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Teenager tells you psoriasis is ruining her life

Jane is 16, has mild but widespread psoriasis and tells you it is ruining her life. She cannot go to the gym or on holiday with her friends and the treatments are all 'rubbish'. Dr Melanie Wynne-Jones advises.

What is it like to have psoriasis?

A 1998 American survey found individuals with psoriasis believed the disease had a profound emotional and social as well as physical impact on their quality of life. Four-fifths of those with severe psoriasis said it had a negative impact, 40 per cent felt frustrated with the ineffectiveness of their current therapies, and 32 per cent reported that treatment was not aggressive enough.

Psoriasis is doubly distressing to teenagers who are particularly sensitive about their appearance and find the discipline of chronic disease treatment hard to deal with.

How mild is mild?

In the same study, respondents reported their most frequent symptoms were scaling (94 per cent), itching (79 per cent) and skin redness (71 per cent). Two-fifths said their psoriasis covered 10 per cent or more of their bodies.

The extent and degree of inflammation can be assessed by asking the patient (may be subjective), clinical examination and by checking the quantities of treatment needed/used.

Some dermatologists use the Psoriasis Area and Severity Index (PASI) score to assess treatment progress (self-administered by patients) but the locations of lesions may be more significant to patients than their severity.

What happens in psoriasis?

Skin cell turnover and shedding speeds up from 21-28 days to three-four days, and blood flow is increased. Psoriasis varies in extent and severity through life; flare-ups may appear to have no particular trigger. It affects 2 per cent of the population and often presents between the teens and middle age; males and females are equally affected and up to a third have a family history.

Stable red plaques with characteristic silvery scaling is the commonest form. These are well demarcated and found mostly on extensor surfaces (knees, elbows) and the scalp. But they can occur anywhere and may appear moister and flatter in skin creases or the natal cleft. Nails can be pitted and occasionally the joints are affected (psoriatic arthropathy).

Widespread psoriasis may also be guttate ('raindrop' patches triggered by a streptococcal throat infection) or pustular and severe. In erythroderma, virtually the whole skin surface becomes hot and red with severe desquamation, shivering and fluid loss ­ a life-threatening condition requiring hospital admission.

How is Jane feeling?

It's not easy being a teenager, and her uncomfortable, embarrassing and time-consuming skin disease may be one of several problems including school, family, friends or boyfriends. She may blame psoriasis for any or all of these, or see it as the final straw.

What do you need to know about her psoriasis?

 · How long has she had it? Is it more severe or widespread than usual?

 · Are any triggers relevant (sore throat, stress)?

 · Is she taking any relevant medication

(?-blockers, NSAIDs, chloroquine, mepacrine, lithium or even alcohol)? Psoriasis may develop weeks after starting treatment.

 · What does she know about psoriasis and its treatment? Does she know about the Psoriasis Association?

 · What exactly has she tried? Find out the actual brands, method and duration of use and the reasons for discontinuing. Explore her dismissive 'rubbish' comment, as a dislike of messy or irritant creams (such as dithranol), fear of steroids, impatience for results/failure to persist, or another idea, concern or expectation may be the clue to treatment failure.

What can be used to treat psoriasis?

Depending on site and severity, topical and/or systemic treatment may be required. Many of these have important contraindications and/or side-effects, or require specialist monitoring.

What are the indications for referral?

The British Association of Dermatologists recommendations are:

 · Diagnostic uncertainty

 · Request for further counselling and/or education including demonstration of topical treatment

 · Failure of appropriately used topical treatment for a reasonable time (a month say)

 · Extensive disease

 · Need for increasing amounts or potencies of topical corticosteroids; involvement of sites that are difficult to treat ­ face, palms, genitalia

 · Need for systemic therapy

 · Generalised erythrodermic or pustular psoriasis (emergency referral)

 · Adverse reactions to topical treatment

 · Special problems consequent upon the area

of involvement (hands, feet, scalp or groin)

 · Occupational disability or excessive time

off work or school .

NICE is also piloting referral advice.

GPs' treatment options

 · Emollients

 · Coal tar preparations

 · Dithranol

 · Topical corticosteroids

 · Topical vitamin D analogues (calcipotriol and tacalcitol)

 · Topical salicylic acid preparations

or coconut oil ointment (Cocois) for thick scalp scale

Specialists' treatment options

 · Phototherapy or photochemotherapy (8 methoxypsoralen-UVA phototherapy-PUVA)

 · UVB phototherapy

 · Methotrexate

 · Oral retinoids such as acitretin

 · Cyclosporin

 · Azathioprine

 · Hydroxyurea

Key points

 · Psoriasis can be disfiguring and unpleasant, patients often have secondary psychosocial problems

 · Teenagers often find chronic disease particularly difficult to cope with

 · Treatment failure should not be accepted at face value ­ check treatment has been used appropriately

 · Severe or widespread psoriasis warrants specialist referral

References and resources

·G Krueger, MD et al. The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol. 2001;137:280-4

·Francesca Sampogna et al. Performance of the self-administered psoriasis area and severity index in evaluating clinical and sociodemographic subgroups of patients with psoriasis. Arch Dermatol. 2003;139:353-8

The Psoriasis Association http://www.psoriasis-association.org.uk

British Association of Dermatologists http://www.bad.org.uk/doctors/

guidelines/psoriasis

National Institute for Clinical Excellence Psoriasis.

Referral practice (version under pilot). http://www.nice.org.uk/

article.asp?a=10612

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