Winter 2012 Special supplement MODERATE-TO-SEVERE PSORIASIS 1.5 CPD credits Prescribing information can be Initiated, funded and found on the inside back cover reviewed by CONTENTS AND INTRODUCTION INTRODUCTION OPINION Psoriasis is a chronic skin condition that can 3 The role of GPs in the management of have a marked physical and psychological moderate-to-severe psoriasis impact on those affected. While most patients Dr Brian Malcolm have mild disease that can be managed in primary care, those with moderate-to-severe FEATURE psoriasis require referral for specialist inter- 4 Diagnosis and management of vention and access to therapy such as biologics. moderate-to-severe psoriasis Biologics are an option for patients who have Dr Rebecca Ellard and Dr Anshoo Sahota failed to respond to standard systemic ther- apy or in those for whom systemic therapy is FEATURE unsuitable. The scope of this supplement is to 6 Achieving long-term control of enhance the understanding of biologics. moderate-to-severe psoriasis Dr Brian Malcolm provides his opinion Dr Amy Foulkes and Dr Richard Warren on the role of the GP in the management of moderate -to-severe psoriasis. CASE STUDY Dr Rebecca Ellard and Dr Anshoo Sahota 8 A patient treated with ustekinumab discuss the key elements of the diagnosis and Dr Alia Ahmed and Dr Anthony Bewley management of moderate-to-severe psoriasis. Dr Amy Foulkes and Dr Richard Warren OPINION focus on long-term control of psoriasis. 9 NICE guideline on the assessment and Dr Alia Ahmed and Dr Anthony Bewley management of psoriasis present a case of a patient who was success- Dr David Chandler and Dr Anthony fully treated with biologics. Bewley Dr David Chandler and Dr Anthony Bewley provide a summary of the recently published MANAGEMENT ALGORITHM NICE guideline on psoriasis. 10 Diagnosis and management of Dr Justine Kluk, Dr Sandy McBride and moderate-to-severe psoriasis Professor Malcolm Rustin present a manage- Dr Justine Kluk, Dr Shantini Rice, Dr ment algorithm to aid the diagnosis, treatment Sandy McBride and Professor Malcolm and referral of patients with moderate-to- Rustin severe psoriasis Dr Paula Hensler, Editor, MIMS Dermatology Published by Haymarket Medical, 174 Hammersmith Road, London W6 7JP. Senior project editor: Joanne Taylor; Managing editor: Hannah Cottle; Editor of MIMS Dermatology: Paula Hensler; Producer: Stephanie Jackson; Commercial director: Sandie Pears; Project manager: Lindsay Aldridge; Group art editor: Pauline Lock; Deputy production manager: Lucy Flatman; Head of delivery: Katie McCormack; Senior commercial director: Clair McHale; Medical director: Robert Brines; Medical education director: Richard Yarwood; Director: Jenny Gowans. The views expressed in this publication are those of the authors and not necessarily those of Haymarket Medical or Janssen. Readers are advised to make their own further enquiries of manufacturers or specialists in relation to particular drugs, treatments or advice. The publishers and printers cannot accept liability for errors or omissions. No part of this publication may be reproduced in any form without the written permission of the publisher, application for which should be made to the publisher. ©2013 Haymarket Medical Media Ltd. Date of preparation: November 2012 (revised April 2013); Haymarket is certified by BSI to PHGB/STE/1112/0755b environmental standard ISO14001 2 OPINION The role of GPs in the management of moderate-to-severe psoriasis GPs have a pivotal role in managing under specialist care, the GP still has a pivotal this condition, says Dr Brian Malcolm. role in repeat prescribing and shared-care plans. Psoriasis is common, affecting approximately SECOND-LINE TREATMENTS 2% of the UK population.1 Such prevalence GPs should have understanding of the patient’s demands that a GP should have an up-to-date individual needs. Furthermore, there should knowledge of this condition, specifically the be an awareness of commonly used second- potential triggers, the treatments available and line drugs and their implications, for example, when to refer patients to secondary care. family planning issues with the use of retin- oids,4 alcohol intake with methotrexate,4 renal PHYSICAL AND PSYCHOLOGICAL DISTRESS function, hypertension and a history of cancer Psoriasis can be very distressing.2 Patients can with ciclosporin4 and a past history of infections, be significantly disabled by plantopalmar pus- particularly TB, and cancer with biologics.6 tular psoriasis, severe scalp psoriasis, fissuring hyperkeratotic psoriasis of the hands, or rarely, REFERRAL TO SECONDARY CARE acropustulosis. Genital involvement can also Referral should be considered when there is diag- lead to high levels of sexual distress.3 GPs are nostic doubt; when topical treatments have failed; well placed to offer support and manage patient in extensive disease and where there are difficult expectations about treatment outcomes. treatment sites. Erythrodermic or generalised pustular psoriasis also warrant referral, as does RECOGNISING TRIGGERS severe arthropathy. GPs have an important role GPs should understand the pathogenesis of in writing relevant and precise referral letters. the psoriasis to avoid exacerbations with the Even when a patient requires specialist care, use of prescribed drugs known to potentially there is potential for a knowledgeable GP to con- worsen psoriasis. These include lithium, anti- tribute to a holistic management approach. malarials and beta-blockers.4 GPs can also offer Dr Brian Malcolm is associate specialist, advice regarding exacerbating lifestyle factors GP principal and GPSI in dermatology in such as alcohol, stress and smoking,4 especially Barnstaple, Devon as there is a growing recognition that psoriasis is an independent risk factor for cardiovascu- REFERENCES lar disease.5 1. Eedy DJ, Griffiths CEM, Chalmers RJG et al. Care of patients with psoriasis: an audit of UK services in secondary care. Br J Dermatol 2009; 160:557–64. TREATMENT KNOWLEDGE 2. Krueger G, Koo J, Lebwohi M et al. The impact of psoriasis on It is important that GPs have a good understand- quality of life: Results of a 1998 National Psoriasis Foundation patient memebership survey. Arch Dermatol 2001 :137:280-4 ing of topical treatments. GPs must also be aware 3. Meeuwis KA, de Hullu JA, van de Nieuwenhof HP et al. that certain topical treatments, particularly ster- Quality of life and sexual health in patients with genital psoriasis. Br J Dermatol 2011; 164:1247-55. oids, may have systemic effects if they are used 4. Menter A, Griffiths CEM. Current and future management of long term.4 Furthermore, the usefulness of psoriasis. Lancet 2007;370:272-84. 5. Ahlehoff O. Psoriasis and cardiovascular disease: simple emollients to keep skin hydrated should epidemiological studies. Dan Med Bull. 2011; 58:B4347. 4 never be underestimated. Even if a patient is 6. MIMS. November 2012. 3 FEATURE Diagnosis and management of moderate-to-severe psoriasis Management should include early and continual assessment from first presentation through to specialist care, write Dr Rebecca Ellard and Dr Anshoo Sahota iStockphoto/ThinkStock Psoriasis is a chronic disease that affects approxi- mately 1-3% of the population,1 with or without psoriatic arthritis. Patients typically present with ‘unsightly’ lesions which are sometimes itchy; for many there is no identifiable cause. Patients present with lesions Psoriasis can have a profound effect on quality of life and is also associated with cardiovascu- with topical therapy.4 More extensive disease lar disease.2 Recent NICE guidance states that (>10% body affected or PASI score >12) usually management should include early and continual needs specialist input. assessment of psoriasis from first presenta- Functional severity can be measured with tion in primary care through to specialist care. quality-of-life tools such as the Dermatology The guidance focuses on disease severity, phys- Life Quality Index (DLQI).5 Psychological ical and psychological effect, assessment for morbidity is not well represented with these referral and treatment choice.2 tools, but can be an important marker for dis- ease impact. NICE guidelines suggest assessing ASSESSMENT OF PSORIASIS impact on daily living, ability to cope with the Various tools can be used to measure physi- treatment regimen, change in mood and impact cal severity or functional severity of psoriasis. on family or carers.2 Physical severity is categorised as clear, mild, severe or very severe, as outlined in the STEPWISE APPROACH TO MANAGEMENT Physicians’ Global Assessment (PGA) or more Management of chronic illness such as psoria- precisely with the Psoriasis Area and Severity sis should include physical and psychological Index (PASI).3 Doctors should also note when aspects.2 It is helpful to manage expectations at nails, face, scalp or genitals are affected as these an early stage and allow the patient control over are particularly difficult to treat, along with their treatment, particularly with topical ther- symptoms or signs of psoriatic arthritis. apy. There is often the need to combine topical The PASI divides the body into head, arms, and systemic treatments. trunk and legs and notes the amount of redness, The first step is topical treatment including thickness and scale, along with percentage of the daily use of emollients. Patients should be area affected. A score maximum of 72 is given, reassured that almost any emollient is useful and can help assess a patient’s response to treat- even if not prescribed