Transcript
Announcer:
You’re listening to On the Frontlines of Psoriasis on ReachMD. And now, here’s your host, Dr. Steve Jackson.
Dr. Jackson:
This is On the Frontlines of Psoriasis on ReachMD. I'm Dr. Steve Jackson, and today, I'm joined by Dr. Mio Nakamura to explore the often overlooked psychological and emotional burden of psoriasis. She's a Clinical Assistant Professor of Dermatology and Director of Clinical Research at the University of Michigan Medical School.
Dr. Nakamura, welcome to the program.
Dr. Nakamura:
Thank you, Steve. Thanks so much for having me.
Dr. Jackson:
Well, let's dive right in. How can psoriasis shape patients' day-to-day emotional and social lives?
Dr. Nakamura:
Yeah, this is a really good question. It's a question that's being asked more and more these days. Psoriasis is a chronic inflammatory skin condition traditionally, but more recently, we're thinking of it more as a systemic inflammatory condition because it does affect all aspects of a patient's health. We often think of psoriasis as having comorbidities such as psoriatic arthritis. Systemic inflammation can also cause cardiovascular disease and metabolic syndrome.
But in addition to that, and very importantly, psoriasis also affects a patient's mental health and overall wellbeing. And so if you think about psoriasis, there are these visible plaques on the skin. They can be very symptomatic, sometimes very itchy, and sometimes very painful, and that can affect your day to day. Some people are not able to sleep at night. Some people are not able to work. And so it really does affect you as a person when you have psoriasis.
In addition to that, the visible nature of skin diseases like psoriasis affects interpersonal relationships. You may not want to be in an intimate relationship, for example. You may be embarrassed to go out in public, and in turn, these can cause mental health issues such as depression and anxiety. People just think, "Oh, it's just psoriasis. It's just a skin condition." But really, it is a medical issue that affects all aspects of the patient.
Dr. Jackson:
Absolutely. Now, how do you approach cases where this psychological impact doesn't match the clinical severity?
Dr. Nakamura:
Moderate-to-severe psoriasis is usually defined by patients who have at least 3 percent of their body surface area covered by psoriasis. Historically, we use the psoriasis area severity index, which is the severity scoring. If that score is high, then the patient has moderate-to-severe psoriasis, and that does often correlate with psychological impact. And so the worse the severity, the worse the impact is on psychological health.
These days, we're also recognizing that it's not just about the body surface area or the severity score. It also depends on what we call high-impact sites, so areas that affect people day to day more, and also areas that are difficult to treat. So these areas are going to be, for example, the scalp, genitals, hands, and feet. And so these are notoriously clinically difficult to treat areas. They're not as treatment responsive for one reason or another, but they also affect the patients more. So if you can imagine having psoriasis on your hands and feet, you're having difficulty walking, for example. And even if it's just your hands or feet that are affected with psoriasis, that is significant and that is severe, and that is going to have a really negative psychological impact. So we are recognizing location burden as a factor in the psychological impact that psoriasis can have on patients.
Dr. Jackson:
Dr. Nakamura, clinicians often define success in psoriasis by skin clearance, but how well does that actually reflect the patient's overall wellbeing?
Dr. Nakamura:
That's a great question because treatment success should really depend on how the patient is feeling. So you can have one patient who starts a treatment, and they go from having most of their body covered with psoriasis to just a little bit, for example, on their elbows and knees. And they're very happy and they're saying, "My life has completely changed. I'm very happy." On the other hand, you could have a patient who you are able to clear with a good treatment but, for example, they're still having some of those comorbidities. They're still having psoriatic arthritis, or maybe their nail psoriasis is resistant to treatment, so they're still having nail psoriasis, and the patient is very much still debilitated by these. Then, it's not treatment success.
So I always ask the patient an open-ended question like, "How is it going?" Not just "How's your psoriasis?" Or "How's your skin?" I always ask them to encompass them holistically. "How are things going? Are you happy where you're at right now?" And that can give you a better idea of treatment success.
Dr. Jackson:
For those just tuning in, you're listening to On the Frontlines of Psoriasis on ReachMD. I'm Dr. Steve Jackson, and I'm speaking with Dr. Mio Nakamura about how psoriasis can impact patient's mental health.
We've been discussing patient experiences, so let's shift now to what all this means for clinical practice. Dr. Nakamura, what are the signs that a patient with psoriasis may be struggling mentally, and how can clinicians identify them?
Dr. Nakamura:
That's a really great question. When we as doctors see patients, it's true of all specialties that we should just try to read the patient, not just look at them as a medical case. You want to look at the patient's demeanor. How are they making eye contact with you? How are they communicating with you? Do they appear nervous or relaxed? And I think these social cues can be really helpful to know the overall wellbeing of a patient.
There are also ways to identify patients who may be struggling with mental health issues by giving very quick surveys, for example. While the patient is waiting in the waiting room, there are various tools where you could assess a patient's mental status. So, for example, we often use the PHQ, which is just a couple of questions asking patients how they're doing in terms of, for example, depression or anxiety symptoms.
There are many other tools that clinicians can use for dermatology. Especially in clinical trials, we're often using, for example, the dermatology life quality index, or DLQI. It's a really quick survey that patients can fill out, and the score will indicate how much their skin is impacting their day-to-day life. So you can get these more quantitative measures of a patient's wellbeing, and you can incorporate that into your clinical practice.
Dr. Jackson:
And how can dermatology providers realistically incorporate mental health support into psoriasis care?
Dr. Nakamura:
Yes, and that's a really good question. I think in terms of psoriasis treatment, dermatologists are pretty lucky because we have a lot of different treatments we can offer to our psoriasis patients that are very effective and very safe. And so oftentimes, by adequately treating the psoriasis, you're automatically also improving patient's mental health.
But as we talked about before, sometimes that's not the case. Sometimes you are improving the psoriasis, but the patient may still be struggling. I think it's always nice to have partners in care. So, for example, as a dermatologist, if you have like a go-to psychologist who you can share patients with, I think that's really great.
The other thing that I find really useful is patient support groups. So in the US, we have the National Psoriasis Foundation, for example. They connect not just providers, but also patients and also advocates and volunteers throughout the country. I think support groups can really help patients know that they're not alone in this journey, and I almost always mention that to my patients.
Dr. Jackson:
And as we wrap up, Dr. Nakamura, what are the most important steps clinicians can take to better support mental health in these patients?
Dr. Nakamura:
I think the first step really is to recognize when patients are suffering mentally or emotionally. I think we talked about different ways to pick up these cues in the clinical setting, but also having more quantitative measures of the mental health impact. And so number one is recognizing it.
Number two is just having your go-to resources. So whether it's a referral to a patient support group or referral to a mental health provider, I think having those resources ready to go for any patient who needs it is really important.
And then the third thing is we should treat these patients adequately and also in a timely manner. So if you think about a patient who has psoriasis and they've had it for a really long time, that duration that they're negatively impacted is longer. So if you see a patient, I wouldn't hesitate to treat them quickly, appropriately, and aggressively so that their skin condition can improve and they have a shorter amount of time suffering in terms of their general wellbeing as well.
Dr. Jackson:
As those insights bring us to the end of our program, I want to thank my guest, Dr. Mio Nakamura, for joining me to share her insights on the mental burden of psoriasis. Dr. Nakamura, it was a pleasure having you on the program.
Dr. Nakamura:
Thanks for having me, Steve.
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