Managing psoriasis in primary care
Adjunct Associate Professor Chong Wei Sheng, Head of the Psoriasis Unit at the National Skin Centre, Singapore, speaks to Roshini Claire Anthony on the vital role played by primary care physicians (GPs) in tackling psoriasis.
The global prevalence of psoriasis is about 1–3 percent of the general population. The prevalence appears to be higher in the West (eg, 2.2 percent and 4.8 percent in the US and Norway, respectively) compared with Asian countries (eg, 0.3, 0.4, and 0.8 percent in Japan, China, and India, respectively). There is no prevalence data available for Singapore, but the estimated prevalence is 0.5–1 percent of the whole population.
GPs form the first point of contact for patients who seek treatment when they develop a rash, regardless of whether it is psoriasis or not. Hence, GPs play a pivotal role in diagnosing psoriasis, and then institute the appropriate topical treatment for these patients and monitor their response to treatment. If response is suboptimal, they can refer patients to dermatologists for further evaluation and treatment. More importantly, as metabolic syndrome is now known to have a strong association with psoriasis, especially severe cases, GPs play a very important role in screening psoriasis patients for metabolic syndrome.
Individuals with a family history of psoriasis, those who are obese, have a history of HIV infection, or are on certain medications (eg, beta-blockers) are predisposed to develop psoriasis. Those who smoke and drink alcohol, who are stressed, or prone to various infections, also tend to have frequent flares of psoriasis.
Diagnosing psoriasis is usually easy and straightforward and it is unnecessary to perform a skin biopsy. However, the clinical presentation may occasionally be atypical, making diagnosis more difficult, especially when the patient has been receiving some form of treatment elsewhere which may have altered the appearance of the psoriatic rash. If in doubt, GPs can refer to dermatologists for further evaluation.
GPs should offer routine metabolic screening for psoriasis, evaluating the height, weight, blood pressure, fasting blood glucose, and lipid levels for all patients with psoriasis, regardless of severity, at the first consultation.
GPs can refer to websites, textbooks, atlases, and journal articles when in doubt.
After diagnosis, topical therapy is the first line of treatment especially when the disease is mild, and GPs are in the best position to start such treatment. Such topical therapy includes the use of topical corticosteroids, vitamin D analogues, calcineurin inhibitors, coal tar, as well as moisturizers to relieve the symptoms of skin dryness and pruritus, and to soothe the skin.
The main challenges GPs will face are diagnostic dilemmas when the presentation of psoriasis is atypical, which will lead to treatment difficulties, or when treatment instituted is not optimal in disease control resulting in psoriasis flares. With the vast information available online, GPs can take the opportunity to constantly update themselves with respect to diagnosis and management of psoriasis. If in doubt, referral to a dermatologist can then be made. Occasionally, a psoriatic patient can also present with joint signs and symptoms reminiscent of psoriatic arthritis, which might pose challenges in diagnosis and treatment of the arthritis; in such a case, referral to a rheumatologist is prudent.
Referral to a dermatologist is recommended when the response to topical therapy is suboptimal, when the diagnosis of psoriasis is in doubt, when the disease is so severe and widespread that topical therapy might not be sufficient to control the disease, and of course, when a patient starts to develop generalized pustular psoriasis (a dermatological emergency).
The main international guidelines include those published in the Journal of the American Academy of Dermatology (JAAD), the S3 guidelines published in the Journal of the European Academy of Dermatology and Venereology (JEADV), and the guidelines published by the Canadian Dermatology Association and the National Institute for Health and Care Excellence (NICE).
GPs can also refer to the very first Dermatological Society of Singapore Clinical Practice Guidelines on Psoriasis.
Patients often deal with low self-esteem and lack of confidence when they have psoriasis, especially when the disease is severe, often with symptoms of pruritus, leading to physical and psychological distress that may impair their quality of life. GPs, being the first point of contact with patients, are in the best position to help patients cope with their disease, allay their concerns and fears, and by instituting early and appropriate therapy, help them control their disease to prevent further complications. This would also help control cost of treatment, as severe disease involves the use of expensive, complicated antipsoriatic therapy that can potentially add to the financial burden for the patient. Early diagnosis and treatment when psoriasis is mild is crucial for optimal management.
As far as the public is concerned, psoriasis is viewed as contagious and psoriatic patients are often shunned. Thus, public education is extremely important to dispel such myths.
As far as physicians are concerned, the main misconception is that psoriasis is just skin-deep, meaning, it is a disease that affects only the skin and nowhere else. This is now found to be not true as psoriasis is a multisystemic disease that requires treatment not just tailored to the skin alone, but to the patient as a whole, identifying risk factors for metabolic syndrome and managing the comorbidities well. This is where continuous medical education comes in to update all physicians periodically.
GPs should make prompt diagnosis of psoriasis and institute the appropriate topical therapy. If in doubt or when response to treatment is suboptimal, prompt referral to a dermatologist is recommended. GPs should also take the initiative to offer metabolic screening to all patients with psoriasis and to minimize risk factors for cardiovascular and cerebrovascular diseases by prevention and appropriate treatment of such risk factors and comorbidities.
National Institute for Health and Care Excellence (NICE) Psoriasis Clinical Guidelines
International Psoriasis Council
DermNet New Zealand