Psoriasis

This new dermatologist podcast is sponsored by SeraVee. SeraVee, SA smoothing cream for dry, rough, bumpy skin, is a non-greasy cream with three essential ceramides designed to improve skin texture while providing all-day hydration. The formula with salicylic acid and urea gently exfoliates the skin without compromising the skin's natural barrier. SeraVee, developed with dermatologists worldwide, available from selected retailers, pharmacies and online. Welcome to the new dermatologist podcast. We are a group of consultant dermatologists who share the same ethos about the future of dermatology and dermatology education. We happen to be friends and we've been involved in a lot of educational events both collectively and individually. This podcast is aimed primarily at GPs but also anyone who has an interest in managing common dermatological problems. GPs are having to manage an increasing number of patients with common skin conditions in primary care now because of the pandemic and we hope that they will find this podcast useful. My name is Victoria Atkras and I'm a consultant dermatologist at St. George's Hospital in London. My special interests are a skin cancer and connective tissue disease and I'm delighted to have my friend and colleague Dr Monica Sahar, a consultant dermatologist with me today. She's been working for nine years at Queen Elizabeth Hospital in London and she has a special interest in medical dermatology and inflammatory dermatosis. So welcome to you Monica. Hi and I'm also very pleased to introduce Dr Bill Chaudre. He's a GP principal in Beckinum Kent and he has a special interest in minor surgery. He has also joined us today for our podcast on Seraasis. So welcome to you Bill. Hi Victoria and I Monica, thank you for having me. So today we're going to talk about Seraasis which is a common skin condition. It has a 1 to 2 percent prevalence in the UK and it is now considered a systemic disease. The psychological and social burden of this disease is significant and there are associated cardiovascular, rheumatological and metabolic comorbidities. The treatments available for this condition have changed dramatically over the last decade and we will touch on treatments available in primary and secondary care. Hopefully so that our GPs can be armed with knowledge when consulting with their patients. The information in this podcast is based on available evidence and the experience of the clinicians involved. It is intended to be a useful guide for clinicians and the advice given in the podcast must take into account an individual patient's background and be adapted accordingly. So without further ado our hand over to you Bill. Thank you. I'll start by saying that it's been a long time since I've done any update on Seraasis so it was quite interesting to look at a few questions that came into my mind. So to start with are there any new theories just to the cause of Seraasis? Is it an immune condition and we all know that alcohol and stress can exacerbate it and what affects those actual factors have? Yeah thanks Bill that's a good question. So Seraasis is a multifactorial disease but it has a strong genetic component so about 35% of patients with Seraasis have a positive family history but there are other factors as you say alcohol, drugs, infections such as streptococcus, stress, smoking and more recently there's been this association with metabolic syndrome. So for example with alcohol yes it does affect the immune system and can increase up regulation of genes coding for creatinocyte proliferation. Now creatinocytes are a key cell in the epidermis that hyper proliferates in Seraasis and also it affects pro-inflammatory cytokines in the Seraasis pathway such as TNF alpha. And interestingly when I was reading about Seraasis and alcohol in a big study with 100 patients with alcoholic liver disease there was a Seraasis prevalence of 15% compared to 2% in the general population. So there definitely isn't a association between Seraasis and alcohol. And just thinking on a practical level when you see patients if you have a patient with severe Seraasis and they are a heavy drinker evidence has shown that decreasing their alcohol intake can improve their Seraasis. And then when you talk about stress, yes stress, anxiety, depression they all have a higher prevalence in Seraasis compared to other medical disease. And there's a possibility that it may be linked to the immune system via the HPA access. But Seraasis is very important. Obviously patients have a stigma associated with chronic disease with this very visible disease and impaired self image in some patients. So I think you have to think about the psychology of Seraasis as well. You did mention on the you touched on streptococcal infection. What's the effects of that in Seraasis? And is that a transient thing or is that a permanent Seraasis after a streptococcal infection? So yeah it's not often useful to ask if a patient has had a sore throat before they get a certain type of Seraasis. Usually it's a gutted Seraasis, that small raindrop type Seraasis. And if they have a genetic predisposition that can lead to Seraasis long term. Thanks Monica for that. Can you tell us a bit more about the association between metabolic syndrome and Seraasis? Because it's been a lot of interest recently about those two things. Yeah so now we think of Seraasis more as a systemic disease. We know it's already associated with psoriatic arthritis. But there's now we know more about an association with metabolic syndrome. Now this is a constellation of obesity, hypertension, dyslipidemia and insulin resistance. And certainly this is something that we can screen for and certainly in the community GPs can screen for and identify. So and also thinking about that smoking is an independent risk factor for metabolic syndrome and for Seraasis itself. And can be associated with a type of Seraasis known as Palmer Planta Pastelosis. One interesting case I had was a gentleman who actually fits the metabolic syndrome. He was a beast and he probably drank a little bit too much alcohol etc. But he also was on long term antidepressants and we switched it. And there was a massive worsening of his Seraasis. So is that linked to the medication do you think and are there other medications that are responsible for worsening Seraasis? So that is interesting actually which medication was it? So he was actually on something called doxapin which is not something we use a lot of and we wanted to use something more mainstream. Okay. Such as Citalipram or Certulein and when he switched it was basically within four weeks he got a worse significant worsening of his symptoms. Yeah so there are some well-known drug associations with Seraasis and they can either act as a trigger or an exasperant and beta blockers in fact a big group. But interestingly they can take up to a year before you actually see the flare of Seraasis whereas something like antimilarials you can see the exasperation of the Seraasis within a few weeks. So sometimes it's really difficult to identify which drug it is and whether it's triggering it or exasperating the Seraasis. But other key drugs are lithium ibuprofen which obviously we use a lot as inhibitors dejoxin and interestingly actually TNF alpha blockers for other diseases rather than Seraasis. Even though we use it for Seraasis you can see a paradoxical Seraasis in safe cranes disease. So some drugs can trigger Seraasis but if the patient has not had Seraasis before and the drug is withdrawn then the disease usually stops. But in some patients who have had Seraasis or have a positive family history they may have an exasperation of the Seraasis and be left with Seraasis long-term. So I think it is important to take a detailed drug history and look at timelines but it can be sometimes difficult to identify. Okay thank you. Now in primary care the medication we often prescribe is sort of often requested by the patients and we often give the last one that was given and it's generally speaking it'll be something called dovabet which is the calcibertrial and beta-methasone or it'll be calcibertrial gel by itself. Should we be thinking more about what we give and when and how long for? Yeah so I think which topical agent really depends on severity and sight of disease. So for example if you have a patient with a wide spread large block Seraasis I probably would reach for something like dovabet or instilar foam or other options are a low-potency steroid cream like beta-v8RD or vitamin D analogues as you say something like calcibertrial or dovabet or next cream which are better for milder Seraasis but there are other things that you can use in the community so tozorating cream which is a retinoid which can be useful. Dithro cream has dithranol which can be a bit irritant but it's very good for large plaque Seraasis and then we have coltar preparations and calcium urine inhibitors but I think the main thing is that you feel confident in using whichever agent you're prescribing and just advise the patients about side effects. And it presumes the mullion as well. Yeah so it's really important to prescribing the mullion as well as the active Seraasis agent because they increase the moisture in the skin they reduce itch scale and dryness and it's important to remind patients to wait at least 30 minutes before applying the active Seraasis cream so both get absorbed and both work better. Which a mullion really depends on patient preference and I guess what your CCGs allow you to prescribe but if you have a very if you have a patient with very severe Seraasis with scaly skin particularly on their palms and soles and a mullion with urea or salicylic [BLANK_AUDIO] a'r acodd yn ymwyr i'n gweithio'r acodd yn ymwyr i'n gweithio. Yn gweithio'r acodd yn ymwyr i'n gweithio. A'r acodd yn ymwyr i'n gweithio. a'r yng Nghymru, a'r yng Nghymru yng Nghymru, a'r yng Nghymru, a'r yng Nghymru a'r Nghymru a'r Nghymru a'r Nghymru a'r Nghymru a'r Nghym 'Burning and Skin Cancer' and we ensure the right intensity or wavelength of light is given for their skin type. And the amount of light is given is monitored very carefully, and we look out for complications. And you don't get that obviously with a patient who has their own phototherapy machine at home. And you'd say a machine is better than a week in Greece? I'd rather have a week in Greece. So at what point would you decide that phototherapy is, well, at what point should I think that phototherapy is the way forward here? So I think it's important to think about psoriasis and the treatment ladder. So we've talked about topicals already, and I think if they're failing in the community and there is more than 10% body surface area, and it's affecting their quality of life, do you think about referring in, and then we'll think about phototherapy or systemics and last lines by logics. So when you send a patient in, we'll assess their type of psoriasis. So if it's parmaplanta psoriasis, hand and foot poover, which is a type of light works very well, or if it's widespread guttate psoriasis, or chronic plaque psoriasis, we will think about UVB, maybe narrow band UVB. You might see some of our letters, we write TLO on therapy. And so we give them a course, which is usually about two to three times a week for 10 to 12 weeks, which can be extended. And this usually, if it works, it pushes the patient into remission for a bit per period of time. Okay, I'm always thinking I should be a little bit more organic from time to time. So there are some anecdotal reports that possibly apple cider vinegar or turmeric can be used in the maintenance therapy of psoriasis. Is there any mileage in that, or? So I haven't seen any evidence of improvement with apple cider vinegar, although I can imagine it being an irritant. But turmeric is more interesting, or curcumin, which is the active metabolite. It is known to have anti-inflammatory, including anti-TNF, which is one of the cytokines involved in psoriasis and anti-prolifative properties. So there is some evidence in its usefulness in psoriasis and other inflammatory disorders. But I guess the main thing is that how do we give it, do we give it in tablet form, and what is the dose, or do we give it in cream form, and how does it compare to conventional psoriasis medication, which is evidence-based and proven. So I think we do need more trials to compare it to conventional treatment. Okay. Now I'll be honest, until I looked into psoriasis for today, I wasn't actually aware that biologics were used for psoriasis. Sorry I think I'll throw up with the yes, but not straight psoriasis. So can you tell me a little bit more about that? Yes, so biologics really have been a big game changer in psoriasis over the last 10 to 20 years. In my own hospital, we have more than 100 patients on a biologic. I don't know, Vicky, you're in a teaching hospital. How many patients do you have here? Yeah, we have quite a number of them too, and the number and a variety of biologics just proliferates months by months. It's difficult to keep track unless you're a medical dermatologist with how many biologics are available, and which ones are good for who? Exactly. So I think they're here to stay, and their place is usually after conventional oral systemics fail. So acetretin, metatrexate, cyclosporin, premalast, and if the disease is very severe and it's affecting quality of life, and the benefit is that it's very effective, and it can cause improvement within weeks and have sustained improvement for months to years. oeddwn i'n baird. injection form usually every week or some are given three monthly. But the problem is it's not cheap and so we have to use it after we use conventional immunosuppressants. But tolerability is actually very good and patients do like this. Regarding psoriatic arthritis, you don't have to have this to be eligible for a biologic. So some biologics work better for psoriasis alone, some for psoriatic arthritis and some for both. So if you see a patient in the community who has severe psoriasis and probable psoriatic arthritis, I'd refer to both a rheumatologist and a dermatologist at the same center so we can coordinate treatment. But biologics really have been a game-changer and I think they're here to stay. Did you do any joint clinics with rheumatology? I do actually, but trust don't like them as they're a bit expensive. So my final question was regarding steroids are steroids ever indicated for a short shot burst maybe before someone's exam or wedding just to get the psoriasis under control is it helpful? So I generally would say I don't recommend oral steroids for psoriasis is different to X-Men and so yes it may temporarily control the psoriasis but once the steroids are stopped you can get this sort of rebound flare or destabilisation of the psoriasis which can be really difficult to control and it can even trigger a sort of pastula or a rhythmic psoriasis and I've seen many patients who come into hospital with de-stabilised psoriasis with this picture. So generally I would say look maximize their topical treatment rather than giving them a course of oral steroids. Thank you for that. I think my take on messages that I'm a bit like Colta. I've been deaf described as irritant and odorous but I'd rather be an older in a goodie. Thank you. Thank you very much for that. I just want to ask Monica can you sign post us to any other sources of information for patients and for GP's on psoriasis that are legitimate and informative and useful? Definitely. There is a lot out there on the internet so it's worth while looking at these kind of sites. So the British Association of Dermatologists is a great resource anyway but they also have these patient information leaflets and there's a very good one on psoriasis and then it's worth while looking at support groups like the National Psoriasis Foundation and you've probably seen Dermnet before which is good for both patients and doctors. I have a very useful yeah. And then also St John's Institute of Dermatology they've got a lot of practical advice leaflets and videos online. Great. I'll definitely take a look at all of those. So thank you guys. That was a really informative session and thanks to our listeners for joining us with a new Dermatologist podcast. I hope you found all this useful in your practice and that you can join us again for more practical tips on managing common skin conditions in the future. 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