Last updated on 16 Jan 2013 at 3:30 PM (Derm05)

Rash on extensor surfaces and joint pains
An 45 year old NZ European man, who is obese, hypertensive, and smokes cigarettes, goes to see his GP about a rash. It has been present for some 20 years on his elbows and knees but is now becoming widespread. This rash bothers him a lot as he feels it is unsightly. On further questioning it becomes apparent that he experiences joint pains of the fingers, wrists and ankles.

 

Applied Science for Medicine
Pathogenesis of psoriasis and psoriatic arthritis (predominantly genetic basis with environmental aggravators)
Explain that: psoriasis can be associated with inflammatory psoriatic arthritis; severe early-onset chronic large-plaque psoriasis is an independent risk factor for cardiovascular disease
Pharmacology of topical steroids, calcipotriol (vitamin D analogue) and coal tar; systemic methotrexate, ciclosporin, acitretin, biologics (tumour necrosis factor-alpha antagonists - adalimumab, etanercept, infliximab; interleukin 12/23 inhibitor - ustekinemab)
Understand the mechanism of action of phototherapy in treating inflammatory skin disorders

Clinical and Communication Skills
History of psoriasis, related conditions and previous management (how treatments were used, efficacy and side effects)
Skin examination to determine the extent and severity of psoriasis
Describe the cutaneous features using dermatological terminology
Establish a provisional treatment plan appropriate for the patient, the nature and extent of his psoriasis and his lifestyle
Undertake a general health review including medical and drug history, examination and appropriate investigations. Address any reversible cardiovascular risk factors
Provide the patient with verbal and written information about chronic plaque psoriasis and the chosen treatment
Establish the psychosocial effect of psoriasis for this patient and his family/whānau

Personal and Professional Skills
Establish a multidisciplinary treatment programme, which may involve a GP, dermatologist, rheumatologist and general physician
Establish a therapeutic relationship with the patient and realistic treatment goals in the management of a chronic disorder, including addressing physical and psychological aspects

Hauora Māori
Engage appropriately with whānau as well as the patient for management of chronic skin disease
Understanding of inequities in access to health services and quality of medical care for Māori, and application of this to clinical decision making and management

Population Health
Epidemiology of psoriasis

 

Conditions to be considered relating to this scenario

Common

psoriasis, seborrhoeic dermatitis, tinea corporis, lichen simplex chronicus

Less common but 'important not to miss'

erythrodermic psoriasis, pustular psoriasis

Uncommon

multiple superficial spreading basal cell cancers, multiple squamous cell carcinoma in situ