it could be considered a severe case. For example, psoriasis involving sensitive areas, such as the face or genital area, or palms of the hands and soles of the feet, are often disabling and may be considered severe even if the rest of the body is not extensively involved.
4. How is impact on quality of life measured?
Disease severity classification serves as a reference point for the physical aspects of the disease, but not the emotional and social aspects. Clinical assessment should include the patient’s perspective on subjective factors such as itching, pain, loss of sleep and effect on daily activities.
The Koo-Menter Psoriasis Instrument (KMPI) is a short assessment tool that includes a validated Health Related Quality of Life index, a Psoriasis Quality of Life questionnaire and other assessments from both the patient’s and the physician’s perspective. Copies of the KMPI can be requested at firstname.lastname@example.org.
5. What are some considerations in making a treatment recommendation?
Treatment goals should aim to gain initial rapid control of the disease, decrease BSA involvement and symptoms, avoid adverse effects as much as possible, improve the patient’s quality of life, maintain long-term remission and avoid relapse.
There is no universally effective therapy or combination therapy, and all treatment must be individually tailored to each patient’s needs. Recommendations should be based on disease severity with topicals generally used for limited disease or as an adjunct to biologics, oral treatments or phototherapy, which are generally used for moderate-to-severe disease.
Key points to keep in mind when recommending treatments:
- Patients should not be forced to fail one therapy in order to qualify for a more appropriate therapy. For more information about step therapy, visit steptherapyinfo.com. Or contact our Patient Navigation Center for help with insurance denials and other treatment access issues that your patients may be facing.
- Ongoing therapy is often required to maintain remission.
- Life factors such as employment, childbearing potential, alcohol intake, access to therapies, comorbidities, response to sunlight, and response to prior therapies must be considered in selecting the ideal treatment for a patient.
- Psoriasis can cause disabilities similar to cancer, diabetes and other major diseases.