Treating psoriasis
James Fogarty examines the incidence and treatment of psoriasis in Ireland
and the role pharmacists play in managing this distressing skin condition
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
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.
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.
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
support and advice from their healthcare
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.
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
“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
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.
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.
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
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