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11/13/24, 8\:19 PM Guide | Psoriasis counselling

Psoriasis counselling

Table of contents

Introduction

Being able to share information in a clear and concise way is an essential skill in all
simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis.
Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may
also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format in order to
communicate more e

Structure

Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information
being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.
Explanation structure

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before
explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to
establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better
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understanding of their problem. After introducing yourself, it is important to take a brief history (this is the
structure)\:
What has brought the patient in to see you today?
What are their symptoms?
Are there any risk factors that can be identi
For example, a patient with psoriasis will likely mention itchy, red lesions with an overlying scale on areas such as the scalp and
extensor surfaces. They may also mention precipitating factors such as recent infections or exacerbating factors like smoking
and alcohol.
Tip\: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all
your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction
and brief history between 1-2 minutes maximum.

What does the patient understand?

Following a brief history, it is important to gauge the patient’s knowledge of their condition. Around one-third of patients with
psoriasis will have a family history of the condition, so the patient may already have a lot of knowledge and experience
regarding it, or it may be their
Due to these reasons, it is important to start with open questioning. Good examples include\:
“ W h a t d o y o u t h i n k i s c a u s i n g y o u r s y m p t o m s ?”
“ W h a t d o y o u k n o w a b o u t p s o r i a s i s ?”
“ W h a t h a s b e e n e x p l a i n e d t o y o u a b o u t p s o r i a s i s s o f a r ?”
Open questioning should help you to determine what the patient currently understands, allowing you to tailor your
explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks
(i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal
communication such as nodding).
Checking the patient’s understanding should not be solely con
throughout by repeatedly ‘chunking and checking’
.
Tip\: Try using phrases such as\:
“ J u s t t o c h e c k t h a t I a m e x p l a i n i n g p s o r i a s i s c l e a r l y , c a n y o u r e p e a t b a c k t o m e w h a t y o u
u n d e r s t a n d s o f a r ?”
. This is far better than only saying “ W h a t d o y o u u n d e r s t a n d s o f a r ?” as the onus is placed upon the quality
of your explanation rather than there being an issue with the patient’s ability to understand.

What are the patient’s concerns?

The patient’s concerns should never be overlooked. Asking the patient if they have any concerns before beginning your
explanation allows you to speci
The “ICE” (ideas, concerns and expectations) format, can provide a useful structure for exploring this area further.

ICE

Ideas\:
What does the patient think is causing their symptoms?
What is their understanding of the diagnosis?
Concerns\:
What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations\:
What is the patient hoping to get out of the consultation today?

Explanation

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After determining the patient’s current level of understanding and concerns, you should be able to explain their condition
clearly.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect.
“ I’ m g o i n g t o b e g i n b y t a l k i n g a b o u t t h e n o r m a l f u n c t i o n o f t h e s k i n a n d t h e n m o v e o n t o d i s c u s s w h a t p s o r i a s i s i s , w h a t c a u s e s
i t a n d h o w w e c a n m a n a g e i t t o g e t h e r .
”
Tip\: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.

Normal anatomy/physiology

“ T h e n o r m a l f u n c t i o n o f t h e s k i n i s t o a c t a s a b a r r i e r . W e c a n i m a g i n e t h e s k i n t o b e l a y e r s o f b r i c k s s t a c k e d o n t o p o f e a c h
o t h e r . I n n o r m a l s k i n , t h e m o r t a r b e t w e e n t h e b r i c k s p r e v e n t s i r r i t a n t s f r o m ge t t i n g i n a n d p r e v e n t s w a t e r f r o m ge t t i n g o u t w h i c h
s t o p s t h e s k i n f r o m d r y i n g o u t .
”

What the disease is

Psoriasis is a chronic in
4% of the population and while it is more common in Caucasian patients it can a
The most frequently a
Patients will typically report developing itchy, red rashes on the skin, that tend to be symmetrically distributed. They may also
have pain/burning sensations around the rashes, joint pain and nail changes such as pitting.

Cause of the disease

" T h e d e v e l o p m e n t o f p s o r i a s i s i s v e r y c o m p l i c a t e d a n d a l o t o f d i
w i t h p a r t s o f t h e i m m u n e s y s t e m b e c o m i n g o v e r a c t i v e , w h i c h l e a d s t o i n
W e d o n' t k n o w t h e e x a c t c a u s e o f p s o r i a s i s b u t k n o w t h a t i t i s d u e t o a c o m b i n a t i o n o f ge n e t i c , i m m u n e a n d e n v i r o n m e n t a l
f a c t o r s . T h e r e i s a g e n e t i c c o m p o n e n t , a n d t h e d i s e a s e w i l l o f t e n r u n i n f a m i l i e s . T h e r e i s o f t e n n o c l e a r t r i gg e r i n m o s t c a s e s o f
p s o r i a s i s .
T h e r e a r e s o m e t h i n g s t h a t c a n p r e c i p i t a t e p s o r i a s i s , f o r e x a m p l e , i n f e c t i o n s , h o r m o n a l c h a n ge s a n d c e r t a i n m e d i c a t i o n s s u c h
a s l i t h i u m . A d d i t i o n a l l y , s o m e t h i n g s c a n m a k e p s o r i a s i s w o r s e o n c e i t h a s d e v e l o p e d , t h e s e i n c l u d e s k i n t r a u m a , s m o k i n g ,
a l c o h o l a n d s t r e s s .
"

Problems/complications

Outlining potential complications of psoriasis is necessary so that the patients can identify problems early and seek medical
advice. Being aware of common problems will also encourage patients to adhere to their treatment.
Explain that you are outlining the potential risks so that they are aware of them. When discussing potential complications
explain that you and the patient will need to work together as a team to reduce the likelihood that they’ll occur.
Complications of psoriasis include\:
Persistent disease and symptoms
Anxiety and depression due to the psychosocial burden of the disease
Reduced quality of life
Development of associated conditions, such as psoriatic arthritis
Patients can also experience
fatal in rare cases.
" A r a r e c o m p l i c a t i o n o f p s o r i a s i s i s t h e d e v e l o p m e n t o f a s e v e r e
T h e s e
b l i s t e r s o n y o u r b o d y q u i c k l y , o r t h a t y o u b e g i n t o d e v e l o p p a i n f u l a n d i t c h y r a s h e s a l l o v e r y o u r b o d y t h e n y o u s h o u l d s e e k
u r g e n t m e d i c a l a d v i c e .
"

Management

Reinforce to the patient that they need to work with you as a team to achieve a good result.
Patients should be advised to avoid any exacerbating factors/triggers such as smoking and alcohol.
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The management of psoriasis follows a stepwise approach, which allows room for increasing the strength and e
treatments in patients that do not respond to
require additional systemic therapies or other therapies such as phototherapy if they do not respond to initial treatment.
Emollient therapy
Emollients should be used regularly regardless of how well-controlled psoriasis is (up to 8 times a day) and regular application
has been shown to reduce the number of
growth (to help prevent folliculitis).
Ointments\:
para
oily/greasy, thick
can stain clothing
the most e
Creams\:
water-based
soak in and disappear
Lotions\:
water-based
replacement for soaps and shampoos
not used as an emollient alone
Topical corticosteroids
Topical corticosteroids are the most commonly prescribed topical therapy for psoriasis. The strength of the preparation can be
adjusted depending on the severity of the disease (plaque thickness), skin sensitivity and the site of the disease.
Other topical therapies
Tar preparations are anti-in
salicylic acid) to help lift scale. This is the preferred topical therapy for psoriasis on the trunk and limbs.
The most common tar preparation is liquor picis conbonis (LPC, coal tar).
Calcipotriol is a vitamin D analogue that can be used as a topical therapy as it has an anti-proliferative e
It is generally given alongside topical corticosteroids.
Systemic therapies
If a patient's psoriasis is not controlled by topical treatment alone then they may require systemic therapy, which is generally
immunosuppressive treatment.
Methotrexate is frequently used as an oral therapy for severe unresponsive psoriasis, due to its ability to slow epidermal cell
proliferation. It is e
dysfunction and pulmonary
Acitretin is an oral retinoid that is anti-in
pro
Cyclosporin is highly e
e
frequently recurs quickly after cessation of treatment.
Biologic therapies may be used in patients with treatment-resistant psoriasis (mostly restricted to severe disease due to the
expense associated with biologic agents). They may also be e
targets include TNFα (in
Other therapies
Psoriasis often responds well to narrowband UVB phototherapy, which down-regulates the immune and in
pathways of the skin. This is the phototherapy of choice for plaque psoriasis, but other forms of phototherapy may be used for
di
Example of how you might explain the management of psoriasis
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" T h e s y m p t o m s o f p s o r i a s i s c a n b e v e r y u n p l e a s a n t a n d d i s r u p t i v e t o y o u r l i f e s o i t' s i m p o r t a n t t h a t w e w o r k t o t r y a n d ge t t h e m
u n d e r c o n t r o l .
"
" T h e m a i n s t a y o f t r e a t m e n t w i l l b e t o p i c a l c r e a m s . Y o u w i l l h a v e o n e t y p e c a l l e d a n e m o l l i e n t . E m o l l i e n t s w o r k b y
c r a c k s b e t w e e n t h e d r y b r i c k s , w h i c h s t o p s i r r i t a n t s f r o m g e t t i n g i n a n d p r e v e n t s w a t e r f r o m e s c a p i n g, w h i c h h e l p s t o
m o i s t u r i s e t h e s k i n . T h i s c a n a l s o r e d u c e t h e n u m b e r o f
d i
y o u . T h i s c a n s o m e t i m e s b e a c a s e o f t r i a l a n d e r r o r a t t h e b e gi n n i n g . I c a n gi v e y o u s o m e s a m p l e s o f t h e d i
e m o l l i e n t s , a n d a s k a s p e c i a l i s t n u r s e t o s p e a k t o y o u a b o u t t h e m t o d a y i f y o u w o u l d l i k e ?"
" Y o u w i l l a l s o h a v e a n o t h e r t y p e o f t o p i c a l t r e a t m e n t t o u s e a l o n gs i d e t h e e m o l l i e n t t o h e l p m a n a ge y o u r s y m p t o m s . T h i s w i l l
g e n e r a l l y e i t h e r b e a s t e r o i d c r e a m o r a c o a l t a r p r e p a r a t i o n . W e t e n d t o t r y t o p i c a l s t e r o i d s
c a n c h a n g e t o a n a l t e r n a t i v e i f t h e y d o n' t h e l p . S t e r o i d s s h o u l d n o t b e u s e d o n t h e f a c e a s t h e y c a n c a u s e t h i n n i n g o f t h e s k i n
a n d o t h e r s e r i o u s s i d e e
"
" I n m o s t p e o p l e , t h e t r e a t m e n t s w e h a v e d i s c u s s e d w i l l c o n t r o l y o u r p s o r i a s i s e x t r e m e l y w e l l . H o w e v e r , w e d o h a v e o t h e r
o p t i o n s f o r t r e a t m e n t i f t h e s e a r e n o t s u c c e s s f u l a n d w e c a n d i s c u s s t h o s e i f i t b e c o m e s a p p r o p r i a t e .
"

Closing the consultation

Summarise the key points back to the patient.
" I n s u m m a r y , p s o r i a s i s i s a l o n g-t e r m c o n d i t i o n t h a t a
d e p e n d i n g o n l o t s o f d i
e m o l l i e n t a n d a t o p i c a l s t e r o i d t o d a y , b u t i f t h e s e d o n' t h e l p t h e n t h e r e a r e l o t s o f o t h e r t h i n gs w e c a n t r y . I f y o u r p s o r i a s i s s t a r t s
t o g e t w o r s e v e r y q u i c k l y o r y o u' r e c o n c e r n e d a b o u t i n f e c t i o n t h e n y o u s h o u l d s e e a d o c t o r t h e s a m e d a y . Y o u a r e go i n g t o
m e e t t h e s p e c i a l i s t n u r s e t o d a y t o t a l k a b o u t t h e e m o l l i e n t s w h i c h w i l l s u i t y o u b e s t , a n d t h e n w e c a n m e e t a ga i n i n a f e w
w e e k s t o s e e h o w t h i n g s a r e g o i n g .
”
Ask the patient if they have any questions or concerns that have not been addressed.
“ I s t h e r e a n y t h i n g I' v e e x p l a i n e d t h a t y o u’ d l i k e m e t o go o v e r a g a i n ?”
“ D o y o u h a v e a n y o t h e r q u e s t i o n s b e f o r e w e
Arrange appropriate follow-up to discuss their psoriasis further. Acknowledge that you have discussed a large amount of
information and it is unlikely that they will remember everything.
O
use to gather more information (examples include patient.info and NHS Choices).
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

References

1. DermNet NZ. P s o r i a s i s . 2014. Available from\: [LINK]
2. British Association of Dermatologists. H a n d b o o k f o r M e d i c a l S t u d e n t s a n d J u n i o r D o c t o r s . 2020. Available from\: [LINK].
3. Patient.info. C h r o n i c P l a q u e P s o r i a s i s . 2020. Available from\: [LINK].
4. NICE. P s o r i a s i s a s s e s s m e n t a n d m a n a g e m e n t . 2017. Available from\: [LINK].
Source\: geekymedics.com
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