Prescription and OTC creams ineffective against itchy lesions
The patient had a chronic condition that featured thickened, scaly patches of skin.
For the past three years, Mr. W, a 45-year-old truckdriver, has treated his itchy, red, flaky skin with topical creams prescribed by his primary-care provider as well as with OTC products. The creams included hydrocortisone cream 1%, clobetasol propionate 0.05% ointment once daily, and calcipotriene ointment 0.005% two times a day. Mr. W prefers not to wear his delivery uniform, which includes shorts and short-sleeve shirts in the summer, because of the noticeable plaques on his arms, elbows, and legs. He was eventually referred to dermatology for treatment.
On presentation, the patient appeared fatigued and irritated and had an all over flat affect. He reported that his daily routine involved waking up at 3 a.m. to give him time to shower, apply cream to his lesions, and allow enough time for absorption. He reported countless nights of restless sleep caused by itchy lesions.
Mr. W has no medical history. He is married and has two children. He has smoked one pack of cigarettes per day for the past 25 years and drinks two beers on the weekends. Family medical history includes his father dying of a stroke at age 56 years. His mother is still alive and has hyperlipidemia but is otherwise in good health. It is obvious that Mr. W's current treatment is not managing his skin disease and is causing him a great deal of physical and psychological distress.
1. EXAMINATION AND TESTS
Mr. W is a well-developed and well-nourished man with evident skin lesions. Vital signs included BP 130/80 mm Hg, pulse 80 beats per minute, respiratory rate 18 breaths per minute, and BMI 29. On examination of his skin, the lesions over bilateral elbows, shins, and knees were confluent, sharply demarcated, scaly, erythematous plaques of various sizes. There was no apparent erythema or swelling over joints. A small biopsy of tissue was taken from a scaly plaque. A complete blood count (CBC) was within normal limits. Tests for hepatitis, syphilis, and TB were also negative.
The initial strategy was to rule out lichen planus, secondary syphilis, pityriasis rosea, and tinea corporis. The patient assessment and physical findings indicated a diagnosis of poorly controlled moderate-to-severe plaque psoriasis. According the American Academy of Dermatology Consensus Statement on the goals of psoriasis management, topical medications have not met Mr. W's needs.1 Since the traditional agents proved ineffective, cumbersome, and had not met the needs of this patient, it was decided that Mr. W would benefit from long-term treatment with the a biologic agent.
Biologic agents are proteins that have the capacity to inhibit the autoimmune response mediated by one of the immune mediators: B cells, T cells, or tumor necrosis factor (TNF)-alpha. The anti-TNF agent etanercept was selected for Mr. W's treatment. This medication interferes with cytokines and chemokines. Mr. W was taught to use the medication with the starting dose of 50 mg twice a week for the first three months followed by 50 mg once weekly. He was re-evaluated at six weeks and again at 12 weeks. During the first year thereafter he was seen every three months and then every six months the second year.
Prior to the start of his treatment plan, Mr. W was educated about the purpose of his therapy, his treatment schedule, how to manage any adverse events, how to report any signs and symptoms of illness or infection, and the importance of compliance. He was assessed for any current illnesses and/or such other conditions as cancer, TB, and congestive heart failure. Baseline labs included CBC with differential, chemistry panel, lipid profile, hepatitis panel, and pure protein derivative (PPD). In the future, a chemistry panel and CBC will be monitored every six to 12 months. PPD will be done annually. Mr. W decided to quit smoking after learning about the harmful effects it can have on his health and the diagnosis of psoriasis. After discovering how alcohol use can trigger flares of psoriasis, he also stopped drinking. Incidence of such comorbid conditions as obesity, heart disease, diabetes mellitus, hypertension, and malignancy is reportedly increased in this patient population.2 Mr. W decided to take walks after work with his wife to promote weight loss.
3. LESSONS LEARNED
Living with chronic psoriasis, Mr. W experienced physical, emotional, financial, occupational, and psychosocial burdens. As clinicians, it is important to understand how the disease impacts a patient's quality of life. Patients with psoriasis have higher rates of depression, anxiety, and anger during flares as well as during remissions. Use of a measurement tool such as the Psoriasis Index Quality of Life3 would seem to be an important adjunct to any treatment plan. Valuing the person's experience with the disease can help build a strong patient-provider relationship. Ultimately, collaboration in the development of a treatment plan will ensure that the patient will comply with and effectively manage psoriasis to improve outcomes.
Dr. Harcus-Wickersham is a family nurse practitioner with Aurora Health Care in Milwaukee.
- Callen JP, Krueger GG, Lebwohl M, et al. AAD consensus statement on psoriasis therapies. J Am Acad Dermatol. 2003;49:897-899.
- Choi J, Koo JY. Quality of life issues in psoriasis. J Am Acad Dermatol. 2003;49(2 Suppl):S57-61.
- Bhosle MJ, Kulkarni A, Feldman SR, Balkrishnan R. Quality of life in patients with psoriasis. Health Qual Life Outcomes. 2006;4:35.
All electronic documents accessed May 12, 2010.