1. How can pharmacists help improve outcomes for patients with psoriasis?
Dr Rod Tucker
Pharmacist/Researcher
This session is sponsored by LEO Pharma

2. Declarations of Interest
Dr Tucker has received sponsorship from LEO Pharma.

3. Psoriasis
Psoriasis derived from the Greek word “psora” which means to itch
A complex and potentially multifactorial, immune-mediated inflammatory disease Cutaneous symptoms include erythematous/ silvery, hyperkeratotic, scaly plaques
Common sites are elbows, knees, scalp, lower back but can occur anywhere

4. Psoriasis: Epidemiology
Affects roughly 2 % of UK population
No difference the prevalence between sexes
Early onset 15 – 25, late onset 50 – 60
Approximately 50% of all people living with psoriasis have nail involvement

5. Psoriasis
Most common form (over 80%) is plaque psoriasis which is generally life-long, following a relapsing remitting pattern
Most patients have mild to moderate disease treatable with topical agents
Currently not curable; requires effective self-management

6. Not just a skin disease

7. Pathophysiology
Related to excessive production of specific cytokines TNF-∝, IL-17A/F
IL-17A stimulates keratinocytes & others to drive hyper proliferation of cells
IL-17A found in lesional skin & serum & synovial fluid of those with RA

8. Co-morbidity Increased risk Notes
Psoriatic arthritis
35%
Crohn’s disease
X 2.5
Metabolic syndrome
X 2
If psoriasis severe
Atrial Fibrillation
X 3
If <50 & severe disease
Stroke
Non-alcoholic fatty liver disease
17 – 60%
Skin cancer
X 5
uveitis
7 – 20%
Depression/Anxiety
1.38
Hazard ratio

9. In the skin

10. Psoriasis: causes/triggers
Genetic disposition known to be important (roughly a third of patients)
Can be triggered by many factors
Skin trauma (Koebner’s phenomenon)
Climate (often worse in winter than summer)
Infections (streptococcal infections)
Medicines (anti-malarials, beta-blockers, lithium, NSAIDs, ACE inhibitors)
Smoking
Stress
Alcohol

11. Patient behaviours increasing risk
Smoking
Physical inactivity
Obesity
Excess alcohol
Poor adherence (32 – 61% Gupta, 2008)

12. Plaque psoriasis

13. Plaque psoriasis

14. Nail changes

15. Impact of psoriasis
Survey by NPF found that 75% of people said that condition moderate/large impact on quality of life1 1.

16. Psoriasis: Topical therapies
Emollients
Topical steroids
Vitamin D analogues
Combined steroid-vitamin D compounds
Dithranol preparations
Coal tar based products
Retinoids

17. Treatment guideline (NICE 2012)
Potent topical steroid & vitamin D analogue either alone or in combination applied separately for up to 8 weeks.
Next step – vitamin D analogue alone twice daily for up to 12 weeks
Next step – potent steroid alone twice daily for 4 weeks OR coal-tar product once or twice daily
Next step – if adherence a problem – offer combination product (potent steroid & vitamin D combination product) for 4 weeks
Next step – discuss other options or refer to secondary care

18. Patient beliefs Evidence from qualitative studies suggest that:
Advice on use of treatments is desired by rarely provided
Patients perceived practitioners as lacking in sufficient knowledge to manage psoriasis
Lacked empathy
Patients want information on condition, co-morbidity, prognosis etc.

19. The PEDESI Study
Aim “To assess patient’s current level of knowledge and understanding of psoriasis and it's management to improve disease outcomes”

20. Pharmacy recruitment
Patients presenting with prescriptions for topical treatments recruited at pharmacy
Held an initial consultation and one follow-up 6 weeks later
Used the PEDESI tool to assess knowledge
SAPASI for disease severity
DLQI for quality of life

21. PEDESI Tool
UK/IE MAT June 2017

22. SAPASI
UK/IE MAT June 2017

23. DLQI
UK/IE MAT June 2017

24. Study outcome measures
In total, 47 patients recruited and 42 attended follow-up appointment
Follow-up vs baseline in:
PEDESI
SAPASI
DLQI

25. Change in outcome measures
* p< 0.05

26. Patient follow-up data

27. Patients level of agreement (n = 38)

28. What did patients like about the study (n = 38)

29. Do you think your psoriasis improved as a result of the pharmacist advice?

30. Pharmacist data

31. Pharmacist interviews
7 pharmacists interviewed
Several themes emerged.
Pharmacists saw themselves as:
Information providers
Members of the management team

32. Pharmacist interviews
Difficulties included:
Patient engagement – especially with follow-ups
Juggling with demands of other work

33. Could the service be extended nationally?
I’ve seen only 7 patients but after what I’ve seen about how little they know about the treatment and how to use it, what about patients who go to other pharmacies ... It couldn’t be just the few people who are doing the study, it could be everywhere.

34. Conclusion Psoriasis is not just a chronic skin condition
Patients rarely receive sufficient advice from healthcare professionals
Pharmacists have a potentially role important educational role to help support patients and improve disease outcomes

35. How pharmacists can help patients

36. How the pharmacists helped: Treatment
Addition of emollients – helps to soften plaques and improve cosmetic appearance
Use of fingertip unit for steroids – 1FTU = one elbow/knee
Scalp scaling – use descaling overnight and wash out with tar-shampoo morning

37. How the pharmacists helped: Lifestyle
Stop smoking - reduce trigger
Weight reduction – some evidence this helps
Exercise – improve cardiovascular health
Reduce alcohol intake

38. References Gupta et al. J Am Acad Dermatol 2008;59(6):1009–16
Tucker In J Pharm pract 2017; 25(2):
Tucker SelfCare 2016; 7(4):