Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives - Episode 4
Melodie S. Young, MSN, A/GNP-C: Do you get any pushback from patients now? We used to, when trying to move patients away from topical agents and move them onto other things.
Lakshi M. Aldredge, MSN, ANP-BC, DCNP: It’s an important question because you can lose a patient quickly if you do not address this. The first thing I say to patients is this: “Tell me what you have been doing to treat your disease either yourself or with other providers,” so I can get a feel for what they’ve been given and what they’ve been told before about their disease. I want to clear up any misconceptions, and I want to see what they’ve used before. The second thing I ask is this: “How did that work for you? How did that fit in with your lifestyle?” Often they’ve been given a topical cream, a tiny tube for their full body, and they're told to put it on twice a day, and it’s ridiculous. They’re not going to do that, especially if they are a young individual.
There were studies that have been done, and on average, patients with moderate to severe psoriasis, which covers a lot of their body, would spend 30 minutes a day putting on ointments and creams. Here’s an important aspect that another patient taught me about regarding the psychosocial impact of the disease: psoriasis is not unlike diabetes and heart disease in that it’s an autoimmune condition. With diabetes and heart disease, you don’t have to put on an ointment or cream. You take a pill or give yourself a shot, and you’re done. Every time you tell a patient to put an ointment or a cream on their plaques, they are constantly reminded that they have this awful disease, and I’ve had patients tell me that they weep every time they have to do that.
There’s a different paradigm now. I always give my patients a topical cream because there’s going to be a time, even if I get them clear, when they may flare a bit. They might have a bit on their elbow, arm, or on their lower back, and it’s perfect for them. It helps relieve itching, but that should not be the mainstay of treatment; for patients who have 1 or 2 plaques, that’s fine. But for patients who have more disease, you need to think about treating the inflammation systemically, and that’s when you talk to them. I describe it as a fire: they have this slow-burning fire inside them. When they think of psoriasis, every time they have a plaque, it’s a little spark or a tiny flame. We want to quash that flame internally. That helps give them a visual.
I’ve had veteran patients who are 60 years old who’ve said, “I don’t care about how my skin looks. I’m fine with the plaques on my legs,” and I say, “Are you fine with a little bit of high blood pressure? Are you fine with a little bit of diabetes?” No, they’re not. They want to get everything under control. You set the expectation that we want to normalize the immune system and normalize the body so that we’re not putting them at an increased risk for heart disease, diabetes, or joint issues. It’s important to set that expectation.
You then say, “I’m going to take you through the gamut of different treatment options.” When we treat it from the outside in, we have ointments and creams, and we have phototherapy. With more severe disease, we treat it from the inside out, and that’s with pills and injections.
The other thing that I have found to be helpful—and I say this with absolute sincerity—is this: I say, “If you were my husband, brother, wife, whomever, what would I do to treat you?” Or I may say, “If I had what you have, this is what I would do, and this is why.” Some of my patients will say, “Do you like your husband?” and I have to clarify that, yes, I do. It’s important to first ask them what they’ve been given before and if it worked for them. What are some limiting factors in their life? Is the patient a college student who’s really busy? Are they going to remember to take a pill every day, twice a day, or a group of pills once a week? Are they terrified of shots and are they completely averse to that?
Here’s another issue. Is the patient experiencing homelessness? Do they have secure housing to keep their medications? Do they have a refrigerator where they can keep an injectable biologic that needs to be refrigerated? These are some factors about which you may not think, and patients may not voluntarily share them with you because they might be embarrassed. We must ask about some of the factors that are limiting them right now or factors that might keep them from doing these treatments.
Melodie S. Young, MSN, A/GNP-C: I will then ask them, “What are your struggles?” I can’t imagine having to spend an extra half an hour putting on topical agents or driving over to get phototherapy treatment 3 times a week in a clinic that is mostly open during office hours. Those are impossible asks for patients, and I’m not even sure that they’re compatible as far as the amount of clearance they can offer and how they can alter the course of the disease by using more systemic and biologic agents.
I try to tell them, “We're talking about medicines now. They’re going to take minutes out of your life to treat your disease as opposed to lots of time out of your day for your treatment. It will no longer be the focus.” I’ve had patients who would tell me that they had to stop their activities, particularly in pediatric situations. Thankfully, we have many therapies now that are also available for pediatric patients with plaque psoriasis or psoriatic arthritis. With the amount of time treatment takes, and the need to have family help you, it can be such an issue.
We must also constantly help them understand what the disease state is and the information that they get. Everybody’s got access to sources, and we know that even reliable, usually trustworthy sources, such as when you’re talking about one of the doctor shows on TV, when they talk about psoriasis, they make my blood boil because they can be ignorant and ill-informed. They are misleading people. If you look at some of the online sources, people who are promising them that if they go on the right diet, take the right vitamin, or alter their lifestyle, then they can impact the disease. One of the first things I’ll say is this: “This disease is not your fault. You didn't do anything to get it. There are some things you can do to make yourself healthier, but this is a disease that requires medication.”
We want to get as close to complete clearance as possible because, as you just mentioned before, we want tight control of blood sugars and blood pressure, and we want tight control of these immune-mediating diseases that can harm you if the inflammation is left unchecked. My job is to find something that works, and something that’s going to be simple and fit your lifestyle.
Transcript Edited for Clarity