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Communication Skills – explain conditions – Psoriasis

Introduction Identification Explanation Consent Ideas Concerns Expectations

How much do they know already?

 (not much doctor, I just got diagnosed with psoriasis)

What the condition is (signs + symptoms) & how it’s diagnosed.

 Psoriasis = common inflammatory skin condition affecting ~2% population

 can occur @ any age – comes & goes unpredictably.
 NOT infectious
 affects skin mainly but nails & joints can also be affected – if notice swelling or stiffness of joints, go to GP
 ↑ risk of heart disease, DVT, stroke, anxiety, depression, DM, obesity, alcoholism etc.
 Skin changes of psoriasis – often known as plaques, are pink or red areas with silvery-white scales – because
of the quick turnover of skin. Normal = 3-4/52 but psoriasis = 3-4 days.
 skin can be itchy esp. scalp, lower legs & groin. If it affects hands + feet, painful fissures or cracks can develop
& may affect use of hands & walking.
 Diagnosis = clinical based on appearance & distribution. No routine tests (unless being considered for
treatment)

Who gets it & what causes it?

 Both genetic + environmental factors – psoriasis is inherited but complex pattern.

Management

 Assessment tools available e.g. physician global assessment (PGA).

 No cure but many effective options – although complete clearance may not be possible
 Avoid triggers e.g. stress, alcohol, infections, smoking, certain drugs e.g. β blockers, lithium
 topical, light treatment (phototherapy), tablet treatment or injection.
 Topical treatment – emollients helps to moisture skin & reduces excessive scaling; tar preparations – helps
to remove loose scales
 Phototherapy – UV light (narrow-band UV B) delivered in a controlled way to treat psoriasis. A course ~8-
10/52 @ 2-3 weekly sessions – done @ a phototherapy unit
 Tablet options include actretin (related to vit. A), ciclosporin (suppression immune system), methotrexate
(slow down rates @ which cells are dividing in psoriasis)
 Biologics such as TNFα inhibitors e.g. adalimumab, etanercept (both given s/c)
 report any joint/nail changes
 adopt a healthy lifestyle – weight loss, balanced diet, stop drinking + smoking, regular exercise

Miscellaneous – pregnancy, drug storage, alert card/bracelet/necklace, education leaflet & contact number

(pause for questions in between sections & reaffirm understanding)

finger-tip units (FTUs) for steroids – if steroid is being used topically, should only use a thin layer on affected area, in
bursts of 3-7 days. If used in combo. with an emollient, then apply emollient first, wait for 30 mins before applying
steroid. One FTU is ~500mg & is enough to treat a skin area about twice palm size.
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NICE CKS Psoriasis (last revised March 2018)

Pustular or erythrodermic psoriasis

 if diagnosed = medical emergency, needs same-day specialise dermatology assessment & management
 if suspected localised pustular psoriasis – offer information, support & refer (urgency depends on clinical
judgement)

Trunk & limbs

 chronic plaque psoriasis – offer information (e.g. lifestyle advice), support

 offer treatment with topical preparations e.g. creams, ointments, lotions
 topical steroids only suitable for localised areas of psoriasis
 review 4 weeks after initiation of treatment to review response & compliance
 seek urgent medical advice if unexplained joint pain or swelling – may be a sign of psoriatic arthritis
 assess CVD risks at least every 5 years esp. if psoriasis is severe
 emollient to help reduce scale & relieve itch
 a potent topical steroid + a topical vit. D preparation (both applied once daily but at different times of day)
 if poor response after 8-12 weeks, increase steroid to twice daily or add a coal tar preparation applied once
or twice daily
 phototherapy, systemic therapy & biologics if sever & poor response to therapy (but these are done in
secondary care)

Scalp

 same as above

Face/flexural/genital psoriasis

 same as above except more cautious with steroids & advise ‘treatment breaks’

Guttate prosiasis

 usually self-limiting resolves ~3-4 months

 not infectious
 management same as above

Nail psoriasis

 keep nails short, avoid manicure and prosthetic nails

 if mild & not causing discomfort or distress – no treatment needed
 if severe then consider if alternative diagnosis, refer appropriately