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Focus on psoriasis

Psoriasis is a chronic, debilitating, inflammatory skin disease, characterised by an accelerated rate of turnover of the top layer of the skin.

Although it is a chronic condition, its course may be variable, with flare-ups and remissions. The cause of psoriasis is not fully understood but evidence suggests that there is a strong genetic component and that environmental factors also play a role, such as emotional stress or infection, which may trigger the first episode of psoriasis or exacerbations.

Psoriasis is one of the most common skin diseases in Ireland and affects at least 73,000 people, 20 per cent of whom will require secondary care, according to international standards.

Psoriasis can occur on any part of the body, but is most commonly found on the elbows, knees, lower back and scalp (seborrhoeic psoriasis). It can also affect the fingernails and toenails.

In addition, psoriasis can cause inflammation of the joints, ie, psoriatic arthritis. Classified from mild to severe, psoriasis may be limited to small, localised patches of skin or can cover large areas of the body.

Comorbidities

Psoriasis patients also have a higher incidence of obesity, diabetes, heart disease and stroke. “It is not just a skin disease and we need to think beyond that when we treat it. For example, we also know that these patients have a higher risk of having other immune diseases such as Crohn’s, irritable bowel disease (IBD) and coeliac disease, and uveitis is also common in patients with psoriatic arthritis,” Prof Brian Kirby, Consultant Dermatologist, St Vincent’s University Hospital, Dublin, previously told the Medical Independent.

Given the significantly higher risk of cardiovascular disease among psoriasis patients, he said they should be monitored closely for cardiovascular risk factors to allow early intervention. Blood pressure, body mass index, blood glucose levels and lipid profile should be measured yearly in all age groups and appropriate therapies initiated. Weight loss interventions should be employed where appropriate and patients should be screened for depression.

Patients should also be encouraged to reduce alcohol intake and cease smoking, and should be assessed for the development of psoriatic arthritis.

Burden of psoriasis

Last year, a major report on the impact of psoriasis on Irish patients was published. The Burden of Psoriasis report stated that the disease places a considerable burden on those who have the disease, and examined in detail the impact on the quality of life of the individual.

   The physical factors associated with the disease cause self-consciousness, embarrassment and stigmatisation, which can ultimately lead to depression and in some cases suicidal ideation. Psoriasis also impacts on the work lives of those who have the condition, with reports of absenteeism, presenteeism, workplace discrimination and restriction of career choice all associated with psoriasis.

An attitudinal survey of people living with psoriasis was conducted to coincide with the report, which focused on the psychosocial impact of psoriasis to illustrate the burden on relationships, career and day-to-day life.

The findings illustrate the wide-reaching impact that this skin disease can have on all aspects of patients’ lives and the negative emotions that can be felt by those living with psoriasis. Of the 119 respondents, the majority were female (77 per cent), and the largest group to answer the survey were those aged 34-to-41 years of age.

An overwhelming number of those surveyed (93 per cent) reported having felt embarrassed by their psoriasis, with 77 per cent indicating their skin has made them ‘hide themselves away’. In addition to this, three-quarters (73 per cent) of those surveyed agreed that their psoriasis has negatively impacted on their social life.

Over half (54 per cent) agreed it had had an impact on their love life and a third (33 per cent) of respondents reported that their skin condition has prevented them from dating entirely.

One-in-five (21 per cent) respondents admitted that their psoriasis has stopped them from applying for a job. The report indicated that people with severe psoriasis are almost twice as likely to be unemployed versus those who have mild psoriasis.

Prof Louise Barnes, Consultant Dermatologist, St James’s Hospital, Dublin, and co-author of the report, pointed out that psoriasis can often be misunderstood and without effective management, can lead to extremely poor quality-of-life issues.

She said it is vital that dermatology is invested in, in order to improve patient care and management of this chronic skin disease, including providing equitable access to specialised care and innovative treatments.

The report also noted that current European guidelines define treatment success for moderate-to-severe psoriasis as achieving a Psoriasis Area and Severity Index (PASI) 75 response (ie, achieving a 75 per cent clearance of psoriasis symptoms as per the PASI criteria). This clinical endpoint may, however, be out of date, the report asserted. The majority of psoriasis patients now achieve PASI 90 responses in randomised trials of the latest-generation biologic agents.

In addition to this, studies report that the complete visible clearance of psoriasis (as per the PASI criteria) is now becoming a realistic therapeutic outcome. With the clear gains in quality-of-life with PASI 90, it may now be pragmatic to revaluate the therapeutic gold standard for people who are treating or are being treated for psoriasis, the report concluded.

Treatment history

Earlier this year, the Irish Skin Foundation (ISF) highlighted the key advances in psoriasis treatment during the last 100 years, to coincide with the 1916 centenary celebrations. The most important of these ‘chance findings’ included dithranol, methotrexate, vitamin D analogues and cyclosporin, and began in 1916 when the effectiveness of dithranol was established.

While these agents still provide valuable treatment options, their identification paved the way for a better understanding of the disease process and the development of more targeted therapies, the ISF noted.

Current treatments

The long-established dithranol is an extremely effective and safe treatment for chronic plaque psoriasis. Early research found it cleared 95 per cent of suitable patients and the average remission is six months when used as an inpatient treatment.

Its main disadvantage is that it stains the skin (temporarily) and clothes (permanently). It can also burn normal skin, so must be very carefully applied to the plaques only. It is started with a low concentration and the strength is gradually increased.

Tar is also an extremely effective treatment, but it is very messy to do in the home setting.

A key treatment currently for moderate-to-severe disease is ultraviolet therapy — UVB phototherapy.

It may be used alone, eg, in widespread, thin-plaque psoriasis or more commonly in conjunction with inpatient or outpatient topical therapy.

Narrow-band UVB is the current wavelength of choice, which has been shown to clear the vast majority of patients, with an average remission of six months.

Some patients achieve prolonged remission on this treatment, though limited access and needing to attend the clinic three times weekly when receiving the therapy is time-consuming for patients.

PUVA therapy is also beneficial, which is a type of phototherapy that combines the oral or topical photosensitising chemical psoralen and exposure to increasing doses of UVA. This has similar success rates to UVB phototherapy and patients attend the clinic twice weekly.

Mindfulness and Psoriasis Research Study

The Department of Dermatology in St Vincent’s University Hospital, Dublin, is conducting new research with people who have psoriasis using mindfulness. If a patient chooses to take part in this research, they will be randomly assigned to one of two possible treatment groups:

1.  Mindfulness-based cognitive therapy, or

2. Treatment as usual.

What is involved in the Mindfulness Group (MBCT)?

Eight weekly classes.

Each class lasts two hours.

Patients are asked for their commitment to attend all classes and complete home exercises.

When?

The first eight-week mindfulness intervention will take place from October to December 2016.

The second eight-week mindfulness intervention will take place from January to March 2017.

All groups will be asked to complete psychological questionnaires and give blood samples on three occasions — at the start of the research, after eight weeks, and after four months. The hospital will attempt to schedule these visits around patients’ routine attendance at their dermatology clinic.

If you would like a patient to participate in this research or discuss it in more detail, please contact Mr Alan Maddock, PhD Scholar with the School of Psychology, Trinity College Dublin via phone on 087 973 9568 or via email on: maddocka@tcd.ie by 21 September 2016,

Please note: this research is open to patients of hospitals other than St Vincent’s University Hospital.

Systemic

For people with very extensive or unresponsive psoriasis, systemic therapy may be required. Current options include methotrexate, fumaric acid esters, acitretin and cyclosporin.

The individual patient profile, lifestyle factors, associated arthritis, drug cost, side-effect profile — which can be serious in these drugs — along with patient preference all influence the drug chosen.

“Methotrexate obviously needs monitoring but is very, very effective if used properly in the right patients at the right time, and is extremely safe, as you can see the warning signs coming. It has about a 60 to 70 per cent success rate,” Prof Kirby said.

He added that the effectiveness of anti-TNFs in the patients who do not effectively respond to methotrexate is “excellent” in most patients.

Prof Kirby also noted the benefits of stress management treatment on psoriasis, noting a number of studies report positive findings.

“Mindfulness has had very impressive results in people with depression and post-myocardial infarction. It can lead to a reduction in depression scores, anxiety and worry, so it is being tried on psoriasis patients,” he said.

Biologics

A number of biologic agents have been licenced for the treatment of psoriasis, including: TNF inhibitors (eg adalimumab, etanercept and infliximab), the interleukin (IL) 12/23 compound ustekinumab, and the IL-17A antagonist, secukinumab. These agents have significantly broadened the range and efficacy of treatment options available and revolutionised the care of psoriasis patients.

Recently, the US Food and Drug Administration approved ixekizumab (a biologic that targets IL-17A), to treat adults with moderate-to-severe plaque psoriasis, providing another important treatment option. This new wave of improved, targeted therapies heralds a new era in the treatment of psoriasis, according to the ISF.

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