LIFE IN FOCUS *446&70-6.&t4&15&.#&3 Treating psoriasis James Fogarty examines the incidence and treatment of psoriasis in Ireland and the role pharmacists play in managing this distressing skin condition P soriasis is one of the most common skin conditions in Ireland, with an estimated 100,000 people affected by the disease. Overall it is part of a range of skin conditions that affects, at any one time, more than one third of Irish people and results in 2.2 million visits to the GP annually. The physical appearance of psoriasis is very distinctive – scaly patches of silvery or red skin appear, which can lead to localised lesions developing on the patient’s scalp, knees, elbows, torso, hands and feet. Symptoms include extreme dryness, scales, redness and inflammation, which can be both uncomfortable and unsightly. While it can affect people at all ages of their lives, psoriasis usually appears for the first time between the ages of 15 and 35. Moreover, a third of these people care be affected by psoriatic arthritis, which, if left untreated, can cause permanent damage to the affected joints. More worryingly, research from the US, looking at more than 9,000 psoriasis patients, found as the condition’s severity increased so too did the patients’ chances of heart disease, diabetes, and liver disease. However, the physical impact of the condition is just part of the story. According to a recent international survey of psoriasis patients, half of people living with psoriasis believe the social stigma is more distressing than the condition itself. Three out of four people who took part in the survey said that they avoid situations where the psoriasis plaques might be visible. Furthermore, more than half of the women surveyed said that their psoriasis had reduced their confidence, with a significant percentage of men also admitting the same. The research also shows that a quarter of people living with psoriasis feel that people treat them differently because of their condition and one in five believe they would have more friends if they didn’t have the condition. DISTRESSING Caroline Irwin is a board member of the recently established Irish Skin Foundation and founder of the Psoriasis Association of Ireland. A psoriasis sufferer and advocate, she knows how devastating the condition can be. “Depending on the severity, it impacts on every aspect of your life,” she explains. “A young man with a mild form of psoriasis, who contacted me, is on an antidepressant.” Many people feel embarrassed and anxious about the reaction of others, she explained at the launch of the Foundation, so it is very important to improve awareness and educate people about psoriatic arthritis. At the release of the survey’s results, Prof Brian Kirby, Consultant Dermatologist, St Vincent’s University Hospital, Dublin, said that while doctors are aware of the physical symptoms associated with psoriasis, patients may not be sharing the psychological consequences with their doctor. “Doctors, both GPs and specialists, tend to under estimate the psychological impact of having psoriasis. People living with psoriasis need to know that with the right treatment, you can restore your confidence and learn to manage the condition so that it doesn’t interfere with your quality of life,” he said. INCREASING AWARENESS There have been a number of announcements recently aimed at increasing awareness of the disease. The Irish Skin Foundation hopes to empower those with skin conditions to seek IN FOCUS LIFE *446&70-6.&t4&15&.#&3 support and advice from their healthcare professionals. In addition, a new information resource, developed by Pfizer and EUROPSO, in association with the Psoriasis Association of Ireland and Arthritis Ireland, has been launched to help those suffering from psoriatic arthritis. Speaking at the launch, Prof Oliver FitzGerald, Consultant Rheumatologist, St Vincent’s University Hospital, Dublin, said psoriatic arthritis can be a very painful and uncomfortable disease, so it is important that the symptoms are recognised as early as possible. “The symptoms of psoriatic arthritis can come and go, just like psoriasis, and sufferers can experience painful flare-ups, or periods of relative inactivity. Men and women are equally at risk of developing psoriatic arthritis, and it can start at any age, but is most likely to appear between the ages of 30 and 50 years,” he said. Diagnosing the condition can be very difficult as psoriasis arthritis can be slow to develop. Furthermore, as with psoriasis symptoms, both their frequency and intensity can also come and go. Men and women are equally at risk of developing psoriatic arthritis and it can start at any age but is most likely to appear between the ages of 30 and 50 years. Psoriasis skin symptoms appear first in three quarters of people, and it can take ten years or more before any joint problems are identified. However, sometimes both the skin and joint problems may appear together, and in other cases joint problems can sometimes occur first. Despite this, there are a few tell-tale signs which can help predict whether a patient will develop psoriatic arthritis. These include if the patient’s skin symptoms involve the scalp, fingernails/toenails or the cleft between the buttocks. PHARMACISTS One of the biggest concerns Ms Irwin has relates to, what she says, is a lack of consistency in advice from healthcare professionals. “The pharmacist can be a great help but from my experience there’s a lot of mixed messages,” she says. “There are such different reports coming into me. For example, for one patient the pharmacist says to use a cream sparingly, while the dermatologist says use it whenever you need. That’s the sort of thing I come across commonly.” “People are not getting the information,” she adds: “Patients call me and say I am using a particular cream and it doesn’t seem to be working. I ask how are you using it, did the doctor or pharmacist say how to apply it? And they didn’t. “I think the role of the pharmacist is going to change because people are either unwilling or unable to pay the GP’s consultation fees. So they will turn to the pharmacist.” In addition, the number of consultant dermatologists in Ireland is very low, well below what is needed, so pharmacists are increasingly being asked for their advice about skin care concerns. Bao-Tam Phan, Pierre Fabre, Avene, trained as a doctor of pharmacy in France and moved to the UK over 10 years ago to work for Pierre Fabre pharmaceutical group. She told Irish Pharmacist that pharmacists are often not aware of the best treatment options available to help their customers, recommending products that can further aggravate the symptoms and skin. However, she maintained pharmacists can have a key role in helping the patient to alleviate psoriasis symptoms. TREATMENTS Due to the powerful treatment options available to combat psoriasis, information for both health professionals and the patient is critical. While treatment options vary, the key aim is to halt the cycle that causes increased production of skin cells and sooth the pain caused by the inflammation. According to the Mayo Clinic in the US, treatment for the condition can be broken down into three types: Topical treatments, light therapy and systemic medications. Topical treatments can come in a variety of different forms and can effectively treat mild to moderate psoriasis. They range from prescription creams such as topical corticosteroids and vitamin D analogues, to over-the-counter medicines such as salicylic acid. For pharmacists, it is important to make their patients aware that long-term or overuse of strong corticosteroid creams can both reduce the cream’s effectiveness and cause thinning of the skin. Other topical treatments can irritate the skin and cause sensitivity to light as in the case of topical retinoids. Over-the-counter treatment products, containing salicylic acid, promote the removal of dead skin and reduces scaling, while coal tar also reduces scaling, itching and inflammation. Both are available in shampoo form. “There is a simple three-step plan we recommend to help with the symptoms, and this can work alongside medical prescription. If a topical medical treatment is being used, ensure the patient knows to wait 10 minutes between its application and the application of the specialist body cream,” Ms Phan explained. The three-step plan includes, firstly, cleansing the body and face with a soap free solution. This leaves the skin deeply cleansed and comforted without stripping it of essential moisture. Step two then involves soothing the skin with a spritz of thermal spring water spray. The water leaves a film of silica on the skin, which locks in moisture and protects the skin’s surface. The final step involves moisturising and nourishing the skin by gently massaging on a special sensitive skin cream for these patients once or twice a day, paying particular attention to the affected areas to help restore skin comfort. In addition, in relation to the scalp, often tar treatments are proposed alongside medicinal scalp treatments such as potent corticosteroids. “But they do not alleviate discomfort such as tightness. They can be messy to use and concordance is sometimes poor,” she noted. “We could recommend to apply Akerat “ cream on the scalp directly (at least 10 minutes after medicinal treatment if any) and leave it 20 minutes minimum or overnight if possible wrapping hair in a towel. Then shampoo with a mild shampoo. It would help to remove excess scales thanks to salicylic and lactic acid as well as 10 per cent urea as well as providing comfort. It can also maintain the results of medicinal drugs and help with patient’s compliance,” Ms Phan said. Light therapies can include both natural and artificial ultraviolet light and have been shown to improve symptoms. However, caution is needed as even with natural light, intense sun exposure can worsen symptoms. However, using moisturisers may reduce side effects such as redness and irritation. Finally, systemic medications can be used on severe types of psoriasis and are available through prescription. According to the Mayo Clinic, because of severe side effects, some of these medications should only be used for brief periods. Furthermore, drugs such as retinoids, while possibly effective against unresponsive psoriasis, can have dramatic side effects such as hair loss. More seriously, as retinoids such as acitretin can cause severe birth defects, female patients must avoid pregnancy for at least three years after taking the medication. Other drugs such as methotrexate have been shown to reduce skin cell production and inflammation. However, while it is well tolerated in small doses, it can lead to stomach upset, and when used for long periods it can cause serious side-effects, such as liver damage and decreased production of red and white blood cells and platelets. Meanwhile, immunosuppressants such as cyclosporine, while effective at treating severe psoriasis, do increase the patient’s risk of infection and other health problems, including cancer. There are also a range of immunomodulator drugs or biologics available, which are given intravenously or by subcutaneous injection. They are used on patients who have not responded to traditional forms of treatment or who have associated psoriatic arthritis. As they work by blocking specific immune cells and inflammatory cells, they too can lead to infections. In particular, people taking these treatments must be screened for latent tuberculosis. With all this information available it can be difficult to keep track for both pharmacists and patients. Ms Irwin explained that the Irish Skin Foundation will shortly be rolling out a psoriasis checklist for GPs. “Maybe we could something similar for pharmacists,” she explains. “I think that pharmacists will be seeing a lot more psoriasis patients. I would love to be involved with the pharmacists and to see our booklets being handed out more at pharmacies.” While treatment options vary, the key aim is to halt the cycle that causes increased production of skin cells and sooth the pain caused by the inflammation.