Psoriasis is more than just skin deep

By Jennifer Laliberté

Many sufferers experience low self-esteem, depression and anxiety — suicide rates are three times higher among psoriasis sufferers than the general population. "All cases of psoriasis should be taken seriously, no matter how mild," concurs Dr Ronald Vender, an associate clinical professor of dermatology at McMaster.

KNOW WHAT YOU'RE UP AGAINST
Diagnosing psoriasis isn't too hard: look for red, thick plaques with a silvery scale, most often found on the scalp, knees, elbows and torso. Men and women are equally susceptible to the condition, which usually presents before the age of 40. A family history is also a strong indicator of psoriasis — Dr Guenther says one-third of patients have a first-degree relative with psoriasis. "Using a dermatology picture atlas as a guide can be helpful," adds Dr Vender. "When in doubt, a skin biopsy will confirm the diagnosis." There are several different forms of the condition, but far and away the most common is plaque psoriasis: the round or oval lesions are covered by a flaky, silvery white buildup called a scale.

The diagnosis is the simplest part of treating a psoriatic patient. Once you've done that, it's imperative that you explain the condition and let your patients know what to expect. First and foremost, make sure the patient understands that psoriasis isn't contagious and is very common. The exact cause is not known, but it's a chronic, lifelong condition that will require maintenance and frequent trips to the doctor. Things like stress, infection and certain medications — like beta-blockers, antimalarials and ACE inhibitors — can all make the lesions worse. "Psoriasis can also be triggered in areas of injury [like a scratch or sunburn] and it can spread from there," explains Dr Guenther.

EVERYTHING'S UNDER CONTROL
Treatment isn't likely to clear the skin up completely, so the primary goal is to control the lesions. What that means is different for each patient. "You can't say that if half the lesions go away, that's better. It also depends on how the patient perceives the improvement in their quality of life," says Dr Vender. And no single treatment works for everyone, so you might have to try a few things first. But keep in mind that time is of the essence. "Treatment should always be given early and the moderate-to-severe cases should really be treated systemically, in the care of a dermatologist," adds Dr Vender. "Don't wait too long to refer them." (See the sidebar for a list of systemic treatments)

For mild or localized disease, a topical corticosteroid is your first line of defense. Available in several forms and potencies, corticosteroids work quickly and are easy to use. But after a while, they stop working and if you take the patient off them, they'll likely have a flare-up, so they're often used with another agent to maintain control.

A newer agent (Dovobet) combines a corticosteroid with calcipotriene, a vitamin D analog. "It's a little slower acting, but it gets you to the same point," says Dr Guenther. "And you don't lose the effects with continued use, or get the rebound effect." If the lesions are under control, she recommends using this cream during the week, and a steroid on the weekend.

Coal tar products like shampoos, lotions, bath oils and soaps can also be helpful for controlling symptoms. But the thick, viscous fluid is messy and smells quite bad, so they're best used at night — warn your patients to pull out ratty old bed linens and pajamas because this stuff stains.

Treatment of psoriasis has improved tremendously in the past few years, so there are lots of therapies to choose from. The best advice Dr Guenther can give is to ask your patients what's important to them. "Most patients feel that treatment isn't aggressive enough. Make sure that if you can't offer it, that you send them to someone who can help them, because we do have treatments that work."