From the American Academy of Dermatology
SAN FRANCISCO—Psoriasis can develop at any age, but it most frequently begins during late adolescence or early adulthood. Patients in this age-group often require special attention during a diagnostic office visit, said Steven Feldman, MD, professor of dermatology, pathology, and public health sciences, Wake Forest University School of Medicine, Winston-Salem, NC, at a roundtable session at the American Academy of Dermatology’s 64th Annual Meeting.
“Most doctors don’t realize the impact psoriasis has on people’s lives,” said Dr Feldman. “Severe disease has a huge impact, but even small amounts of localized psoriasis can have an impact.” The majority of patients (85%) have only localized disease, but the red, scaling patches of psoriasis on exposed areas, such as the elbows and knees, can be especially disconcerting for young adults.
“The first thing I do when I diagnose psoriasis is stress that it is not contagious,” he explained.
• Emphasize this by making a point to touch lesions during the examination, which should be conducted without gloves. Also explain that psoriasis does not cause scarring or any other permanent damage.
• Initiate treatment even for localized disease that involves very little of the body surface. “Part of the reason physicians dismiss psoriasis is that they think there is nothing to do about it, but there are so many good treatments now that we can get almost all psoriasis under control,” Dr Feldman said. “Many patients I see wish they would have gotten help sooner.”
• The majority of patients with localized disease will do well with topical treatments. Improved vehicle technology has resulted in a host of less messy corticosteroid creams, gels, foams, and sprays, meaning that patients no longer have to rely solely on ointments.
• Check patients for scalp psoriasis and ask if they have bouts of dandruff, which is a primary symptom of scalp psoriasis. “Treating scalp psoriasis is one of the most daunting tasks, but the newer clobetasol spray or shampoo [Clobex] is useful, as are foam [Obux] preparations,” Dr Feldman said.
• Phototherapy is especially helpful for psoriasis of the palms and soles of the feet. This can be very debilitating and often does not respond well to topical therapies, which do not penetrate well in these areas. Patients who do not have access to nearby phototherapy equipment can try commercial tanning beds. “Not only is it more convenient, but the cost is dramatically lower. One office treatment would cost the same as a month of tanning bed sessions,” Dr Feldman said.
He conducted a 6-week study of a group of patients who underwent a median of 19 commercial tanning bed sessions and found that Psoriasis Area Severity Index scores were significantly reduced in a dose-response fashion according to the number of tanning sessions. “Patients can try it. It certainly isn’t going to hurt anything. A tanning bed is safer than systemic treatment options, such as methotrexate [Trexall] and cyclosporine [Sandimmune],” he said.
• When should you consider a systemic or biologic therapy? “When the patient has a lot of disease, which I define as too many spots to put a topical on,” Dr Feldman said. Some 15% of psoriasis patients have this extent of involvement.
Be sure to ask all patients about joint pain, because approximately one third of them develop psoriatic arthritis, which can be successfully treated with biologic therapies.
Most cases of psoriatic arthritis occur at an average of 10 years after the appearance of skin disease, but some patients develop arthritis early in the disease process.
“There are so many good treatments now that we can get almost all psoriasis under control.”
—Steven Feldman, MD
“A lot of young adults with psoriasis also have depression,” Dr Feldman said. Depression may be more common in those with severe disease who feel their social interactions and activities are limited. “It is important to look for good eye contact, energy level, and depressed affect and to ask about symptoms such as sleep disturbance. If there are signs of depression I am likely to refer these patients to a psychiatrist.”
He recommends referring all newly diagnosed patients to the National Psoriasis Foundation at www.psoriasis.org/home, for education and support. ?
Demonstrate that psoriasis is not contagious by touching lesions without gloves during your examination.
Emphasize that psoriasis does not cause scarring or other permanent damage.
Consider a systemic/biologic treatment when the patient has “too many spots” to put a topical agent on.
Look for signs of depression.