5 Things Clinicians Should Know About Psoriasis

Allison Gilchrist, Associate Editor
Published Online: Thursday, August 4th, 2016
August is Psoriasis Awareness Month, making it the perfect opportunity for clinicians to brush up on the wide variety of health issues often associated with the disease.
 
The National Psoriasis Foundation (NPF) reports that as many as 7.5 million Americans have psoriasis, an autoimmune inflammatory disease. It can occur in all age groups, but it primarily affects adults.
 
As the prominence of retail clinics continues to rise, an increasing number of patients with diverse conditions are turning to convenient clinics for counseling. Psoriasis patients are no exception.
 
To prepare, here are some must-know facts about the condition:

1. Double check if patients with psoriasis are up to date with vaccines.
When a patient’s psoriasis progresses from mild to severe, the treatments that he or she needs intensify, Debra Michaud, RN, MS, ARNP, FCP-C, MBA, explained to Contemporary Clinic. Many patients may require biologic therapies such as Humira (adalimumab), Remicade (infliximab), or Enbrel (etanecept).
 
“There are live vaccines that cannot be given to these patients,” she said. “So, we want to make sure all of their vaccinations are up to date.”



According to NPF, patients taking psoriasis therapies that suppress the immune system can receive vaccinations containing inactivated viruses because they’re less likely to progress toward infection.
 
Here are the routine vaccination recommendations from NPF:

 
Vaccine Before systemic therapy During systemic therapy
Flu Vaccinate with either live or inactivated vaccine. Vaccinate yearly with inactivated vaccine.
Chicken pox Test for immunity; if negative, offer vaccine. Not recommended in most cases. Discuss with physician.
Zoster 1 dose for adults older than 50 years. Not recommended. However, limited data from one study suggests that it may be feasible.
HPV Recommended for males and females up to 26 years. Recommended for males and females up to 26 years.
Hepatitis A Vaccinate if at high risk. Vaccinate if at high risk, and consider verifying immunization afterward.
Hepatitis B Vaccinate if tests show no disease or immunity and if risk factors are present. Use high-dose vaccine, and consider verifying immunization afterward.
Pneumococcal Recommended, but precede with PPSV23 vaccination. Vaccinate first with PCV13, then with PPSV23.
Hib Vaccinate unvaccinated adults. Vaccinate unvaccinated adults.
MMR Vaccinate if there’s no history of disease and tests show no immunity. Not recommended in most cases. Discuss with physician.
Tdap If wounds are high risk and patient has had no pertussis vaccination, vaccinate with Tdap, provided the last Td vaccination was more than 2 years prior. Administer booster dose if it was more than 10 years prior. If wounds are high risk and patient has had no pertussis vaccination, vaccinate with Tdap, provided the last Td vaccination was more than 2 years prior. Administer booster dose if it was more than 10 years prior.
Meningococcal Vaccinate if at high risk. Vaccinate if at high risk.
Polio Vaccinate if at high risk. Vaccinate if at high risk.
 

2. Psoriasis can take an emotional toll on patients.
Up to 60% of psoriasis patients report that the condition negatively impacts their quality of life. Recent study results published in JAMA Dermatology suggest that patients with psoriasis are at higher risk of developing major depression than those without the inflammatory skin condition.
 
Depending on where the psoriasis is located on the body, some patients might feel embarrassed about their condition. Other patients report that the condition interferes with their relationships, and women report experiencing a greater negative impact on quality of life than men.
 
“The disease process can actually make them feel pretty uncomfortable because of the rashes on their arms or if it’s on their face,” Michaud said. “That can affect how they’re feeling and create stress as they think about what other people think of them.” 



Given the condition’s psychological impact, clinicians can encourage patients to seek professional help if they’re feeling depressed or avoiding social events because of embarrassment. Professional guidance can assist patients with coping skills.

3. Psoriasis is often associated with comorbidities.
Hypertension, diabetes, obesity, and autoimmune diseases such as Crohn’s disease and inflammatory bowel disease are all associated with psoriasis. Research has also demonstrated that psoriasis is an independent risk factor for cardiovascular disease.

Additionally, severe psoriasis is associated with early mortality of 3.5 years for men and 4.4 years for women. Women report a greater impact than men. Meanwhile, 20% to 30% of patients with psoriasis will develop psoriatic arthritis, usually within 12 years of initial onset.

For patients experiencing comorbidities due to modifiable behaviors, such as obesity or smoking, clinicians can offer nutritional and exercise counseling points to help them better manage their condition.
 
4. There are several distinct avenues to treat patients with psoriasis.
It’s not uncommon for patients to grow weary, impatient, or frustrated when certain treatments aren’t producing the results they want. Clinicians should be familiar with each of the treatment options so that they may suggest alternatives to patients if necessary.
 
Common psoriasis treatments include:
·      Topical corticosteroids
·      Keratolytic agents
·      Vitamin D
·      Topical retinoids
·      Antimetabolites
·      Immunomodulators
·      Tumor necrosis factor antagonists
·      Coal tar
 
Meanwhile, phototherapy, or laser therapy, although effective, is used on treatment-resistant patches and can be time-consuming. Ultraviolet B is often combined with systemic agents, as the combination increases efficacy and allows for reduced systemic medication doses.
 
Clinicians should emphasize that the best outcomes are achieved with early intervention; patients should never postpone treatment. Current symptom severity isn’t predictive of future symptoms.
 
5. Pregnancy can affect psoriasis.
Up to 25% of pregnant women experience worsening of symptoms. Ask your pregnant patients about symptoms, and depending on the circumstance, discontinuing the medication during the pregnancy may be the optimal option.
 
Discontinuing medication during pregnancy may not be an option for women with psoriatic arthritis. Clinicians should let their patients know which pain medications can be used safely during pregnancy.
 
Additionally, one study published in the Journal of the American Academy of Dermatology found that women with severe psoriasis face a greater risk of delivering a baby with a low birth weight than their counterparts without the disease. However, that effect wasn’t observed in women with mild psoriasis.
 


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