Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives - Episode 5

Individualizing Care for Patients With Plaque Psoriasis

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Melodie S. Young, MSN, A/GNP-C: As you begin to talk with patients about the disease, you have to remind them constantly about things that trigger flare-ups. For example, I have families who have kids, and the kids start bringing home diseases. They’ll get strep throat from their child, and for the psoriasis disease that’s done beautifully on 1 medicine for months or years, they’re now saying, “What happened? I haven’t had psoriasis in years. Suddenly, I’m breaking out. What’s going on?”

You then find out that one of the kids in their family has strep throat, and you say, “I bet you've been exposed to strep throat.” Or it may be that the disease changed, and you start digging to find out why. With the new drugs that we have and the stability of what they offer, you should not have a waxing and waning or flaring of disease, but some drugs cause it, as do sunburns.

I’m sure you’ve got other things that you can mention related to triggers as well. We also talk about things to make them healthier: lifestyle modification like diet and exercise, not really focusing on that as being meaningful or impactful for disease therapy. Even in Portland, where there are people who are focused on health and wellness. Is that a question that you get at the VA [US Department of Veterans Affairs Portland Health Care System]?

Lakshi M. Aldredge, MSN, ANP-BC, DCNP: It’s a big deal here in the Pacific Northwest. Everybody wants to try a naturopathic remedy. Everybody swears by turmeric, and I say, “I have turmeric every day, and I still have eczema.” The 1 diet that I talk about with people that has been shown to help a bit in autoimmune-mediated conditions is the Mediterranean diet, and that’s a healthy diet. It’s low fat, it has less red meat, and it’s a healthier diet. There’s no diet that is going to keep this from happening. You hit on a good point, Mel, because patients will sometimes come in with a whole lot of guilt about what they did that caused this. They say, “Was it the cigarettes that I smoked in college? Was it that one-night fling that I had?”

We need to reassure them that there are myriad factors that can trigger psoriasis. There’s definitely a family hereditary factor to it: about 40% of people have a family propensity for the disease. Certain medications such as β-blockers can also trigger psoriasis. That’s why you'll see people who are in their 50s who have never had a skin issue suddenly break out in psoriasis. You can ask them, “What's happened in your life?” It could be that they just started having blood pressure issues, and their doctor put them on a β-blocker. That can be a trigger. Stressful events like loss of a loved one, loss of a job, loss of a house or home, emotional trauma, or stress can trigger psoriasis. Environmental factors can also trigger psoriasis. In the Pacific Northwest, we have a lot of mold. It’s very rainy, so it can happen if you move from one climate to another. I have many veterans who go abroad for deployments and are exposed to chemicals. Those kinds of things can trigger psoriasis as well, as can certain infections such as strep throat. We must reassure our patients.

As you mentioned, we know that certain lifestyle factors can make psoriasis worse or less amenable to the treatments that you give them, such as smoking, significant alcohol use, and a sedentary lifestyle. To the points that you made, once we get them on the right treatment and get their skin clear, we want to focus on the rest of their health. They all start feeling better. They want to go to the gym. They’ll start working out. They quit smoking. They decrease their alcohol intake. They start socializing. They start getting more confident. They work on lowering their blood pressure because they’re out running and working out. We are talking about it holistically. You hit on all of those points

There is no 1 treatment. If any of you are working with other providers, perhaps a supervising physician, and they say, “No. We’re only going to treat our patients with this medication or this modality,” then you need to find a new place to work because there is every treatment option available, and every patient should be given all of those options to consider. The big buzzwords in health care are mutual decision-making or shared decision-making, and that’s what this is about.

Melodie S. Young, MSN, A/GNP-C: You shouldn’t have to coax the patient into it. When the patient makes an appointment to come and see you, they’re paying you for your time. They want your expertise and your knowledge, and you owe it to the patient to do your very best and tell them, “Here's what I know,” and to stay current. We don’t do Mohs surgery in our clinic [Mindful Dermatology]. We have a lot of excellent Mohs surgeons in the Dallas area, so I’m fortunate. I say, “That's not something that we do, but I’m happy to help you find someone who’s going to meet your expectation, and that’s our goal.” That’s the same way it is with these therapies. Psoriasis is a complex disease, and there’s not just 1 pathway.

Lakshi M. Aldredge, MSN, ANP-BC, DCNP: That’s why, with psoriasis, we talk about the art of medicine, and this is it. Sometimes, it’s like mixing the colors on the palette to find what works for the patient. There’s not 1 thing that’s going to work the same for all patients, and it’s sometimes a bit of a witch’s brew to make sure that we’re looking carefully at other factors. They could be on 1 agent doing beautifully, and then they flare. You think that the medication has stopped working, but that may not be the case. Ask them what’s going on with their life. It may be that they’ve had more stress. It may be that they’ve had an infection, so their immune system is flaring a bit. That’s where a topical agent or even adding an oral agent to get them by, that can work very well.

Melodie S. Young, MSN, A/GNP-C: If they’re overweight and a smoker, losing weight and stopping smoking are the 2 most important things you can do. But those are things we talk about later; don’t make them think that they have to do that to get a biologic agent. All the data show that biologics are incredibly effective in overweight patients because most of the patients in the clinical trials are overweight. It’s the case for male and female patients no matter where they are in the world: patients with psoriasis tend to be heavier.

The whole research community is interested in psoriasis because there are a lot of similarities with other diseases. It’s one of the things you mentioned when we were talking about drug triggering. We have seen patients who’ve had perhaps Crohn disease who get a treatment, and it’ll cause them to develop psoriasis because a lot of these different immune-mediated diseases will run in families. You can have more than one. You can be an unfortunate patient who has hidradenitis suppurativa, psoriasis, and psoriatic arthritis. For those patients, fortunately, there are some medications that can treat multiple diseases at once. That is what’s made our job fun and meaningful.

Transcript Edited for Clarity