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Archive

Autumn 2013, Vol. 21 No. 3

Hong Kong J. Dermatol. Venereol. (2013) 21, 131-133


Views and Practice

Psoriasis challenge: are we meeting the needs of our patients?

W Gulliver

As a dermatologist involved in the treatment of patients with moderate to severe psoriasis, it is often useful to take time to self reflect and ask oneself are we truly meeting the needs of our psoriasis patients.

In Canada, a group of experienced dermatologists gathered to write a position paper on a new class of psoriasis therapies known as biologics.1 They concluded that after reviewing all aspects of the patient's medical history, physical examination and laboratory evaluations, treatments for moderate to severe psoriasis, including systemic therapy, phototherapy and biologic therapy should be considered equally. In 2009, I along with many other dermatologists experienced in the treatment of psoriasis gathered to write the Canadian Psoriasis Guidelines.2 The message was exactly the same in that after careful evaluation, patients should be offered appropriate therapy, whether that be phototherapy, systemic therapy or biologic therapy. With these recommendations and a multitude of other excellent guidelines, it seems that very few patients are satisfied with their current treatment, although safe and effective therapies are available. Recently Canadian data reports that the majority of patients are being treated with topical therapy and only 24% of the patients surveyed were satisfied with the current therapy.3 In 2009, a SKIN survey confirmed that psoriasis was having a significant burden on our Canadian patients.4

With the treatment modalities available to dermatologists and patients, along with the myriad of high-quality guidelines, why does it seem that many dermatologists have not risen to the occasion and taken the psoriasis challenge and met the needs of their patients?

When it comes to treating psoriasis, it is extremely important that patients and their families have a thorough understanding of the risks and benefits, and must take their therapeutic journey with psoriasis treatments. As clinicians, it is our job to understand how deeply impacted the patient's family is by psoriasis and its treatment. We must assess the patient's entire medical history to ensure the best options are considered. As physicians, we also need to develop a treatment programme that is within the risk tolerance of the patient and their family in order to achieve the patient's desired therapeutic outcome. Truly this is something that is not as simple as it might seem. To support the complex nature of this relationship, the physician and patient must be open and honest with each other in all aspects of the family history and share the therapeutic history as well. Physicians must take a comprehensive medical history and undertake a detailed physical and laboratory evaluation, using all tools available to measure psoriasis severity and its impact on quality of life, in order to understand the particular needs of that patient. Once the comprehensive evaluation is complete, the physician truly understands the patient and their psoriasis, only then can the therapeutic options be discussed in an open and honest manner. An informed decision on treatment approach can be mutually agreed upon. An important aspect is assessing the patient's risk profile as it plays an important role. We all know that some patients are extremely risk averse while others are not. Many patients may be comfortable with therapies that have a long track record, such as topicals and UVB therapies. Others are willing to accept methotrexate, cyclosporine or biologics. The key to a successful therapeutic outcome is to use approaches that fall within the risk tolerance of the patient and their family, which will provide an acceptable therapeutic outcome.

When it comes to phototherapy, we know it is a treatment that many patients will accept and most dermatologists are happy to consider. Issues arise around the availability and the risk of melanoma and non-melanoma skin cancer. Systemic PUVA is rarely used as a form of phototherapy as it has unacceptable risk in most patients. Patients who have undergone organ transplant or taking immunosuppressants are one group that may be at an even higher risk. When it comes to systemic therapy, either oral or injectable, some patients are concerned about taking medicine internally for a disease that just appears on the skin. As we know patients with psoriasis have multiple comorbidities,5,6 and the choice of systemic therapy has to be done based upon the information gathered during the physician's evaluation. In the case of anti-TNFs, patients with personal or family history of multiple sclerosis or demyelinating disease may present too great a risk, whereas an anti-IL12/23 may have an acceptable risk safety profile. The converse is true in some patients using methotrexate or anti-TNF as seen in patients with ischaemic heart disease or stroke.7,8 For other forms of heart disease such as congestive heart failure, anti-TNFs may not have an acceptable risk benefit profile and molecules that target IL12/23 would have a lower risk profile. Psoriatic arthritis is another example where a psoriasis comorbidity would dictate the therapeutic pathway and lead us to either using methotrexate or an anti-TNF.

Again we must emphasise that before starting any therapy a patient should have a very thorough screening and assessment. Special consideration should be given to patients with greater risk of infections or with a history of comorbidities or malignancies. An important message we must convey to our psoriasis patients is that therapeutic options are now available in dermatology which can provide safe and effective control of their psoriasis for prolonged periods of time in the majority of patients. And yes, as dermatologists, we can meet the needs of our patients and accept the psoriasis challenge with knowledge and enthusiasm.

References

1. Guenther L, Langley RG, Shear NH, Bissonnette R, Ho V, Lynde C, Murray E, et al. Integrating Biologic Agents into Management of Moderate-to-Severe Psoriasis: A Consensus of the Canadian Psoriasis Expert Panel. J Cutan Med Surg 2004;8:321-37.

2. Papp K, Gulliver W, Lynde C, Poulin Y, Ashkenas J; Canadian Psoriasis Guidelines Committee. Canadian Guidelines for the Management of Plaque Psoriasis: Overview. J Cutan Med Surg 2011;15: 210-9.

3. Poulin Y, Papp KA, Wasel NR, Andrew R, Fraquelli E, Bernstein G, et al. A Canadian online survey to evaluate awareness and treatment satisfaction in individuals with moderate to severe plaque psoriasis. Int J Dermatol 2010;49:1368-75.

4. Lynde CW, Poulin Y, Guenther L, Jackson C. The burden of psoriasis in Canada: insights from the pSoriasis Knowledge IN Canada (SKIN) survey. J Cutan Med Surg 2009;13:235-52.

5. Gulliver W.. Long-term prognosis in patients with psoriasis. Br J Derm 2008;159(Suppl 2):2-9.

6. Gulliver WP, Macdonald D, Gladney N, Alaghehbandan R, Rahman P, Adam Baker K. Long-Term Prognosis and Comorbidities Associated with Psoriasis in the Newfoundland and Labrador Founder Population. J Cutan Med Surg 2011;15:37-47.

7. Prodanovich S, Ma F, Taylor JR, Pezon C, Fasihi T, Kirsner RS. Methotrexate reduces incidence of vascular diseases in veterans with psoriasis or rheumatoid arthritis. J Am Acad Dermatol 2005;52:262-7.

8. Wu JJ, Poon KY, Channual JC, Shen AY. Association Between Tumor Necrosis Factor Inhibitor Therapy and Myocardial Infarction Risk in Patients With Psoriasis. Arch Dermatol 2012;148:1244-50.