Practical Management of Plaque Psoriasis: Nurse Practitioner and Physician Assistant Perspectives - Episode 3
Douglas DiRuggiero, PA-C: That kind of leads us to the next portion, which is looking at what the burden of this disease is on our patients. You just hit the nail on the head, Margaret, because people can come into this diagnosis with a lot of baggage or with no knowledge at all. Maybe they’ve watched their mother or father have debilitating arthritis and psoriasis and depression associated with it. Therefore, when you tell them that, they’re going to fall apart because they’ve seen the impact it’s had on family members. Or they’ve never heard of it before and didn’t think anyone else that they knew had it.
You have to feel it out, because the burden of the disease can be tremendous in 3 different ways that I see. Regarding the burden of disease on the psychosocial side of things, in terms of having a disease that’s on the skin that’s always seen by other, there is an increased risk of depression in patients with psoriasis. We know that. Right now, the current data demonstrate that about 8.5% of Americans are treated for depression, while 16.5% claim they have depression with the diagnosis of psoriasis. It’s almost twice as prevalent as the general population.
But we also see that it impacts their work. If you can’t go to work, it impacts the pocketbook as well. We’re talking about intimacy issues with relationships. We’re talking about risk of depression and suicidal ideations associated with it. We’re talking about the impact on your ability to have gainful employment. And then, just the quality of life, and thinking about what you’re going to do in the future. “Can I pick up my kids? Can I go on hikes? Am I going to be able to do these things?”
Something I think I’ve heard you say before, which impacted me, is that when patients are diagnosed with cancer or lose their sight, which are very unfortunate things, the response from others is very different, even though that’s debilitating information to receive. There’s empathy and sympathy there. But when someone is diagnosed with this visible disease, which is affecting them, the response is very different. It’s not empathy or sympathy. Repulsion is probably a hard word, but it’s definitely 1 that’s different from someone else who’s dealing with…
Melissa Davis, PA-C: I think patients feel that way. I have a lot of patients who report going to the pool and people getting out of the hot tub when they get in. I had a patient tell me that. The data show that the psychosocial burden as well as the physical burden, with psoriasis could be equivalent to chronic lung disease. When I worked in primary care before dermatology, in lung disease patients, that’s a lot. I mean, the physical burden and the psychosocial burden there for those patients… When I saw the data that showed that patients ranked their physical burden and emotional burden equivalent to those patients, that really surprised me. I feel like patients don’t complain as much. But I also think they don’t want to be seen as a complainer, so we need to dig a little more and ask those patients a little more. “How are you feeling?” Because if they have hypertension or diabetes, nobody knows. But if you have psoriasis on your hands or arms or legs, people can see that. That really impacts the patients in a way that those of us without psoriasis may not consider, even though we take care of them.
Melodie Young, MSN, RN, ANP-C: Looking at it over the last few decades, we had drugs that would not clear patients. We could get them better, or we could improve certain areas, or they could pick months out of the year in which they could be clear and other months for which they wouldn’t be clear. It was incredibly impactful when all we had was methotrexate, phototherapy, topical treatments. Then to see where the disease is gone from their life. One of the other things I really think about is knowing what would have happened to patients through the years had they not been able to be clear.
I always think about a 20-year-old who showed up at my clinic a couple of years ago, in May. She had experienced her freshman year of college after having developed psoriasis at age 18. She had a strep throat, and her disease became visible on her face and everywhere. She had to go through the whole sorority thing during her whole first year of college with psoriasis. The dermatologist at the college town that she was at had given her topical therapy for small plaque and guttate psoriasis, which wasn’t going to work. She was treated with some phototherapy, which didn’t help. Then when we got her clear, she made the comment to me of, “My freshman year would have been a completely different experience if I’d have been clear,” because of, I think, the psychosocial burden.
As clinicians, we have 1 job, and that is to help people be at their maximum level of wellness with everything we have in our armamentarium. Looking at the burden of disease—just think about, if you can, if this person could be clear, what other choices and experiences they might have. This is a visible disease, and we treat visible diseases all the time—vitiligo, alopecia disorders—and those people are greatly disturbed. They can’t hide it, especially if it’s a flaky, bloody disease and they’re greasy from over-the-counter products or topicals. They really don’t feel like they fit in, and they will say things like, “I just want to be clean.” They don’t even know that they can use the word clear. They’re just thinking, “How do I not look so awful?”
Douglas DiRuggiero, PA-C: I’m just going to say, too, that while it is a visible disease, there is an internal burden that we recognize as well. We will get to this maybe a little later on, but that burden is in the form of a lot of comorbidities that we have to look at and manage. There are increased risks, with the psoriasis itself being a pro-inflammatory autoimmune disease. This is an inflammatory state. Because of that, the burden of disease impacts increased risk of diabetes, increased risk of hypertension, increased risk of certain types of cancers. Arthritis, of course, we know is there too. I think we’ll probably home in on that in a little, but I think it’s important for us to see that.
Melissa Davis, PA-C: For our patients, a really important question to ask them is, “Do you have a primary care provider?” I had a patient say just recently, “You and my ob-gyn are.” I was like, “Well, I’m not a primary care provider. I’m a dermatology PA [physician assistant].” I encourage them to get a primary care provider because of the cardiovascular risk factors, and making sure that if they have other heart disease risk factors in their family that they’re screened appropriately and are managed correctly by us and their primary care provider.
Transcript edited for clarity.