Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives - Episode 6

Approaches to Care in Plaque Psoriasis by Disease Severity

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Melodie S. Young, MSN, A/GNP-C: I’m of this mindset: When I see your psoriasis, I’m going for it. I’m going for the best therapy I can offer you right then. We’re going for it as opposed to wearing the patient down and getting them more frustrated.

Sometimes, I associate 2 different things. When you’re looking at the National Psoriasis Foundation, the American Academy of Dermatology, or other organizations that focus on guidelines of care and standards of care, we think about whether all drugs should be available to all patients or if we should put people in buckets. If you have mild to moderate disease, what is that? What’s moderate to severe? Is it different for certain people? Is it just the body surface area [BSA]?

Lakshi, talk a bit about how you have a preconceived idea of mild vs moderate. We all know what severe is. Severe is a bad disease. Severe people are miserable. They have widespread, uncomfortable disease, and people will definitely move toward using progressive—I wouldn’t say aggressive, I would say progressive—therapies for them. How do you handle this mild, moderate, severe conversation with colleagues or patients?

Lakshi M. Aldredge, MSN, ANP-BC, DCNP:It’s a good point and an important question. Typically and traditionally, how we have categorized mild, moderate, and severe disease has to do with body surface area, where 1 palm-size equals 1 BSA. Traditionally, how we classified it was that 0 to 3 BSA was considered mild disease, 3 to 9 BSA was considered moderate disease, and anything over 10 BSA was considered severe disease. That’s somewhat true, and it’s what we use in clinical trials as well as some other complicated scoring mechanisms.

It’s important to ask the patient about what it is keeping them from doing and what is most symptomatic for them. You may have a small area on the genitals or on the palms and soles of the hands and feet, which would be 4% or 5% body surface area. If you told me that, that might be considered moderate, but if you have genetic psoriasis that is bad, that is a severe disease for some people. If you have scalp psoriasis, and it’s only affecting your scalp. If you have big, thick plaques in your scalp, it feels like someone has put papier-mâché on your head; it is dried, hard, itchy, and painful. That is a severe disease. If you have palm pustular psoriasis on your hands, and if you’re a health care worker like Mel and me who sees patients, or if you’re in sales—even if you’re typing on a computer all day, that can be devastating if you develop fissures and sores. Don’t simply go by the amount of body area that is covered. Ask the patient how it’s affecting them.

The next most important thing to ask is if they have any joint symptoms: stiffness or soreness, especially in the hands or the feet but also in the back and any other joints. It can be an indication that they have something called psoriatic arthritis. About 30% of patients with skin psoriasis can go on to develop joint inflammation called psoriatic arthritis. Unlike the skin, where we can produce new skin cells, once you start having joint inflammation, you can have a loss of function of that joint or that bone, and then they can’t get it back. This can lead to disability. Think about it: If they’re a mechanic, a machinist, or an electrician and can’t turn a screwdriver or even open a can of beans, this is disabling. We want to ask them about this as well.

They might have limited skin involvement, but they sometimes start telling me, “I wake up in the morning, and it takes me 30 minutes to get moving around,” or “When I have my cup of coffee, it helps warm my hands, and then I can start functioning,” or “I get in the shower and that loosens stuff up.” Some other things they’ll tell you are, “I get up in the middle of the night to walk around because it loosens up my back” or “If I go for a long car drive, I have to stop every so often to get out, so I can walk around.” That should cue you in to think about psoriatic arthritis in these patients. You can have mild skin involvement, but when you add early symptoms of psoriatic arthritis, that puts you in a different category. You need to treat those patients systematically either with a systematic oral agent or a biologic agent.

To answer your question—this was long-winded, I know—severity is in the mind of the beholder with the provider asking important questions about what areas are involved, asking about joint symptoms, looking at other comorbidities that they have, and making a decision about what the right therapy is. It’s less about the severity and more about that whole picture.

Melodie S. Young, MSN, A/GNP-C: With the typical therapies you’re going to give, as you said before, I tell patients, “Topical agents will help you with symptoms, but it does not do anything to control the disease.” Topical therapies may help with it, or they may make your skin not as dry, inflamed, cracked, and sore. But we still need to layer that with something else.

Transcript Edited for Clarity