Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 5
Melodie Young, MSN, RN, ANP-C: One more quick thing I’d like to briefly look at would be the assessment process. Melissa, do you want to talk about what you’re looking for and all those different areas that Margaret had mentioned before—scalp, nails, ears, gluteal cleft, etc?
Melissa Davis, PA-C: Yes. First of all, the PASI [Psoriasis Area and Severity Index] and the IGA [Investigator Global Assessment] scores that we talk about a lot are clinical trials. We don’t use those in our clinical practice. We use PGA [Physician Global Assessment]. I use the PGA score in the clinic. However, most of us use BSA [body surface area] in the clinic, and we evaluate that for candidates for biological therapy. It’s important to evaluate and document that. But as you said, patients fluctuate. You’ll see a patient 1 time and maybe they have 10% BSA. The next time, maybe they have 8%, or up a little or down a little. It’s important to tell patients they are going to have a little bit of a fluctuation. BSA-mild psoriasis is up to 3%; 3% to 10% is moderate, and greater than 10% is severe.
But you mentioned those others—gluteal cleft; Margaret, you were talking about the genital area. It’s important to know that if a patient has psoriasis that’s difficult to control in a special area—palmoplantar psoriasis, genital psoriasis, scalp psoriasis—sometimes they are candidates for systemic therapy or biological therapy even though they don’t meet that 3% to 10% or greater than 10% BSA.
But also, we need to evaluate their psychosocial status, as we discussed earlier, to make sure we’re asking them, “How do you really feel? We’ve improved you, but how are you feeling? Are you happy?” Usually, you can tell right when you walk in the room. They’ve got a big smile on their face, and last time they were in they had their head down when you came in the room. I find that happens. We need to be making sure that we’re evaluating them in a complete way—screening them for comorbidities—and ensuring that they have a primary care provider and are getting in for those types of screenings as well.
Melodie Young, MSN, RN, ANP-C: Anything additionally that you have on your routine for how you assess patients, not just initially but for subsequent visits?
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: For me, 1 of the most important things in leading to our decision that we’ll talk about is psoriatic arthritis. They come to us, as dermatology providers, because they’re bothered by their skin. They haven’t related the fact that they’ve got this back pain, foot pain, or heel pain. They don’t associate that with their skin. So that is 1 of the things I know we’re all so engaged with now, because we know not only that one-third of patients will likely have psoriatic arthritis but the disability associated with it. We can fix your skin, but we can’t reverse that disability when it occurs. So I know that we’re all very much looking at their joints, because the patient isn’t going to think about that. And we are also looking at their nails and other parts of severity that I know we all look at, because it’s important in our decisions that lead us to management as well.
Melissa Davis, PA-C: I did have a patient who came in the other day, who had a little bit of rash. He said, “I have a rash. I think I got into something.” He had a little here on his elbow—kind of a little more his forearm than actually right on his elbow—and he had another place over here in his antecubital fossa. It looked like psoriasis on his elbow, but over here it kind of looked like a contact dermatitis. I started asking him questions. I said, “Do you have any in your scalp?” He said no, he didn’t think so. I looked at his knees. They were clear. But then I said, “Do you have any in the top of your crack of your bottom?” This is what I say to patients, because when I say gluteal cleft, they don’t know what I’m saying. He’s like, “Actually, yes.” Patients think that’s a weird question, but oftentimes they think it’s yeast or sweating; or somebody has been treating them for yeast or fungal infection for years and they don’t realize that it’s connected with psoriasis. So I think that’s an important question.
Melodie Young, MSN, RN, ANP-C: As clinicians, it goes back to that total-body skin check, inside and out, all the different pieces. You may not get that all done during the first visit and the first go at it, but I think that’s something you constantly have to think about and ask those questions because of all the different presentations and types of disease—erythrodermic, pustular, palmoplantar. There are a lot of ways the disease can manifest itself. As clinicians, it’s our job to be aware of those and realize that patients can have multiple presentations within their life or within their family. Sometimes people have other family members who have this, but they always thought it was fungal in the nails. In fact, it’s actually nail psoriasis that they were missing.
Transcript edited for clarity.