Dermatology Express Report™

Dermatology Nurses' Association 26^th Annual Convention

Publication date: 2008-05-30

Nursing Considerations when Treating Patients with Moderate to
Severe Psoriasis and Associated Comorbidities

This report was reviewed for medical and scientific accuracy by Mark Gendreau, MD, MS, Senior Staff Physician, Lahey Clinic, Burlington, Massachusetts

Expert Commentary

Jennifer Cather, MD, Division of Dermatology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas

Psoriasis is a chronic, immune-mediated disease characterized by recurring and remitting inflammatory disease, ranging from mild to severe and affecting the skin, the scalp, and sometimes the joints. Psoriasis affects approximately 2% of the general population,¹ with a peak onset in young adulthood. Psoriasis has a detrimental impact on quality of life and may lead to emotional suffering and frustration. Moreover, approximately 20% to 25% of patients with psoriasis have extensive disease requiring systemic therapy.²

Psoriasis is linked to a number of comorbid conditions that can seriously impact a patient's overall health. Psoriasis patients are at increased risk for obesity, diabetes, hyperlipidemia, hypertension, heart failure, myocardial infarction and lymphoma.^3,4,5,6,7 In addition, patients with psoriasis may suffer from depression, and frequently smoke and consume alcohol in excess.^8,9,10 Indeed, a recent study indicates that there is an increased risk of death in patients with severe psoriasis with the relative risk of mortality greatest in younger patients compared to older patients.¹¹ Although the associated comorbid conditions are more commonly observed in patients with moderate-to-severe psoriasis, these conditions can also be observed in patients with mild psoriasis.¹²

Traditional treatment approaches for psoriasis are aimed at controlling symptoms of the disease. Patients with mild-to-moderate psoriasis can generally be managed with topical therapies. For patients with moderate-to-severe psoriasis, systemic therapies have dramatically improved patient outcomes. These treatments include phototherapy, traditional systemic medications (eg, acitretin, methotrexate, and cyclosporine), and the newer biologic agents. The biologic agents work to control the inflammatory response that underlies psoriasis. For example, the tumor necrosis factor (TNF) inhibitors (eg, adalimumab, etanercept, and infliximab) control inflammation by binding to TNF-α, a proinflammatory cytokine, which is over expressed in psoriatic skin and joints. In contrast, the T-cell inhibitors block T-cell migration and activation (efalizumab), or inhibit T-cell activation and selectively reduce memory T cells (alefacept) in psoriatic skin.

In order to provide optimal care for their patients, dermatology nurses should recognize the relationship between psoriasis and associated comorbid conditions, and be knowledgeable of recent advances in treatment options for patients with psoriasis. This Dermatology Express Report™ reviews data and strategies for treating patients with psoriasis and associated comorbidities with TNF inhibitors presented at a CE-certified satellite symposium held during the Dermatology Nurses' Association 26^th Annual Convention, March 25-27, 2008, in Las Vegas, Nevada.

Psoriasis Patients Are at Increased Risk for Comorbid Conditions

Obesity is associated with more severe psoriasis3 and is reported about twice as frequently among psoriasis patients as in the general population.4 "Patients with psoriasis, especially when it is moderate to severe, likely have health concerns that extend beyond the condition of their skin," said Jennifer Clay Cather, MD, Division of Dermatology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas.¹³ There is a pathophysiological link between obesity and psoriasis, and common inflammatory mechanisms. Intra-abdominal fat is an endocrine organ that releases pro-inflammatory cytokines such as TNF-α and IL-6.¹⁴ These cytokines, which are over