Building Trust in Psoriasis Care: Tools for Better Patient Conversations

ReachMD Announcer:
You’re listening to On the Frontlines of Psoriasis on ReachMD. And now, here’s Ryan Quigley.

Ryan:
Welcome to On the Frontlines of Psoriasis on ReachMD. I’m Ryan Quigley, and today we’re exploring how clinicians can strengthen communication with patients living with psoriasis. Joining me in this discussion is Dr. Ben Ehst, who is a board-certified dermatologist in Portland, Oregon, who sees patients at the Broadway Medical Clinic, is also an investigator and co-owner of Oregon Medical Research Center, and a Clinical Associate Professor at Oregon Health and Science University. Dr. Ehst, welcome to the program.

Dr. Ehst:
Thanks, Ryan. I’m happy to be here and talk to your audience today. 

Ryan:
To start us off, Dr. Ehst, when you first diagnose a patient with psoriasis, how do you approach that initial conversation?

Dr. Ehst:
Some of the biggest constraints usually is you’re trying to talk about a chronic disease in a short period of time. I think one of the first things I like to explain is that this is not an uncommon condition. I think patients always like to hear that they’re not entirely unique, so I think I hit that up first. I like to break apart the idea of autoinflammation and autoimmunity. There’s a lot you can read about psoriasis, and I think many patients have heard that this is an autoimmune condition, and I think there’s a somewhat misconstrued connotation around autoimmunity where you get the sense that your body’s attacking itself. And my take on psoriasis is that I like the term “autoinflammatory.” I explain to patients that this is a normal immune response. It’s not abnormal; it’s only excessive. And so the manifestation they’re seeing in this rash on the skin is the skin’s actually responding to a normal immune pathway excessively, and trying to tamp down that overexpression of the immune response in the skin and other body areas is what we’re going to try and do with therapy. So this idea of correcting excess inflammation and bringing that back to a normal level as opposed to suppressing somebody or causing damage with an autoimmune process.

We now know psoriasis is also a more systemic inflammatory process. So I do like to bring patients initially into the conversation that they need to be on the lookout for other comorbidities. I think it’s an underappreciated comorbidity around mental health and psoriasis, so I like to reassure patients about that. I think the joint inflammation that can occur in patients manifests as what we call psoriatic arthritis, bringing that in the conversation early on is a good idea, and also reassuring patients that not everybody gets it, and if they do, we can treat that. It’s important to talk about cardiovascular risk as we now know that systemic inflammation can contribute to overall inflammatory burden in the body, and that can manifest as increased risks of things like heart attack and stroke. And again, not to scare patients, but actually to bring them into the conversation that we do have to treat this, but we have plenty of ways to do that.

Ryan:
And what are some common misconceptions you hear from patients newly diagnosed with psoriasis?

Dr. Ehst:

Great point, and I think with the spread of social media and the easy access to both good information and potentially bad information out there, you do have to address that a lot. I think we touched on one: the misconception that psoriasis is a “autoimmune process.” I think that just sets the discussion off on the wrong foot and patients, again, are thinking their body is inappropriately attacking itself, and I like to clear that up right away.

A lot of people want to know if it’s going to be passed down to their kids, so that’s one of the common things you hear, and there can be a misconception that it’s a huge risk and kids are all going to get psoriasis. And sure, there is a very strong genetic component, but it’s not a monogenic disease where 50 percent of kids are going to get this, so you do have to bring that up, but it’s not something I tell patients to overtly worry about.

I think the other thing is there’s some misconception about it not being a big deal. I think providers 10, 20 years ago also had a role in that too, and some probably still do, and that is to say “it’s just localized in areas of the body.” But we do want to realize there is systemic inflammation behind this, and the real possibility that you can have low disease on the skin and low disease burden in terms of just the extent of disease, and yet you could still develop, you know, disabling arthritis.  So I think bringing up the idea that we want you to keep this in context, but it’s not something we want to just blow off completely. We have to talk about this. 

Ryan:
For those just tuning in, you’re listening to On the Frontlines of Psoriasis on ReachMD. I’m Ryan Quigley, and I’m speaking with Dr. Ben Ehst about effectively communicating with patients about psoriasis.

So, Dr. Ehst, when it comes to discussing treatment options, how do you engage patients in shared decision-making?

Dr. Ehst:
In general, I like to start broad and then narrow it, so I do say there are a lot of options, and I categorize them as topical, and oral, and biologic systemic therapies. I like to try and get a sense up front and even ask the patients themselves, “Do you want a list of choices? And we’re going to go through those if you want. Or do you want me to tailor that a bit more and give you some of my thoughts on what I think the best treatment might be?” I still like to give options within those narrow categories, but patients have very different approaches to these things, and I don’t want to come off as paternalistic. I want them to have a big say in this decision. I will try and sit back and take the time to explain the options. It can be a challenge when you’re pressed for time, but I think that’s what a newly diagnosed patient deserves. The final thing I do, I guess, would be to actually draw some of the immune pathways. So I like to explain a little bit about the pathophysiology behind what’s happening in the skin, and I think because most, or a lot, of our current therapies that are highly effective are targeted to specific proteins in the immune pathways, giving an overview of the different cytokines and the proteins that drive the inflammation in the immune system and the skin, I think that’s important. And that level of engagement, I think, will have the patient feeling like they’ve had some shared decision-making. 

Ryan:
Now, given the evolving treatment guidelines and emerging therapies, how do you adapt your communication so that patients don’t feel confused or overwhelmed by all of their options?

Dr. Ehst:
Yeah, another good question. I think I was alluding to it a little bit, I do try and tailor it to where I think the patient may end up. If I have a patient who has scalp psoriasis and it’s fairly localized, you know, I may start to talk about therapies that have been shown to be effective on the scalp because it can be harder-to-treat area. I like to address the quality-of-life impact, so if I have a patient who has limited psoriasis, I’m going to ask, “What’s the impact on your day-to-day living?” And that may make us choose a more aggressive option. Again, it’s that balance between overwhelming patients with all the options in an attempt to really engage the patient in shared decision-making and not just giving them an option and saying, “Here’s your old topical steroid and get out the door.”

Ryan:
Now, I know you mentioned a little bit earlier in this conversation the difficulties that psoriasis can have on someone’s mental health. So if we zero in on that, how can we best support patients’ mental and emotional health when they’re dealing with psoriasis? 

Dr. Ehst:
One of the big things is just to acknowledge that this is not just their skin. Survey after survey shows that dermatologic diseases are as devastating as cancer to some patients. It’s something that they have to see every day and others can see every day. That takes a big toll mentally, whether that’s your interpersonal relationships, work relationships, family. So I think just acknowledging the fact that that is an issue for most patients with psoriasis. That’s an easy way to sort of bring that level of comfort into the discussion.

Especially when talking about therapies, patients will ask, “Is this something I’m going to have to live with?” And the answer is usually, “Yes. Unfortunately, this is driven by genetics and different triggers, and our goal is to get you clear and have you living without any obvious psoriasis, but it may always still want to come back.” And that’s a huge thing to take in when you’re sitting in front of someone who you just told, “I’m going to be dealing with this for the rest of my life.” So I also say, “Let’s actually just think about the next three to six months. Let’s try and get you clear—that’s our goal—so you can forget about your psoriasis and have your life back to normal. And then after that, let’s think about the next 6 to 12 months or the next couple of years.

And then I talk about the fact that there’s a lot of support out there. You can go online to support forums, and you can talk with other patients, and you can build a real sense of community, as we know. I think organizations like the National Psoriasis Foundation have great patient support all the way from what is psoriasis to what are the various treatments, to how do I get onto these treatments that my providers try to give me. I always name drop the National Psoriasis Foundation as well. 

Ryan:
Now, Dr. Ehst, before we wrap up, I have one last question for you. What’s one key piece of advice you’d like to share with clinicians looking to strengthen their communication with patients who have psoriasis? 

Dr. Ehst:
My one point is slow down. You have to take the time in that encounter, even though it’s been a busy day and it may be your 30th patient to say this is a person who I just gave a new diagnosis or chronic disease to, and let’s take the time and slow down. Whenever I leave the encounter, the last thing I say is “Any more questions?” because I want them to feel like they’ve had their fair share to engage with me. And you’ll pick up things that you forgot to talk about or that’s the time the patient may actually really show that this is more devastating than they’ve been letting on. I guess the one thing to providers out there is just to remember: of all the things we treat as dermatologists, this is potentially a really clear case where we can get somebody to clear skin and change their life. 

Ryan:
And that’s a great takeaway for us to think on as we wrap up our discussion, and I want to thank my guest, Dr. Ben Ehst, for joining me to share his perspective on improving communication in psoriasis care. Dr. Ehst, it was great having you on the program today.

Dr. Ehst:
Yeah, likewise. It’s been a pleasure talking with you. 

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