The four stages of therapy management, as we have seen, are questioning, explanations, negotiations and prescription.
4.1. Questioning
The questioning phase allows you to start getting acquainted with the patient in his or her social, familial and professional environment, to know the health context in which the therapeutic strategy is going to have to fit into, to assess with him or her the gravity of the psoriasis, his or her capacity to take care of himself/herself, objective and subjective relations to the various treatments he or she has already tried and, of course, what he or she expects from the present consultation.
The questions on age, occupation, the conditions under which the patient exercises that occupation, number of children, longevity of the psoriasis and the familial or non-familial nature of this psoriasis will form a basis for an initial approach.
Age is important, especially physiological age, as it will determine the need or not for a nurse to apply topical treatments, and because retinoids may only be given in very small doses in elderly people. Renal function declines with age, and methotrexate dosage will therefore have to be decreased; the side effects of cyclosporine increase with age. Weight, and particularly recent weight gain, are important to know because adult psoriasis often develops in tandem with a gain in weight, and because obesity increases the risk of side effects and reduces the effectiveness of topical and systemic treatments. The option of using cyclosporine or not will be conditioned by arterial pressure. Increased cholesterol will dictate the need to monitor closely patients on retinoids; an increase in triglycerides will contraindicate taking retinoids. Most often, a hepatic disorder, a simple steatosis, an onset of cirrhosis or chronic hepatitis will contraindicate methotrexate and require collaborating with the hepatologist. Smoking generally increases inflammatory skin responses. However, stress brought on by quitting smoking, sometimes in combination with substantial weight gain, may be at the root of a psoriasis attack. Alcohol abuse invariably aggravates psoriasis, increasing the side effects of retinoids and contraindicating methotrexate.
The patient’s profession, especially the conditions under which it is practised, will make some forms of treatment impossible. Extreme working hours make topical treatment virtually impossible. The same goes for frequent travelling, which makes phototherapy equally impossible. Frequent business dinners, the decrease in physical activity and the increase in professional responsibilities form a trio particularly conducive to the development of psoriasis. Questioning about the occupation provides an opportunity to assess the impact of the profession on the quality of life and the impact of psoriasis on the profession.
Of course, it is important to be familiar with all the drugs being taken by the patient. This will help to provide a better knowledge of the associated pathological states and to identify treatments capable of aggravating psoriasis, such as withdrawing general corticotherapy, lithium, beta-blockers, interferon and – according to data acquired more recently - inhibitors of angiotensine converting enzymes and calcium inhibitors. Some drugs will potentially contraindicate the use of antipsoriatics, Bactrim contraindicates the use of methotrexate, and a great many drugs interfere with the cyclosporine metabolism.
Questions about previous treatments are particularly instructive. The nature of the treatments, but more particularly on the strategies deployed, allows to test the patient’s compliance to the different treatments and to discover any reasons for suboptimal compliance. The patient’s opinion about the different treatments will help to provide better insight into what he expects from the possible different treatments and the constraints he is capable of accepting. Some treatments have proved disappointing because they have been used with a poor strategy or because the patient has stopped treatment once the skin lesions have disappeared. It is particularly important to be fully aware of whether the relapse the patient is complaining about appeared during the treatment or after stopping it. Finally, it is most important to assess whether any real resistance exists to the treatments prescribed, as this is a severity factor. These questions will also help to gauge the degree of discouragement in the patient when faced with his psoriasis and to identify which treatments the patient is willing to use.
All these questions will gradually prepare the patient to help the doctor assess an essential point of therapy management: the severity of his psoriasis. This severity is connected, firstly, with the magnitude of the impact on the quality of life.
Is this psoriasis an old companion that one has somehow gradually become used to? If that is the case, the way psoriasis has potentially altered the patient’s relationships with himself, his nearest and dearest, his spouse and his children will need to be assessed. Has this psoriasis made him miss out on opportunities, has it had an adverse influence on his professional career, on his possibilities when choosing a sport, on his way of dressing, on the choice of holidays suitable to him? Does he feel that the appearance of this psoriasis has coincided with some life event? Are the circumstances that have unleashed the expression of the disease still topical? What plans does the patient have for changing those circumstances and thus taking control, in some way, of his illness, or at the very least what his illness expresses? Can the patient agree to watch his psoriasis disappear for a set period of time that he has chosen, only to then live through a relapse, without becoming even more disheartened than before, can he accept intermittent treatment? Is the psychological pain brought about by psoriasis continual, or more intense at certain times of the year or because of certain locations? In a chronic illness, the patient rearranges his life around that illness to minimize the suffering it causes him. It is important to assess this restructuring process in order to visualize, together with the patient, the best way of managing the various options provided by the drugs and the manifold possible utilization strategies.
Is this psoriasis a newcomer? In this case, any crisis situation that does occur will need to be managed. The patient will not intuitively imagine being involved in his psoriasis. His therapeutic model is often that of the antibiotic, which facilitates healing by killing an external invader; or that of surgery, which severs the good from the bad with the aid of a scalpel. The questioning phase is going to be thus particularly important, because, by the very nature of the questions asked, it will change little by little the scenario within which the patient reasons. He is going to progressively discover that his psoriasis may be expressing something and that anyhow it is impacting on many of the relationships that drive his daily life. He discovers that it is his own image that will have to be managed with the help of his doctor, that it is his quality of life that will need improving and that, for this reason, it is essential for him to be involved in the choice of therapies. The questioning will then be geared towards the stress, the possible territorial conflicts, and the quality of relationships the patient enjoys with himself and others, as well as the essential components that he thinks define his quality of life.
It will be thus possible to progressively define the kind of therapeutic scenario into which the patient, taken as a whole, can fit. Is it better to enact an urgent treatment to get rid of the lesions, and benefit from the remission period to help the patient to regain control over his distressed life, focusing then on putting in place a maintenance therapy with all the necessary mutual adjustments between the three partners - patient, doctor and drugs? Or, on the contrary, is it better to choose from the start a strategy centred on the long term with a very gradual improvement in the quality of life?
The expressed psychological suffering may strike as being major and disproportioned to the lesions’ extent and the visibility. This may lead to suspect that the psoriasis is revealing of psychological troubles that must be taken into account separately with the help of a psychologist or a psychiatrist.
This whole questioning stage does not end when the explanations start - quite the contrary. The explanations about the illness and its treatment will allow new questions to be asked and their importance to be apprehended by the patient, thus enhancing the quality of the replies, since the explanations given will increasingly empower the patient to question himself and therefore choose more freely.
4.2. Explanations
These must give details on the psoriasis and the treatments. They serve to allow the patient to understand the general therapeutic strategy, acute treatment and maintenance treatment, to make him realize that there are plenty therapeutic options, all of which entail side effects or inconveniences and hence impinge on daily life. But the patient alone has the information that will allow putting in place a strategy to improve his quality of life.
The information will focus on the psoriasis:
- It is a genetic, multigenic disorder unveiled - not brought upon - by environmental factors: infectious diseases, seasonal changes, stress, drugs, skin irritation - in short, by anything that accelerates skin renewal.
- The psoriasis plaque is the consequence of skin regenerating too rapidly. When the skin starts to peel, it is the seat of an inflammation that attacks the skin and fuels the disease. The mere act of scratching the skin or picking the scales speeds up skin renewal and five minutes of scratching is enough to reactivate the psoriasis for a fortnight. The battle against itching is therefore a mainstay in the treatment of psoriasis.
- Psoriasis is not contagious. It does not jeopardize physical health. It is an illness whose severity depends on the lesions’ effect on the quality of life. It is the patient, therefore, and he alone who knows whether his psoriasis is serious and hence whether this psoriasis can benefit from major systemic treatments or not - that is to say treatment calling for close monitoring and involving potential risks to health.
The information will focus on the treatments:
- The aim and consequence of all treatments is to slow down skin renewal, so if treatment is stopped as soon as the plaques have disappeared, relapse is rapid. It is therefore essential to continue treating oneself once the lesions have disappeared. Six months after the disappearance of a psoriasis plaque, the skin is still completely abnormal under the microscope. This is why treatment is usually continued for one year after the lesions have disappeared.
- The aim of the treatment is to improve the quality of life. That is why the patient alone can truly assess its effectiveness. The patient is not doomed to treat himself continuously, but he can nurse himself at certain times of the year only, or nurse certain sites only, in function of his personal equilibrium between the inconveniences caused by the illness with that entailed by the treatment or treatments.
- Having laid this foundation, the second part of the explanation phase will focus on each of the topical and systemic treatments available by explaining their application technique, the constraints involved in everyday life, the side-effects and the monitoring strategy.
4.3. Negotiations
This is the most important phase of the therapy management. It evolves from consultation to consultation, as and when the patient becomes better and better informed through questioning and explanations, and is thus capable of conducting a dialogue on an equal basis with his doctor, albeit from an obviously different and complementary point of view.
The objective of the negotiations is to find the best compromise between the constraints, as experienced by the patient, associated both with the disease and with the treatments, and the objective data known to the doctor on the benefit/risk ratios of each treatment, therapeutic combinations and succession of treatments. Like in all good negotiations, both parties - the doctor and the patient - must come out of these negotiations feeling that they have voiced and obtained concrete acceptance of their views in the decision made. This is the condition for obtaining therapeutic compliance.
[|Very good chapter,
Seldom discussed!|auteur193]
4.4. Prescription
It is the contract ending a negotiation. Ideally, this contract should be signed by the doctor and the patient, thus attesting the participation of both. On no account is this “a medical order”, but a mutual agreement.
