To the majority of the outside world, psoriasis is seen as a cosmetic nuisance, an unsightly skin condition that they are glad they don’t have to deal with but not likely a major quality-of-life deterrent. But for a patient living with this chronic skin condition, the impact of psoriasis cuts far deeper than the appearance of the skin.
Psoriasis does not discriminate. While there are known genetic links and environmental triggers, there does not need to be a specific cause for the condition to develop in a given individual. In many patients, psoriasis will initially emerge as mild itching with no obvious indication that anything more serious is wrong. The nail involvement that may be a more significant clue is often overlooked by primary care physicians and certainly is not on the radar of the general public. It’s typically not until silvery scales and bright red, well-demarcated plaques begin to appear that patients are sent to the dermatologist for further evaluation.1
Psoriasis can present other challenges aside from skin issues. Patients with psoriasis are at increased risk for cardiovascular events, type 2 diabetes mellitus, metabolic syndrome, and lymphoma. Obesity can also worsen psoriasis.2 This is something we are used to seeing in rheumatology and only reinforces the need for our overweight patients with PsA to exercise and embrace a healthy diet.
“I am lucky to work in a practice where dermatology is just down the hall, and it is easy to send patients back and forth to co-manage their care.”
Within the walls of rheumatology, we typically don’t see psoriasis patients until they develop joint symptoms, so we don’t often hear about the early impact of the skin disease on patient quality of life. Certainly, in those patients for whom the disease progresses to psoriatic arthritis (PsA), we must become attuned to issues related to both the joints and skin, but we are generally more skilled at dealing with joint pain and swelling due to the general patient population that we treat.
To advance my own personal education, I walked down the hall recently to meet with members of the dermatology team at my institution to try to get a better sense of some of the issues they typically have to deal with in their newly-diagnosed psoriasis patients. Here are some of the highlights regarding what I learned:
1. There are several variants of psoriasis.
While the majority of patients will have plaque psoriasis (the indication that many of the biologics and small molecules that crossover into rheumatology are approved to treat), there are less common subtypes such as guttate, inverse, and pustulate psoriasis that all present and progress in a different fashion and require different management approaches.
2. When assessing patients with any skin condition, it is vital to do a full-body assessment from head to toe, front to back, and everywhere in between.
Psoriasis sometimes “hides” in skin folds or under the hair. The nail beds are often one of the most obvious areas to look for signs of disease. Dermatologists look for pitting and thickening of the nail beds, which can sometimes be the only visible sign of early disease.
3. As with virtually any medical condition, getting an accurate diagnosis of psoriasis subtype is the first key step in determining an appropriate treatment regimen.
Treatment then is typically based on the severity of the psoriasis (ie, the percentage of the body covered by rash) and the impact of the disease on the patient’s quality of life. Most patients will begin with topical corticosteroids as long as involvement excludes the scalp, genital area, and nail area. When there is moderate-to-severe scalp, genital, and/or nail involvement, oral biologics are often used as frontline therapy.
4. Patient preference is a key consideration when determining treatment as topical regimens require frequent and consistent application to be effective.
Biologics, of course, have their own issues that we are well aware of in rheumatology (injection vs. infusion vs. oral, cost/insurance hurdles, etc.).
I am lucky to work in a practice where dermatology is just down the hall, and it is easy to send patients back and forth to co-manage their care. The rule of thumb for my dermatology colleagues is to send over any patient with psoriasis who develops joint stiffness and/or inflammation lasting >30 minutes to rheumatology for further evaluation. Conversely, we’ll often send patients with PsA over to dermatology to rule out atypical presentations such as drug eruptions (which often require a biopsy) in a patient who develops a new or atypical rash that appears unrelated to PsA.
In our center, we lead the management of the majority of patients with PsA. Taking the cue from our dermatology colleagues, our first step in any patient referred to us is to repeat that head-to-toe physical exam, looking both for any new rash as well as joint swelling/stiffness throughout the body. While this may sometimes seem redundant for our patient, this “double checking” ensures that nothing critical is missed and that we are able to set our patients on the right path of treatment.
Regardless of the pathway a patient with PsA takes to diagnosis, our job is to provide the best patient-centered care that is possible and to involve the patient in any decisions that will impact their health. Listening to the patient and the day-to-day challenges that they face can provide you with a wealth of information that will guide their treatment.
References
1. Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med. 2009;361(5):496-509.
2. Papadakis MA, McPhee SJ, Bernstein J (Eds). Quick Medical Diagnosis & Treatment 2021: Psoriasis. McGraw-Hill.
AUTHOR PROFILE: Joni Fontenot, RN, is an RN Staff Nurse at Ochsner Health System – The Grove – Infusion/ Rheumatology Infusion in Baton Rouge, LA, and Chapter Development Chair on the Rheumatology Nurses Society Board of Directors.
Participants will receive 2.75 hours of continuing nursing contact hours by completing the education in our course:
The Intersection of Dermatology and Rheumatology in the Management of Psoriatic Arthritis