Psoriasis management should be more than skin deep

Patients with psoriasis need more than dermatological intervention and GPs could play a key role in monitoring these patients for associated comorbidities

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Patients with psoriasis need more than dermatological intervention and GPs could play a key role in monitoring these patients for associated comorbidities such as psoriatic arthritis, diabetes and cardiovascular disease, researchers say.

A narrative review, recently published in the Medical Journal of Australia, said that while skin was the most visibly affected organ in psoriasis, evidence now supported the idea that the condition was a chronic, multisystem disorder with many associated conditions.

The study authors conducted a database search between 1999 to 2019 to evaluate the most recent evidence of comorbid disease in patients with psoriasis, with a special focus on the role of primary care management in these patients.

Psoriatic arthritis was the most prevalent comorbidity in people with psoriasis, affecting between 6% and 41% of all patients.

“In most people, the skin manifestations precede arthritis, but an estimated 15% of cases present with joint symptoms before or concurrent with skin lesions,” the study authors said.

But early treatment of psoriatic arthritis was found to significantly improve the joint and quality of life outcomes.

The authors recommended clinicians use a questionnaire-based screening tool, such as the EARP, to screen all patients with psoriasis for arthritis.

The authors said early diagnosis was critical, with delays between symptom onset and a rheumatology consult as short as six months being found to increase joint erosion, and lead to a greater chance of long term disability.

Dr Tom Kovitwanichkanont, co-author and research fellow at the Skin Health Institute in Victoria, said the historical focus on psoriasis as a skin disease was why patients went unscreened for other comorbidities.

“Many people still treat it as purely a skin problem and I think this is due to a lack of awareness in both the general and medical community,” he said.

“On history we should routinely ask patients with psoriasis about their quality of life, including screening for excessive smoking and alcohol consumption and for depression and anxiety, because we know there is an association with these conditions too.”

But while psoriasis was said to be associated with several other metabolic risk factors, including obesity, type 2 diabetes, hypertension and dyslipidemia, the study provided no absolute risk of these conditions occurring.

But for GPs wanting to routinely monitor patients with psoriasis, annual blood tests to monitor blood glucose, liver and kidney function were considered appropriate investigations.

“A lot of management comes down to time pressure and because patients aren’t aware of all the comorbidities, they are usually focused on the skin and then ultimately their doctor might only pay attention to the skin,” Dr Kovitwanichkanont said.

“Unless we have a structured approach to managing psoriasis, we can miss these comorbidities.”

MJA 2020, 11 May (Online)