THE DOCTORS' PERSPECTIVE
Psoriasis is a common inflammatory skin disease which affects 2% of the white population in Northern Europe. It is less common among Asian and black patients, affects both sexes equally and may develop at any age for the first time. Psoriasis is a highly visible condition, and although only life-threatening when it is erythrodermic, often causes a marked psychological burden similar to that experienced in patients with cancer, diabetes, and heart disease. Up to one in four patients are thought to be affected by a seronegative inflammatory arthritis and the disease is also associated with other chronic conditions including Crohn's disease, diabetes mellitus, uveitis, and atherosclerosis.
During the almost six decades that Mr Pickering has suffered from psoriasis the management options available to him have improved considerably. The majority of patients with psoriasis have minimal and limited disease and this can now be easily treated with creams or ointments, such as calcipotriol, which are far easier and safer to use long term in a primary care setting than their messier tar-based predecessors.
Hospital based Ultraviolet light B (UVB) and Psoralen-UVA photochemotherapy (PUVA) remain the mainstays of management for patients with more widespread or resistant disease. However, home based UVB has now become available in some centres, offering a convenient, although admittedly expensive, treatment option delivering care closer to home.
In the past, Mr Pickering chose not to continue methotrexate treatment because of the risk of liver fibrosis and a fear of the regular liver biopsies required to monitor this. Now serial blood assays of amino terminal type III procollagen peptide levels assist in reducing the need for such invasive procedures.
Other systemic treatment alternatives introduced during Mr Pickering's lifetime with psoriasis include acitretin, ciclosporin and fumaric acid esters (Fumaderm®), which, due to their different side effect profiles, allow dermatologists to tailor their management according to individual patient preferences and medical history.
Treatment with gold is now fixed well in the past, but the new biologics including TNF (for example, adalimumab, etanercept, and infliximab) and more recently interleukin-12 (ustekinumab) antagonists can now offer the convenience of effective treatment of both psoriasis and psoriatic arthropathy at the same time. As the number of effective treatment options available to patients with psoriasis continue to expand, Mr Pickering's account reminds us that when we treat patients we should be mindful of their experience of the disease rather than just the skin signs we see in front of us.