Blog entry by Rcgp Learning
World Psoriasis Day takes place every year on 29th October. It aims to raise awareness of the condition and provide support to people with psoriasis, which affects around 2% of people in the UK. It can start at any age in both men and women, but it typically develops in adults under 35¹.
Psoriasis is a complex, chronic, multifactorial inflammatory skin condition with an increase in the epidermal cell turnover rate. Like other autoimmune diseases, psoriasis can wax and wane, with patients varying between mild and severe symptoms depending on systemic, environmental and personal factors. Normally, skin cells are produced and replaced every 3-4 weeks, but in areas affected by psoriasis this process only takes around 3-5 days. This results in a build-up of epidermal hyperplasia which creates patches of scaly and erythematous skin².
Its pathogenesis is still not completely understood. It is likely that there is a genetic susceptibility to psoriasis, although it is not a genetic condition in itself. Immune dysfunction can also contribute. Excessively rapid production of keratinocytes leads to infiltration of T cells, dendritic cells, macrophages and neutrophils, causing inflammation³.Flares in psoriasis can be caused by a variety of factors, including non-immunological problems. A list of the most common of these can be found here on the NHS website.
Aside from the physical symptoms of psoriasis, it is also a visible condition which can affect many areas of a patient’s life. The psychosocial impact of psoriasis is not always considered during treatment, but it can affect a person’s functioning in life, work, relationships and social situations. According to a membership survey conducted by the European Federation of Psoriasis Patient Associations (EUROPSO), 77% of respondents said that psoriasis was a problem or a significant problem for their lifestyle and well-being⁴. Another study, that focussed on patient experiences of living with psoriasis, reported that the emotional and social impacts were frequently mentioned during interviews with the participants. Feelings of anger, frustration, shame and self-consciousness were reported. The social impacts discussed included avoidance of social activities and meeting new people⁵.
Psoriasis can also affect the quality of life for families of patients with psoriasis. A 2006 study found that the lives of relatives and partners can be significantly affected by the condition. Only 8% of participants reported that their quality of life wasn’t affected at all. 57% stated that they were psychologically affected, with feelings of anxiety, upset and worry about their relative/partner’s future. 55% reported social disruption due to lack of confidence or embarrassment and 44% said that leisure activities were limited by their relative/partner’s psoriasis. The study concluded that clinicians should consider appropriate care strategies for not only the patients, but also their families⁶.
Although the psychosocial impact of psoriasis is often difficult to avoid, GPs can play an important role in helping patients to overcome any difficulties they may face as a result of their condition. A 2016 review about ‘The Potential Psychological Impact of Skin Conditions’⁷ outlines a few suggestions of how to do this during a consultation:
- Managing the patient’s expectations
Before treatment starts, discuss with the patient about what outcomes are most important to them, what they expect to see and how possible it is to achieve this. By discussing their expectations in a realistic and practical way, the patient is more likely to comply to the treatment and recognise if the treatment isn’t working for them.
- Encouraging patients to see beyond the symptoms
Patients can feel impaired by the symptoms of their psoriasis and the degree of impairment can vary between people. Support from the GP is needed for patients to see beyond this and recognise that their symptoms don’t need to rule their life. A way of addressing this is to ask the patient “what would/could you do if you did not have these symptoms?”. Referral to mental health professionals may also help to provide patients with coping mechanisms.
- Helping patients to explain their symptoms
A large part of a patient’s psychosocial issues may be that they feel self-conscious about their visible psoriasis symptoms. Having to explain their condition and face potentially negative reactions from other people can be a source of anxiety. GPs can equip patients with the right words to explain their psoriasis, giving them an appropriate and informed range of responses to use if necessary. This will empower them to take control in social situations and feel comfortable discussing their condition. The ‘living with psoriasis’ patient leaflets by Leo Pharma suggest some simple ways that patients can explain their condition.
You can find out more about psoriasis in our eLearning resources. RCGP members can benefit from free access to EKU12: Assessment & Management of Psoriasis and EKU Podcast: Assessment & Management of Psoriasis. All healthcare professionals can also access the ‘Inflammatory conditions’ in the Dermatology Library for free.
The ‘See Psoriasis: Look Deeper’ campaign has some useful documentation for patients, which you can access here. The following video ‘The skin I’m in’ also provides in-depth accounts from psoriasis patients. It was produced by See Psoriasis: Look Deeper, Dermatrust and The Royal Free Hospital.
¹ NHS. Psoriasis Overview. [Internet]. Available from: https://www.nhs.uk/conditions/psoriasis/
² NHS. Psoriasis Causes. [Internet]. Available from: https://www.nhs.uk/conditions/psoriasis/causes/
³ Cai, Y., Fleming, C., Yan, J. (2012) New insights of T cells in the pathogenesis of psoriasis. Cel Mol Immunol 9(4) 302-309. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4132586/
⁴ Dubertret L, Mrowietz U, Ranki A, et al. EUROPSO Patient Survey Group. European patient perspectives on the impact of psoriasis: the EUROPSO patient membership survey. Br J Dermatol 2006;155(4):729–36
⁵ David Pariser, Brad Schenkel, Chureen Carter, Kamyar Farahi, T. Michelle Brown, Charles N. Ellis & for the Psoriasis Patient Interview Study Group (2016) A multicenter, non-interventional study to evaluate patient-reported experiences of living with psoriasis, Journal of Dermatological Treatment, 27:1, 19-26, DOI: 10.3109/09546634.2015.1044492
⁶ Eghlileb, A. , Davies, E. and Finlay, A. (2007), Psoriasis has a major secondary impact on the lives of family members and partners. British Journal of Dermatology, 156: 1245-1250. doi:10.1111/j.1365-2133.2007.07881.x
⁷ Tuckman, A. (2016) The Potential Psychological Impact of Skin Conditions. Dermatol Ther (Heidelb) (2017) 7 (Suppl 1):S53–S57. DOI 10.1007/s13555-016-0169-7