PSORIASIS: THINK TWICE

A third of people with psoriasis haven't had their treatment reviewed by a GP in five years1.

Treating psoriasis doesn't need to mean a complicated mix of creams, emollients and ointments.

Dear Doctor...

Dr Sarah Jarvis has been a GP partner in the same busy inner city London practice for over 23 years. She is a familiar face from TV and regularly features on radio. Dr Jarvis has also authored many popular and award winning books.

Dr Jarvis is passionate about improving the partnership between patient and doctor. Here she answers some common patient questions about psoriasis.

1. How often should I visit my GP to discuss my psoriasis and treatment options?

Regular dialogue with your GP to discuss what treatment and support you need depending on how your psoriasis is affecting you is key. Everyone is different but regular reviews, a minimum of one a year, to check for signs of psoriasis-related arthritis are recommended by NICE.1 However, it is worth noting that some treatments are applied in courses of a few weeks and it is best to review progress with your GP at the end of the course. If you feel your current treatment is working for you, you shouldn’t need to see your GP so often.

If, on the other hand, your symptoms aren’t controlled, it’s completely different. The fact that you have a repeat prescription absolutely doesn’t mean you aren’t ‘allowed’ to make an appointment with your doctor to discuss other options. In fact, given how many treatment options there are, I would actively encourage you to see them regularly. It is important to know the potential side effects and exactly how to use whatever psoriasis treatment you are using. Please read the information leaflet that comes with your treatment and talk to your doctor if you are unsure how to use your treatment, or for how long you should use it.

Reference:
1. Psoriasis NICE Clinical Guideline 153 (Oct 2012) Available: http://www.nice.org.uk/nicemedia/live/13938/61190/61190.pdf Last Accessed: June 2014


2. My doctor has given me the same repeat prescription for several years but my psoriasis isn’t getting better. What can I do?

Some people with psoriasis do well on the first or second treatment they’re given, and there’s no need to change if your treatment is working well. However, your GP won’t know your psoriasis isn’t controlled unless you make an appointment with them. While psoriasis can’t be cured, there are many treatment options available and what works for one person may not suit another. There’s absolutely no reason why you should have to stick with one that isn’t helping you.

Make an appointment with your doctor to explain your concerns. If they say they don’t have any alternatives they can offer, you have a right to ask for a second opinion.


3. I’m not sure if I’m using my treatment correctly. What should I do?

You’re right to be concerned. Unlike tablets, which are simply swallowed or chewed, there are lots of different ways to apply psoriasis treatments to your skin – this can have a major impact on how well they work. Some need to be applied just to affected areas; some left on for different lengths of time before being washed off; others need to be removed with oil.

Your pharmacist is a useful port of call in the first instance. They can often offer advice about the best way to use a treatment. But if your treatment isn’t working for you and you’re not sure if you’re using it correctly, speak to your GP about a referral to a hospital specialty department. Many departments have specialist nurses who can show you exactly how to use your treatments to best effect.


4. I’d like to try a different treatment but my doctor keeps giving me the same prescription. I don’t think they understand I need something to better suit my lifestyle. How should I bring this up at my next appointment?

This is a common challenge. Your doctor may not realise how much of an impact your condition is having on your life, or how impractical it is to have to apply messy treatments frequently. They may not even realise your treatment isn’t controlling your symptoms unless you tell them.

Try writing down your concerns with some examples of the impact your treatment is having on your life. You may find it helpful to take a family member with you so they can give their perspective, too.

>> For more advice about speaking to your GP, go to 7 Tips for 7 Minutes

You might also want to have a look at the dermatology life quality index (www.dermatology.org.uk/downloads/dlqiquest.pdf). This will give you an idea of the sort of questions specialists ask to assess how much of an impact your psoriasis is having on your overall quality of life.


5. What are the different treatment options available to me?

Treatments for psoriasis are divided into topical treatments (ones which you put on your skin), phototherapy (light treatment) and systemic treatments (affecting the whole body), which can include tablets or injections. It is important to know the potential side effects and exactly how to use whatever psoriasis treatment you are using. Please read the information leaflet that comes with your treatment and talk to your doctor if you are unsure how to use your treatment, or for how long you should use it.

Topical treatments include:

  • Moisturisers (emollients) – these can be used in addition to other treatments to help keep the skin supple and reduce cracking and itching
  • Coal tar preparations – these used to be the mainstay of treatment, but tend to be messy, don’t smell nice and can stain clothes. More modern versions may be less messy and smell less strong. Coal-tar based shampoos can be useful for scalp psoriasis
  • Dithranol creams – these can work well but irritate normal skin and have to be applied very carefully. They can also stain clothes and need to be used for a very short time at first before being washed off (the time can be gradually extended from a few minutes)
  • Vitamin D analogues – these are widely used and often very effective – they’re also less messy and smell less than coal tar preparations and don’t stain clothes like dithranol or coal tar. A minority of people get skin irritation and you need to be careful not to exceed the licensed dose (100g of ointment a week for adults)
  • Steroid creams and ointments – these work by reducing inflammation and are easy to use. They tend to be recommended in courses rather than continuously to reduce the risk of flare-ups when you stop using them
  • Vitamin D analogue and steroid combined in an ointment or gel – using a combination can help you get on top of flare-ups quickly and effectively if your psoriasis is not controlled by one or other of these two treatments.
    Phototherapy and systemic treatments are usually only given by specialist hospital departments and tend to be reserved for severe psoriasis that hasn’t responded to topical treatments.
  • Most systemic therapies work by suppressing the immune system. Because psoriasis is an autoimmune condition (where you body’s immune system, which normally protects you against infection, recognises itself as an ‘enemy’) these can be highly effective. However, they can have significant side effects and need careful monitoring
  • Light therapy can involve courses of exposure to either ultraviolet B (UVB) or PUVA (psoralen and ultraviolet A) which involves ultraviolet A light along with a tablet called psoralen, to increase the effect

6. I'm feeling depressed and think my psoriasis might be one of the reasons. What should I do?

There’s no question that people with psoriasis are at increased risk of depression, as well as anxiety. Psoriasis is so much more than ‘just a skin condition’. It can have a major impact on your self-esteem and general well-being, which in turn can affect your mood.

Regardless of the cause of your depression, it’s important to seek help for it. The usual screening questions asked to tease out depression are:

  • in the last 2 weeks, have you been troubled by feeling down, depressed or hopeless and
  • have you taken little interest or pleasure in doing things?

If the answer to either is ‘yes’ on more than half of the days in the past 2 weeks, you may be depressed. Your GP can talk to you about all the options available, including counselling and medication if appropriate.


7. My psoriasis has recently improved. Does this mean I should stop my treatment?

I’m delighted that your psoriasis has improved, but this doesn’t necessarily mean you can stop using any or all of your treatment. It may be that it’s improved because your psoriasis is being kept under control by the treatment and would come back if you stopped. However, psoriasis does tend to run in cycles of flare-ups with less severe phases in between.

If you’re only using topical treatments and your symptoms have been well controlled for a couple of months, you may be able to stop using one treatment, then another if things don’t get worse again. Speak to your GP regularly for advice. What you should consider stopping and when depends on the medication you’re using. For some topical treatments, you will need to finish a course of a few weeks to give it the best chance of working. Again discuss with your doctor and read the Patient Information Leaflet in the pack for information. If you’re taking tablets or injections for your psoriasis, you should never stop except on the advice of your doctor.


8. My GP has told me my psoriasis won’t get any better. What do I do now?

If your GP doesn’t have any more options for treatment that they feel confident prescribing and your condition is not adequately controlled, they should be offering to refer you to a specialist. A dermatologist (skin specialist) is likely to have access to treatment options the GP can’t give. It’s not acceptable for a non-specialist doctor to say that you will have to live with your condition without giving you the opportunity to access all the treatments available.

Psoriasis can’t be cured, but there are now far more effective and much less messy and cosmetically acceptable options than there were even a couple of decades ago. You need to speak to your GP again.

I know it can be difficult not to get frustrated, but it is best to put your case calmly and objectively so you’re not on the back foot. Try practicing what you’re going to say beforehand, or writing down a list of the ways in which your psoriasis is affecting your life. That way, you’ll be able to give a full picture.


9. I’m going on holiday soon and I'm really embarrassed about my psoriasis and don't like to take my clothes off at the beach. Is there anything I can do to hide the lesions?

The appearance of psoriasis, whether plaques or the less common ‘guttate’ (drop-like) psoriasis, can be distressing at the best of times. In summer, when everyone around you appears to be shedding layers of clothes with every passing day, it can be even more difficult to cope with. For many years, the Red Cross offered a service for anyone with visible skin conditions, using trained volunteers to teach about using camouflage make-up. In 2012, they handed over this important work to Changing Faces, the leading not-for-profit organisation supporting and campaigning on behalf of people with conditions that affect their appearance. Depending on where you live, you may be able to refer yourself to one of their clinics – you can find out whether you live in a qualifying area by visiting www.changingfaces.org.uk/Skin-Camouflage/I-want-an-appointment. Otherwise, ask your GP to refer you. If you want more information, you can phone the Skin Camouflage Service on 0300 012 0276.


10. My GP can be quite dismissive during my appointments. How can I get them to take my psoriasis more seriously?

It’s possible that there are just crossed wires, and your GP doesn’t realise how much distress your psoriasis is causing you. Make an attempt to get on the same wavelength as them by planning what you want to say.

Write down your concerns so you remember everything you want to explain. Make an appointment just to discuss this, rather than tagging it on to another medical query, so you have the maximum time to go through your concerns in detail and do tell the doctor how much impact your condition is having on your life.

>>For more advice about speaking to your GP, go to 7 Tips for 7 Minutes

If you still feel you’re not being taken seriously, consider seeing another GP from the same practice or, if that doesn’t work, you may need to register with a different GP practice.


11. I've heard psoriasis can cause other, more serious conditions. What are they and should I be worried?

About half of people with psoriasis have pitting of their nails – mostly fingernails but also toenails.1 About 1 in 8 people also have joint problems.1

Also the psychological impact of psoriasis, which can lead to debilitating depression, shouldn’t be underestimated.

In addition, people with psoriasis are more likely to have conditions such as type 2 diabetes, high cholesterol and high blood pressure. These are much more likely to be an issue if your psoriasis is classed as severe. It’s important to discuss with your doctor if you need checking for these conditions. If you have any risk factors for these conditions (such as being overweight, smoking or having a family history of heart attack or type 2 diabetes), you should get checked out for these issues at least once a year. Otherwise, your GP may suggest less frequent checks.

Reference:
1. Psoriasis NICE Clinical Guideline 153 (Oct 2012) Available: http://www.nice.org.uk/nicemedia/live/13938/61190/61190.pdf Last Accessed: June 2014