Psychosocial Challenges for Psoriatic Patients

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Having a chronic inflammatory skin disease can be socially and psychologically detrimental

Psoriasis is a systemic inflammatory skin disease characterized by well-delineated erythematous plaques covered by silvery scales. It is one of the more common chronic skin disorders and is encountered in various medical settings.1

In the United States, the prevalence of psoriasis has been estimated to be 2.2% to 2.6%, with over 100,000 new cases diagnosed each year. Higher incidents of psoriasis have been reported to occur in white populations in comparison to other ethnic groups. Lower rates of psoriasis within black and Asian groups have been attributed to possible genetic and environmental factors.

Age also plays a significant role in the occurrence of psoriasis, with most cases occurring between the ages of 15 and 30 years. Gender does not seem to affect disease prevalence as psoriasis is equally common in males and females.1-3

Clinical Presentation

Psoriasis has several clinical phenotypic presentations. The most common form is plaque psoriasis, which presents in 90% of patients. Plaque psoriasis is characterized by well-defined erythematous plaques covered in silvery-white scales that can measure up to several centimeters in size.4

Histologically, plaque psoriasis presents with epidermal hyperplasia and increased dermal vascularity.4 This increased vascularity is often witnessed with presentation of pinpoint bleeding upon removal of scales from psoriatic lesions. This phenomenon is known as the Auspitz sign and sometimes presents clinically in patients with plaque psoriasis.4

Another clinical manifestation of psoriasis is the appearance of lesions within skin folds. This form of psoriasis is known as inverse psoriasis and is characterized by its predilection to flexural surfaces of folding skin.1 Although uncommon, patients can also present with erythrodermic psoriasis, which is the complete spread of psoriatic lesions across the entire body surface. Such widespread erythema can lead to hypothermia and life-threatening conditions such as cardiac failure.1,5

Other presentations of psoriasis include pustular or guttate forms. Pustular psoriasis results from the aggregation of neutrophils in the skin, while guttate psoriasis is characterized by drop-like salmon colored papules that localize primarily to the extremities and trunk.1 Additionally, psoriatic patients may also present with nail dystrophy of the hands and feet. In fact, 50% of psoriasis patients exhibit nail-pitting and other nail changes at the time of diagnosis. 1,3

Treatment

Psoriasis treatment is individualized and dependent upon patient presentation, clinical history, and physical assessment.6 For most psoriatic patients, topical medications are the first line of therapy.1,7 The mechanism of action for topical medications involves reduction in inflammation, as well as control of cell proliferation.8,9

In addition to steroid drugs, there are also over-the-counter topical medications, such as coal tar and salicylic acid (both of which are FDA approved) that can be used to treat patients.10 Phototherapy, in which patients expose their skin to ultraviolet radiation for scheduled periods of time to retard the rapid cell proliferation associated with psoriasis, can be used under medical supervision.11

Systemic drugs are used in patients who have failed first-line treatment and phototherapy. Systemics include medications such as cyclosporine and methotrexate, as well as a new class of systemics called biologics.

Biologics, which are given via injection or intravenously, are protein-based drugs derived from human or animal tissue that work by blocking the functions of either T-cells, interleukins, or TNF-α. When initiating treatment of a biologic in a patient with psoriasis, it is important to obtain a thorough history, physical exam and a record of baseline laboratory tests.1,12

While patients with psoriasis may be assessed initially by their primary care provider, referral to a dermatologist should be considered when treatment modalities such as systemic medications and phototherapy are utilized. Phototherapy requires the supervision of a dermatologist trained in ultraviolet light irradiation modalities. Additionally, when a patient has widespread severe disease or confirmation of diagnosis is needed, a dermatology referral is appropriate.13

Psychosocial Impact

The skin plays an integral role in an individual’s life. It serves not only as a barrier for protection, but acts as a vehicle for social and physical interaction as well as sensation. As a result, its health and physical integrity can greatly impact an individual’s self-perception and acceptance by others.

For many psoriatic patients, having a chronic lifelong inflammatory skin disease has proven to be socially and psychologically detrimental.14 Compared to healthy individuals, psoriatic patients are 1.5 times more likely to develop symptoms of depression.15

In one study consisting of psoriatic patients, 58% suffered from anxiety disorders, and 24% experienced depression, while a significant 89% admitted to having feelings of embarrassment and shame as a result of their appearance.14

In another study that assessed the emotions of patients diagnosed with psoriasis, feelings of worry, shame, and annoyance were most commonly seen in females as opposed to males.16

In addition to generating negative feelings and mood disorders, psoriasis has been shown to cause conflict within home units as well as impede patients’ sexual functioning.14 Generally speaking, patients with psoriasis report a 25% to 40% decline in sexual activity upon onset of the disease due to embarrassment about their physical appearance, diminished sexual desire and discomfort.17

Many patients with psoriasis compare the level of disability caused by their skin condition to that of an individual suffering from a terminal illness such as cancer. One study consisting of 149 psoriatic patients reported that more than 90% of the test subjects warranted a psychiatric diagnosis, as most presented with either a mood disorder or an anxiety disorder.14

Suicidal ideation presents as a potentially serious problem, as many individuals with psoriasis often feel extremely isolated as a result of their condition. Studies have shown that psoriasis patients’ feelings towards their condition worsen with severity of symptoms, particularly with increased pruritus or bleeding.13

Furthermore, patients are often subjected to social stigma due to misconceptions regarding psoriasis’ etiology and concerns of possible transmission. Such stigmatization, combined with a lack of social and emotional support, make dealing with psoriasis all the more challenging for individuals diagnosed with the disease.18

Proactive Approach

Psoriasis is a chronic lifelong skin disease that can be both physically and emotionally injurious to patients. As a result, clinicians must strive to address not only the physical symptoms that accompany psoriasis, but the psychological and social ones as well.

While there are currently no cures available, healthcare providers can improve overall outcomes for psoriatic patients by screening for social and psychological features of the disease such as mood disturbances, suicidal ideation, or impairment to daily functioning.

References

1. Menter A, Gottlieb A, Feldman SR, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J American Academy of Dermatology 2008; 58(5):826-850.

2. Parisi R, et al. Global epidemiology of psoriasis: a systematic review of incidence and prevalence. J Invest Dermatol. 2013;133(2):377-85. doi: 10.1038/jid.2012.339.

3. Gottlieb A, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis : Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008;58(5):851-64. doi: 10.1016/j.jaad.2008.02.040.

4. Bernhard JD. Clinical pearl: Auspitz sign in psoriasis scale. J Am Acad Dermatol. 1997;36(4):1.

5. Griffiths CE, et al. Pathogenesis and clinical features of psoriasis. The Lancet 2207; 370:263-271.

6. National Psoriasis Foundation. Psoriasis Treatments. http://www.psoriasis.org/about-psoriasis/treatments.

7. Wolberink EA, Vet al. Cellular features of psoriatic skin: Imaging and quantification using in vivo reflectance confocal microscopy. Cytometry B Clin Cytom. 2011;80(3):141-9. doi: 10.1002/cyto.b.20575.

8. National Psoriasis Foundation. Topical Treatments. http://www.psoriasis.org/about-psoriasis/treatments/topicals.

9. National Psoriasis Foundation. Mild Psoriasis: Topical Steroids. http://www.psoriasis.org/about-psoriasis/treatments/topicals/steroids.

10. National Psoriasis Foundation. Over the counter, not over your head. http://www.psoriasis.org/about-psoriasis/treatments/topicals/over-the-counter.

11. National Psoriasis Foundation. Phototherapy. http://www.psoriasis.org/about-psoriasis/treatments/phototherapy.

12. National Psoriasis Foundation. Traditional Systemic Medications. https://www.psoriasis.org/about-psoriasis/treatments/systemics

13. Feldman SR. Treatment of psoriasis. UpToDate. www.uptodate.com/contents/treatment-of-psoriasis.

14. Russo PA, et al. Psychiatric morbidity in psoriasis: a review. Australasian J of Dermatology. 2004;45:155-161.

15. Dowlatshahi EA, et al. The prevalence and odds of depressive symptoms and clinical depression in psoriasis patients: a systematic review and meta-analysis. J Invest Dermatol. 2014;134(6):1542-51. doi: 10.1038/jid.2013.508.

16. Sampogna F, et al. Living with psoriasis: Prevalence of shame, anger, worry, and problems in daily activities and social life. Acta Derm Venereol. 2012;92(3):299-303. doi: 10.2340/00015555-1273.

17. Meeuwis KA, et al. Genital psoriasis awareness program: physical and psychological care for patients with genital psoriasis. Acta Derm Venereol. 2015;95:211-216. doi: 10.2340/00015555-1885.

18. Hayes J, Koo J. Psoriasis: depression, anxiety, smoking, and drinking habits. Dermatol Ther. 2010;23(2):174-80. doi: 10.1111/j.1529-8019.2010.01312.x.

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Sarah R. Winston, MPA, PA-C

Sarah R. Winston, MPA, PA-C - Georgia Regents University

Sara Haddow Liebel, MSA, PA-C

Sara Haddow Liebel, MSA, PA-C - Georgia Regents University

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