Amy McMichael, MD, discusses the impact of psoriasis on a patient’s quality of life.
Ryan Haumschild, PharmD, MS, MBA: You touched on this already, but if you would go into it a little deeper. When you’re identifying patients with psoriasis compared with other skin diseases, how do you create a differential diagnosis across the skin types? How do you differentiate that postinflammatory hyperpigmentation compared with other active inflammation with skin of color?
Amy McMichael, MD: That’s a great question. Part of it is looking for the patterns. Psoriasis is still a disease that likes to be symmetrical and likes to go to certain areas. Typically the scalp, umbilicus, gluteal cleft, gluteal fold, and places physicians often don’t look, but you can ask patients if they have involvement there. They’ll tell you even if they’re covered with clothing at the time. Ask about that. Look at the elbows, and once you start to treat, if you’re treating for eczema or something that’s not psoriasis and the patient isn’t responding, that might give you an indication to do a biopsy. I tend to biopsy early and often. I especially do it in children because I want to document that they have this, so that they don’t go through adulthood without the correct diagnosis.
Biopsy early and pay attention to the patient. If they’re telling you they’re using their drugs, the topicals, whatever systemic agent you’re giving them, and they still have very thick lesions, and you’re thinking something like prurigo nodularis or lichen simplex chronicus, then you’re going down the wrong path. If they’re not responding, then that’s the time to do a biopsy and to consider psoriasis. But those special areas give us a hint. We need to go toward the psoriasis diagnosis.
Ryan Haumschild, PharmD, MS, MBA: Recognizing psoriasis is so important because it impacts the lives of these patients. It impacts their ability to stay compliant with treatment. Honestly, at the end of the day, it impacts their quality of life. Dr Lopes, I’d like to transition to you. When we think about psoriasis impacting the quality of life, how does the quality of life differ across skin prototypes? If someone is misdiagnosed or underdiagnosed, how does that impact their quality of life?
Maria Lopes, MD, MS: When you have a disease, usually you’re focused on not just symptoms but also what’s happening around you and what impact it’s having on your function. Psoriasis can have a detrimental impact. It’s been quantified to be similar to other diseases, like ischemic heart disease, diabetes, and even cancer. Among patients with psoriasis, the prevalence of anxiety, depression, anger, and even suicidal ideation is quite common. So are feelings of rejection and stigma. Depending on where the lesions are and how visible they are on the face, hands, or feet has implications for not only function but also this feeling of stigma.
It’s very important to diagnose correctly and also to then address what the implication for these lesions on patients’ quality of life, and how you treat the whole patient. Not just impose your values on the presumption that patients are taking medications as prescribed, but asking what’s important to the patient, how they’re feeling, and what other elements are part of their life. Psoriasis can also be part of other comorbidities, including diabetes and heart disease. Obesity is often a risk factor for psoriasis. It’s important to take all this into consideration because, at the end of the day, you’re treating the whole patient.
Ryan Haumschild, PharmD, MS, MBA: You hit on some important topics. Patients living with this disease oftentimes might feel a little bit of shame. They might not have the greatest mental wellness and metabolic disease, and those comorbidities also lead to more difficult treatment because we want to make sure they’re having that therapeutic effect. We’re seeing clinical improvement, and we’re recognizing it early on, so patients aren’t suffering significantly from this disease. When I think about that, and if I think about a misdiagnosis, there’s also a lot of health care resource utilization that comes with these patients. Dr Sherman, what are the drivers of health care resource utilization in patients with psoriasis?
Bruce Sherman, MD, FCCP, FACOEM: From our experience, in terms of commercially insured populations and individuals with commercial employer-sponsored insurance, the bulk of health care utilization relates to ambulatory services. That’s the primary component of health care resource utilization, particularly in relation to medications for the topical treatment of psoriasis. A minority of individuals with psoriasis may be receiving biologic medications, which may contribute substantially to health care costs for those individuals. But by and large, this is an ambulatory disease and is focused on medication services or medication use primarily.
Ryan Haumschild, PharmD, MS, MBA: That’s why it’s so important for us to have an accurate diagnosis and make sure these patients have good adherence and a proportion of days covered, so they can get the benefit we’re looking for.
Transcript edited for clarity.