Drs Angela Goyal and Kash Bhatti provide an overview of the PCDS primary care treatment pathway for psoriasis and discuss the importance of lifestyle advice and skin-directed treatment

Dr Angela Goyal

Dr Angela Goyal

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Read this article to learn more about:

  • how to assess a patient with psoriasis and what clinical features to examine
  • the importance of recognising psoriatic arthritis as soon as possible
  • recommended pharmacological therapies.

Key points

Implementation actions for STPs and ICSs

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General practitioners will often encounter patients with psoriasis, a condition that affects about 2.8% of the UK population.1 Psoriasis has a varied clinical picture and, as a multisystem disorder, it can have a huge impact on the quality of life for the affected individual. Although ample guidance for treating psoriasis exists, there remains a lack of confidence in managing this disorder compared with other conditions.2–4

In September 2017, the Primary Care Dermatology Society (PCDS) published its Psoriasis—primary care treatment pathway, which aims to provide GPs with a user-friendly, at-a-glance reference guide to help them recognise and manage patients with psoriasis.5 The pathway complements the comprehensive information and advice on psoriasis already available on the PCDS website.6

A key point the PCDS sought to emphasise through its pathway is that psoriasis affects more than only the skin: it is a chronic, relapsing, inflammatory condition affecting the skin, scalp, nails, and joints, and is associated with cardiovascular and psychological co-morbidities.

Background

An average GP’s list size may include up to 50 patients who are affected by psoriasis.1 Of these patients, up to 30% may develop psoriatic arthritis.7,8 Psoriasis is associated with increased all-cause mortality and cardiovascular morbidity,9 and is also linked to increased anxiety, depression, suicidal ideation, obesity, excess alcohol use, and time away from work.10–12

Although psoriasis can occur at any age, typically it has a bimodal distribution of onset, with a peak between the ages of 16 and 22 years and a second peak between 57 and 62 years.13 A positive family history is associated with psoriasis, and both sexes are affected equally.14

Diagnosis and assessment

The clinical features of psoriasis can vary; however, it typically manifests as sharply demarcated dull red plaques with silvery scales that shed easily. Practitioners should refer to the PCDS pathway5 for a more extensive list of clinical features associated with the different types of psoriasis and different affected areas.

Psoriasis can affect any part of the body, including areas of traumatised skin such as surgical scars (this is known as the Koebner phenomenon). Chronic plaque psoriasis is the commonest form, affecting 80–85% of patients with psoriasis.13 Nails can be affected in up to 50% of patients5 (though estimates vary in the literature) and can cause significant dystrophy. Scalp and genital psoriasis can be socially embarrassing and may cause severe psychological distress.

Psoriasis, like any other chronic disease, requires a holistic approach when assessing the patient. Attention should be directed towards identifying any triggers or exacerbating factors, including:5

  • drugs
  • infections
  • stress
  • smoking
  • alcohol intake
  • obesity. 

The skin should be assessed in good lighting and sites such as the scalp and nails should be closely examined. Psoriasis can be found in flexures and the umbilicus. Anogenital symptoms are often forgotten so it is important to ask about these specifically. 

A cardiovascular examination should be performed, and appropriate blood tests may be required, to assess cardiovascular disease risk using tools such as QRISK® 2 or 3,15 or JBS3.16

Psychosocial impact should be determined with the following simple open question: ‘How are you coping?’ The Dermatology Life Quality Index (DLQI), a validated questionnaire of 10 simple questions, can be used as an objective score of wellbeing and to serially monitor quality of life.17

The authors stress the importance of recognising psoriatic arthritis, which may exist without cutaneous lesions, but is more likely after skin disease is established (approximately 75% of cases).9,18 Psoriatic arthritis should be suspected if there are symptoms or signs of:5,13,19

  • inflammatory arthritis (prolonged morning stiffness and joint swelling)
  • dactylitis (inflammation of a digit)
  • early morning back stiffness, buttock, or sciatic pain
  • heel pain (Achilles tendon enthesitis) or plantar fasciitis.

The PCDS pathway signposts to the Psoriasis Epidemiology Screening Tool (PEST) as a validated screening tool for psoriatic arthritis, though practitioners should be aware that this does not screen for axial psoriatic arthritis.5,13

Psoriatic arthritis also exhibits the Koebner phenomenon and can occur in a traumatised joint or tendon. Patients who are suspected of having psoriatic arthritis should be referred urgently to rheumatology to prevent permanent joint destruction.5

General practitioners are constrained by consultation times, so it is likely that (as with any other chronic disease) the assessment will span multiple consultations. The authors emphasise treating patients individually, and GPs should:

  • tailor advice and treatment according to the patient’s concerns and wishes
  • discuss and manage expectations
  • establish a regular review:
    • although psoriasis is not part of the quality and outcomes framework, it is advisable to perform an annual review of patients with psoriasis
    • symptoms of psoriatic arthritis should be explored at each review
  • offer opportunities for support, or signpost to:
    • agencies that provide access to psychological therapies, smoking cessation, alcohol reduction, and weight management
    • support groups and charities such as the Psoriasis Association (www.psoriasis-association.org.uk).

Management of psoriasis

The psoriasis treatment pathway emphasises the importance of addressing modifiable triggers and exacerbating factors, and reducing co-morbid risk. The pathway branches into ‘lifestyle-directed advice’ and ‘skin-directed treatment’, with the aim of treatment being to control, not cure.

Lifestyle-directed advice

There is a growing body of evidence to support the use of lifestyle interventions. Recommended lifestyle interventions include: improving diet*, physical activity, alcohol reduction, smoking cessation, and relaxation techniques; these interventions reduce psoriasis severity and improve cardiometabolic health.5,20 This is particularly important because patients with psoriasis have a higher prevalence of co-morbidities that increase cardiovascular disease risk, including obesity, type 2 diabetes, hypertension, and dyslipidaemia.9 Psoriasis may also be an independent risk factor for myocardial infarction,21 which is thought to be due to a link between sustained cutaneous inflammation and vascular inflammation.

*There is a plethora of diets and although no one diet is validated to help psoriasis, a sensible suggestion is to vary advice in accordance with the patient’s circumstances. The Mediterranean diet is the most evidence-based cardioprotective diet and may be a good starting point but other diets exist such as low-carbohydrate or low-calorie diets.22

Skin-directed treatment

Practitioners are advised to refer to the psoriasis treatment pathway5 for a full list of treatment options and advice on the type of psoriasis they should be used for.

Emollients are the foundation of psoriasis treatment for all patients, and can be used in conjunction with other more ‘active’ treatments. Emollients for plaque psoriasis can reduce symptoms of dryness and itch, and improve hyperkeratosis.5 No single moisturiser is better than another, and choice should be a shared decision between the patient and the healthcare professional. Generally, ointments are the preferred type of emollient to prescribe; however, the best moisturiser is ‘the one the patient will use’.

Suggested treatments for psoriasis include:

  • topical corticosteroids
  • vitamin D analogues
  • combination products (e.g. salicylic acid and betamethasone dipropionate, betamethasone dipropionate and calcipotriol monohydrate)
  • calcineurin inhibitors (where allowed by the CCG).

The PCDS acknowledges that its treatment advice may stray from SIGN and NICE guidance in terms of the order of product use, but PCDS advice is intended to be practical and easy for the patient and practitioner. For example, the pathway recommends a corticosteroid/vitamin D analogue combination product to treat plaque psoriasis, whereas NICE recommends applying a corticosteroid in the morning followed by a vitamin D analogue in the evening (or vice versa).3,5 The PCDS states in its pathway that its treatment protocol is ‘… more patient centred and clinically effective using once daily dosage.’

Applying emollients, and using soap substitutes, therapies for scalps etc, can be exhausting enough for the patient, and the PCDS wishes to promote effective treatment and aid treatment adherence. Of course, any treatments offered should be part of a shared decision-making process and reviewed regularly to check acceptability and use.

The PCDS pathway distinguishes between the active treatment of psoriasis (to combat a flare) versus maintenance treatment of psoriasis (when lesions are asymptomatic or in remission).5 During flares, treatments might be needed daily to induce remission and ‘get it good’; in remission, treatments can be used twice a week, such as on weekends to ‘keep it good’.

When to refer

There is advice in the pathway on when referral should be considered. Immediate referral via a same-day discussion with a dermatologist should be considered for erythrodermic psoriasis (>90% body surface area affected). Consider acute admission if the patient is febrile or systemically unwell (unstable psoriasis) or if there is widespread pustulosis (generalised pustular psoriasis).

Routine referral is warranted for psoriasis that does not respond to topical treatment or is extensive (defined as >10% total body surface area coverage). An urgent referral may be warranted for either severe symptomatic psoriasis or if psoriasis is causing severe psychological distress. Although the pathway is focused on primary care, examples of what treatment options may be given to patients in secondary care are listed, and these include phototherapy, systemic therapies, and biologics.5

Conclusion

The PCDS guidance reinforces the message that psoriasis is more than just a skin disease. It requires a thorough assessment and working partnership between patient and doctor.

Psoriasis is eminently controllable. Most patients with psoriasis are treated in primary care only; this puts the onus on GPs to get the treatments and advice right. The aim of the PCDS in creating this treatment pathway was to instil confidence among GPs and to help them navigate through the myriad of treatments available and give practical advice as to their use.

Dr Angela Goyal

GPwSI Dermatology, Leeds; dermatology specialty doctor; Founder of Inspired Medics.

Dr Kash Bhatti

GPwSI Dermatology in community and hospital-based clinics, GP trainer; executive committee member of the PCDS.

Key points

  • Patients with psoriasis often do not complain and live with their chronic condition however disabling it may be—GPs should treat patients with psoriasis like those with any other chronic disease, aiming to optimise treatment and carry out regular review
  • Psoriasis is more than just a skin disease—it can affect joints, the scalp, and nails, and can cause severe psychological co-morbidities. It is also linked to metabolic syndrome and cardiovascular disease risk
  • Do ask about the genitals—patients may be too embarrassed or self-conscious to mention that they are affected, but will be grateful that you raised the question as it can be uncomfortable and distressing for them
  • Do screen for symptoms that may suggest psoriatic arthritis
  • Lifestyle advice has been shown to reduce psoriasis severity—interventions include: improving diet, exercise, reducing stress and alcohol consumption, and smoking cessation. The effectiveness of lifestyle interventions on psoriasis should not be underestimated
  • Do ask your patient how they are coping
  • Emphasise to patients that the aim of treatment is to control the psoriasis, not cure it
  • Prescribe adequate amounts of emollients and active therapies for your patients. Mention pre-payment certificates as they can get expensive
  • Safe, natural sun exposure is a good treatment option but advise the patient to not ‘overdo it’ and that commercial tanning salons should be avoided
  • Be wary of using oral corticosteroids in patients with psoriasis (e.g. to treat an exacerbation of COPD) as sudden withdrawal may precipitate unstable psoriasis; always try to wean patients off corticosteroids gradually
  • The PCDS website has comprehensive advice on management and gives guidance on the various subtypes of psoriasis.6
COPD=chronic obstructive pulmonary disease; PCDS=Primary Care Dermatology Society

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources. 

  • Involve specialist providers and primary care representatives in developing local care pathways with local integrated care systems, using this guidance as a model
  • Educate primary care providers through events run by specialist providers to help awareness and better management of psoriasis and introduce the local pathway
  • Include the local care pathway, patient information leaflets, and cost effective formulary choices in local formulary guidance or apps, to enable GPs to consult the guidance in real time with patients 
  • Employ community based specialist nurses and/or GPwSIs to help support primary care
  • Identify clear triggers for referral in the pathway, and consider setting up a teledermatology advice service to help reduce the demand on dermatology outpatient services.

STP=sustainability and transformation partnership; ICS=integrated care system

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Read the Guidelines summary of the PCDS Psoriasis—primary care treatment pathway for more advice on managing psoriasis

References

  1. Springate D, Parisi R, Kontopantelis E et al. Incidence, prevalence and mortality of patients with psoriasis: a UK population-based cohort study. Br J Dermatol 2016; 176 (3): 650–658.
  2. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic arthritis in adults. SIGN Guideline 121. SIGN, 2010. Available at: www.sign.ac.uk/sign-121-diagnosis-and-management-of-psoriasis-and-psoriatic-arthritis-in-adults.html
  3. NICE. Psoriasis: assessment and management. NICE Clinical Guideline 153. NICE, 2012 (updated September 2017). Available at: www.nice.org.uk/guidance/cg153
  4. Nelson P, Barker Z, Griffiths C et al. ‘On the surface’: a qualitative study of GPs’ and patients’ perspectives on psoriasis. BMC Fam Pract 2013; 14: 158.
  5. Bhatti K, Cunliffe T, Goyal A et al, the Primary Care Dermatology Society (PCDS). Psoriasis—primary care treatment pathway. PCDS, 2017. Available at: www.pcds.org.uk/ee/images/uploads/general/Psoriasis_algorithm-web-1.pdf
  6. Cunliffe T. Psoriasis: an overview and chronic plaque psoriasis. PCDS, 2017. www.pcds.org.uk/clinical-guidance/psoriasis-an-overview (accessed 13 March 2018).
  7. Lenman M, Abraham S. Diagnosis and management of psoriatic arthropathy in primary care. Br J Gen Pract 2014; 64 (625): 424–425.
  8. Villani A, Rouzaud M, Sevrain M et al. Prevalence of undiagnosed psoriatic arthritis among psoriasis patients: systematic review and meta-analysis. J Am Acad Dermatol 2015; 73 (2): 242–248.
  9. Dregan A, Chowienczyk P, Molokhia M. Cardiovascular and type 2 diabetes morbidity and all-cause mortality among diverse chronic inflammatory disorders. Heart 2017; 103 (23): 1867–1873.
  10. Snast I, Reiter O, Atzmony L et al. Psychological stress and psoriasis. A systematic review and meta-analysis. Br J Dermatol 2017; Epub ahead of print. DOI: 10.1111/bjd.16116
  11. Singh S, Taylor C, Kornmehl H, Armstrong A. Psoriasis and suicidality: a systematic review and meta-analysis. J Am Acad Dermatol 2017; 3: 425–440.
  12. Al-Jefri K, Newbury-Birch D, Muirhead C et al. High prevalence of alcohol use disorders in patients with inflammatory skin diseases. Br J Dermatol 2017; 177 (3): 837–844.
  13. Burden A, Kirby B. Psoriasis and related disorders. In: Griffiths C, Barker J, Bleiker T et al, editors. Rook’s textbook of dermatology9th edition. Chichester: Wiley, 2016: 35.1–35.47. Available at: www.rooksdermatology.com/manual/c35-sec-0001?view=chapter
  14. World Health Organization (WHO). Global report on psoriasis. Geneva: WHO, 2016. Available at: apps.who.int/iris/handle/10665/204417
  15. ClinRisk Ltd. Welcome to the QRISK® 3-2017 risk calculator. qrisk.org/three/ (accessed 13 March 2018).
  16. Joint British Societies for the prevention of cardiovascular disease. JBS3 risk calculator. Available at: www.jbs3risk.com/pages/risk_calculator.htm (accessed 13 March 2018).
  17. Department of Dermatology, Cardiff University. Dermatology Quality of Life Index (DLQI). sites.cardiff.ac.uk/dermatology/quality-of-life/dermatology-quality-of-life-index-dlqi/ (accessed 13 March 2018).
  18. Tillett W, Charlton R, Nightingale A et al. Interval between onset of psoriasis and psoriatic arthritis comparing the UK Clinical Practice Research Datalink with a hospital-based cohort. Rheumatology 2017; 56 (12): 2109–2113.
  19. Primary Care Dermatology Society. Psoriasis: psoriatic arthritis. Available at: www.pcds.org.uk/clinical-guidance/psoriatic-arthropathy (accessed 13 March 2018).
  20. Naldi L, Conti A, Cazzaniga S, Patrizi A, Pazzaglia M, Lanzoni A et al. Diet and physical exercise in psoriasis: a randomized controlled trial. Br J Dermatol 2014; 170 (3): 634–642.
  21. Jensen P, Skov L. Psoriasis and obesity. Dermatology 2016; 232 (6): 633–639.
  22. Barrea L, Nappi F, Di Somma C et al. Environmental risk factors in psoriasis: the point of view of the nutritionist. Int J Environ Res Public Health 2016; 13 (12): 743.