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The benefits of switching to nurse-led management of patients with psoriasis

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Caroline Riddoch, RGN.

Nurse Practitioner, Department of Dermatology, Aberdeen Royal Infirmary

Psoriasis is a chronic, inflammatory, non-infectious skin condition (Jackson, 2002) that affects about 1-2% of the UK population. It is incurable and presents equally in both men and women and can occur at any age. In 75% of cases presentation occurs before the age of 40 (Griffiths and Kirby, 1999).

Psoriasis is a chronic, inflammatory, non-infectious skin condition (Jackson, 2002) that affects about 1-2% of the UK population. It is incurable and presents equally in both men and women and can occur at any age. In 75% of cases presentation occurs before the age of 40 (Griffiths and Kirby, 1999).

The disability caused by psoriasis has been likened to that of diabetes, angina or asthma and is recognised as a lifelong condition following a pattern of remission and relapse (Marks, 2003).

The psychological impact of living with psoriasis is as important as the physical implications and it is accepted that the severity of the condition does not necessarily reflect the despair the condition causes individuals and their families.

Improving the dermatology service in Aberdeen
The dermatology unit at Aberdeen Royal Infirmary caters for a population of 500,000 spread over a large geographical area. It provides ongoing specialist care and support to patients with dermatological conditions including psoriasis, eczema and acne. Figures from the hospital's information department show that between 2003 and 2004 the out-patient facilities had a throughput of about 10,000 patients, with 3,000 being new referrals.

A national shortage of dermatologists and ever-increasing demands and requirements in our unit prompted us to evaluate our provision of services by embarking on a redesign project. In 2002, as part of this process, five in-patient beds were closed and a day-treatment area dedicated to treating patients with psoriasis or eczema was opened. Today, one-part-time trained nurse is allocated to the day treatment area. The service enables patients to carry on with their normal lives. In the past, many treatments would have necessitated admission, but patients now have the option of choosing not only their treatment but also the times they are treated.

Although day treatment has advantages for many patients, adjusting prescriptions in the unit proved to be an ongoing problem, causing frustration for both the patients, nurses and doctors. In an effort to overcome this initially, the extended independent and supplementary nurse prescribing course was undertaken by one member of staff. Currently there are two nurse prescribers in the dermatology department and a third nurse is taking the course. The increased knowledge these nurses now have has enhanced patient care, allowing experienced nurses to work in partnership with medical staff to decide the most appropriate treatment regimes for each patient.

The benefits of nurse prescribing for dermatology patients include easier and quicker access to specialist help. In an effort to provide a high standard of dermatology care, nurses practising in the field are required to maintain a high level of knowledge about the disease process and keep up to date with changing treatments. Cox et al (1995) found that many experienced dermatology nurses are as capable of advising and providing appropriate treatment options as senior house officers.

Patient acceptance of nurse prescribing is necessary to ensure efficient and effective practice and generally this appears to be the case within the dermatology setting. Assessment, observation, provision of information and the approachability of staff have been identified by patients as areas that have been improved when consultations are undertaken by a nurse (Brooks et al, 2001).

Nurse consultations and nurse prescribing are two areas that nurses in the unit have embraced, and recently the department has secured two nurse practitioner posts. This was done with the aim of introducing a nurse-led service in order to improve accessibility for patients with psoriasis, eczema and acne.

This service will provide an open-door policy, a telephone helpline and an increase in education and support for patients and other health-care professionals. The helpline will be manned three days a week by secretarial staff, and the calls will be logged electronically and accessed by the nurse practitioners, who will offer advice over the telephone or at a routine or urgent appointment.

This nurse-led service is available now and allows for 30-minute consultations in which disease management and the patient's perception of the condition are discussed, information and guidance are given, and treatment plans are assessed for effectiveness, are altered or initiated using nurse prescribing.

The causes of psoriasis
Although the trigger factors are widely accepted, the exact cause of psoriasis is not fully understood. A genetic link is indisputable, with a child having a one in four chance of inheriting psoriasis if one parent is affected, and a three in five chance if both parents have it (Venables, 1994).

Although much work has been undertaken in the field of genetics, advances in molecular research have increased the understanding of the importance of the immune system in psoriasis pathogenesis (Sterry, 2004).

Several non-genetic factors are recognised as leading to exacerbation - for example, stress is accepted as a trigger by both patients and health-care professionals (Cloote, 2000). However, it could be argued that psoriasis, and its associated physical and psychological dysfunction causes the patient to become stressed rather than anxiety causing the condition to flare.

Other trigger factors include certain medications, for example, beta-blockers, antimalarials, lithium and ACE inhibitors. Streptococcal upper-respiratory tract infections are accepted as a trigger for guttate psoriasis and for causing flare-ups of chronic plaque psoriasis (Davison et al, 2000). Trauma to the skin - for example, from a surgical excision, tattooing or even areas of sunburn or scratch marks - can lead to psoriatic lesions, known as the isomorphic response or Knobner's phenomenon. These lesions occur at the site and follow the pattern of injury.

Research into potential links between alcohol and smoking and the increased risk of psoriasis has proved inconclusive, although it is accepted that a high alcohol intake makes control of psoriasis difficult, possibly owing to the dehydrating effects of alcohol, coupled with the time and effort required to maintain healthy skin and control the condition.

Pathophysiology
The three key histological features of a plaque of psoriasis are epidermal hyperproliferation, vascular proliferation and inflammation. In normal skin, keratinocyte migration from basal layer to stratum corneum takes about 28 days but in psoriatic skin it takes four days.

Because there are more immature cells, the epidermis is thicker, resulting in loose, silvery scales. As the capillaries in the dermis become dilated they are surrounded by an infiltrate composed of white blood cells which, coupled with the hyperproliferation of the keratinocytes, causes erythema, inflammation and loose, silvery scales - all characteristics of chronic plaque psoriasis.

Treatments
Psoriasis is a chronic disease - its effects range from one or two localised plaques to extensive body coverage that impinge on all aspects of the person's life. Treatment options are to some degree dictated by the severity of the condition at any particular time and by the side-effects, the response and an individual's lifestyle.

First-line topical preparations are favoured; second-line systemic treatments are used only when control of the condition cannot be gained. Phototherapy and photochemotherapy or ultraviolet radiation are also effective treatments for many patients.

Common topical treatments

Soap substitutes and emollients come in the form of bath and shower additives, creams, gels and ointments and are known to moisturise, lubricate and soothe dry, scaly skin (Van Onselen, 1998).

Once applied to the skin, emollients form a film over the surface of the stratum corneum, trapping water in between. As the amount of fluid increases, it pushes back into the stratum corneum, stopping excessive evaporation and further loss of water. The excess water in the skin increases its pliability and elasticity, providing relief and comfort to patients.

Emollients should be applied at least twice a day and more frequently if the skin is dry. As with all topical preparations, they should be applied in a downward motion, following the line of the hairs to prevent folliculitus (Penzer, 1996). Although oil-based preparations are of great benefit for dry skin, they can be messy, so patients are encouraged to use a lighter, water-based cream for day use and an ointment for overnight.

Topical steroids, used in conjunction with emollients - while not generally accepted as a mainstay treatment for psoriasis - are useful where the condition affects the face or flexures. They have anti-inflammatory, immunosuppressive and antimitotic effects and are consequently effective in the management of inflammatory disease (Davis, 2001). However, prolonged use can cause thinning of the skin, striae, rebound flare-up and, in some cases, pustular psoriasis, therefore careful monitoring is necessary. Steroids come in varying strengths and should be applied using the finger-tip method. As the condition improves, the potency of the steroid can be reduced, along with the frequency of the application. They should be used only as instructed by medical or nursing staff, as potency will restrict areas that can be treated.

Coal tar - Crude coal tar has been used in the treatment of psoriasis for many years. Its action is poorly understood, but it is a known keratolytic and it may possess anti-inflammatory and anti-proliferative properties (Griffiths and Kirby, 1999). Messy and odorous, it is generally used only in hospitals and the strength of preparation is increased depending on patient response and tolerance. Coal tar may cause skin irritation and will stain skin and fabric. It can cause photosensitivity, therefore information is given regarding sun exposure and sun cream.

Dithranol - This is an alternative topical preparation to coal tar. Available in the form of a paste, cream or ointment, it inhibits mitosis and also has an anti-proliferative effect. Irritation from dithranol is not uncommon and is not suitable for the face or flexures.

Vitamin D analogues - These preparations are clean treatments, and are used for treating plaque psoriasis. They are effective for many patients, although they can cause local skin reactions such as itching, erythema and paraesthesia.

A further option for the management of psoriasis is a new type of product that combines a vitamin D analogue with a topical steroid. The preparations can be used for limited periods only and are not recommended for anyone under 18. If total clearance is not achieved in the expected timescale, the product can be alternated at four-weekly intervals.

Conclusion
Psoriasis affects up to 2% of the population and accounts for 10-20% of visits to a hospital dermatology unit (Naysmith and Rees, 2003). While it is rarely life-threatening, the full impact of this often disabling and distressing condition is not always appreciated.

Some of those affected may need little or no input from the medical profession, while others will require lengthy hospital admissions and laborious lifelong treatment regimes. The condition is incurable and the main goal is to control the psoriasis.

Advances in the understanding of the pathogenesis of psoriasis and the introduction of immunotherapeutic drugs may herald a positive change in disease management (Menter et al, 2002). This, coupled with the high level of expertise and support offered by specialist health-care professionals, will enhance care and improve the quality of life for many patients.

An evaluation in 2003 of our treatment facility indicated a high level of satisfaction from both staff and patients of our day treatment programme.

Latest policy
Clinical guidelines for psoriasis care are published on the British Association of Dermatologists website: www.bad.org.uk

Indications for referral to a consultant dermatologist:

- Diagnostic uncertainty

- Request for further counselling and/or education

- Failure to respond to topical treatment after one month

- Extensive disease

- Need for increasing amounts of topical corticosteroids

- Involvement of sites that are difficult to treat - for example, face, palms, genitalia

- Need for systemic therapy

- Occupational disability or excessive time off work or school

Types of psoriasis and their treatment
Pssoriasis has many forms, ranging from chronic plaque to guttate, flexural, pustular and erythrodermic.

Topical treatments include emollients, topical steroids, tar, dithranol and vitamin D analogues.

Some preparations are cleaner or more user-friendly than others but all require a certain amount of commitment from the patient.

Author's contact details
Caroline Riddoch, Nurse Practitioner for Dermatology, Dermatology Out-patients Department, Old Infirmary Building, Woolmanhill Hospital, Aberdeen AB25 1LD. Email: caroline.riddoch@arh.grampian.nhs.scott.uk

Brooks, N., Otway, C., Rashid, C. et al. (2001) Nurse prescribing: what do patients think? Nursing Standard 15: 17, 33-38.

Cloote, H. (2000)Psoriasis. Nursing Standard 14: 45, 47-52.

Cox, N.H., Walton, Y., Bowman, J. (1995)Evaluation of nurse prescribing in a dermatology unit (Letter). British Journal of Dermatology 133: 2, 340-341.

Davis, R. (2001)Treatment Issues Relating to Dermatology. Dermatology Nursing - A practical guide. Edinburgh: Churchill Livingstone.

Davison et al (2000)Pocket Guide to Psoriasis. Oxford: Blackwell Publishing.

Griffiths, C., Kirby, B. (1999)Psoriasis Pocketbook. London: Taylor and Francis.

Jackson, K. (2002)Chronic plaque psoriasis: an overview. Nursing Standard 16: 51, 45-52.

Marks, R. (2003)Roxburgh's Common Skin Diseases (17th edn). Oxford: Oxford University Press.

Menter, A., Barker, J,, Smith, C. (2001)Psoriasis. Abingdon: Health Press.

Naysmith, L. Rees, J.L. (2003)Psoriasis and its management. The Journal of the Royal College of Physicians of Edinburgh 33: 2, 104-113.

Penzer, R. (1996)Psoriasis. Nursing Standard 10: 29, 49-53.

Sterry, W. (2004)Biologicals in psoriasis consensus. British Journal of Dermatology 151, Supplement, 69.

Van Onselen, J. (1998)Psoriasis in Practice. London: Haymarket Publishing Services Ltd.

Venables, J. (1994)Knowledge needed to educate patients about psoriasis. Nursing Times 91: 21, 38-39.

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