Chronic Disease Management in Plaque Psoriasis

Melodie Young, MSN, RN, ANP-C: When we talk about the burden of disease, don’t think about the burden of disease just being the plaque because we’re focusing mostly on plaque; people can have more than 1 type of psoriasis. Oftentimes they do. Margaret, do you want to talk about some of the other types of psoriasis that we need to always keep in mind?

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: Following what you both said, the onus is on us to help our patients understand that this is not 1 and done. It’s the burden of chronic disease, and we have to teach that. “Today we’re going to treat you, and this is not going to go away with a 10-day therapy. This is a lifelong disease.” In that lifelong disease, you may have genital psoriasis. You may have inverse. So we have to teach patients that there are different types of psoriasis that are plaque.

Now, regarding genital psoriasis, which is 1 of the most underdiagnosed forms, what do we know? The onset—this is a young person’s disease. So going back to Melodie’s patient who’s 20 years old, in the prime of her life, maybe she thinks she has an STD [sexually transmitted disease] instead because it doesn’t look like the other plaques. A patient who’s exposed to strep and has strep and then ends up with a guttate plaque psoriasis. But most important, going back to those patients, doing a good body evaluation and discussing everything with them so that they can plan.

Also, “What’s happening in your life? What is your weight? What are your comorbidities?” Us addressing them and helping them understand that this isn’t just on the outside. This is on the inside as well. From my perspective, this is a chronic disease. It’s going to be a long-term relationship, and 1 for which we can help address the comorbidities.

Douglas DiRuggiero, PA-C: Don’t you feel like that’s uniquely focused on our skill set as advanced practice clinicians? I mean as NPs [nurse practitioners] and PAs [physician assistants], this is exactly what we are trained and encouraged to do.

Melodie Young, MSN, RN, ANP-C: Chronic disease management.

Douglas DiRuggiero, PA-C: To take on that time. That’s not to say that the dermatologists aren’t taking the time—those who are focused on this. But at least in our clinical practice, I’m empowered and encouraged to be the one who can take that time to review these comorbidities, do these exams, and be educated on these medications, allowing my physician to have time to do things they want to focus on, which may be more surgery and other things. I’m not trying to pigeonhole us 1 way or the other, but it is nice that as NPs and PAs, we feel like this is the skill set we definitely bring to the table—managing chronic disease, talking about the whole patient, and doing these things.

Melissa Davis, PA-C: I say that to patients too. I say, “This is a disease that we’re going to manage together. This is a chronic problem. I may be able to get you very clear or completely clear, but it is still something that we’re going to do together, long term. Hopefully you won’t have to come in to see me as frequently as maybe you do up front, but we’re going to do this together.” I tell them that in that way too, because I feel that working together with our patient as a team is really important. It’s important that they know I’m on their side, they’re on my side, and we’re going to try to get them clear together.

Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: As nurse practitioners and PAs, we’ve been working in dermatology for a long time, and there are so many new needs coming in from access to dermatologic care. Because the rising need and the limited access to care is there, it’s going to be exciting to see nurse practitioners and physician assistants addressing people holistically. We can address their chronic disease and acute care diseases. But the onus is also on us, being specialists in dermatology, to understand that it’s not just a label. We are invested in education, in training. Many of us are involved in research, clinical trials. We have many nurse scientists. We are also engaged in publications. We are educators in universities and colleges, or in our local communities, and we work as a collaborative team.

All of use, no matter where we are as an expert in dermatology, should be working collaboratively with dermatologists. What happens when we have those patients who are outside the box? That’s what we get. We have experts across the country, and consulting and collaborating are so important with our board-certified dermatologists, with rheumatologists, with our surgeons. It’s exciting, but the onus is on us to make sure that we are accountable, that we are educated and trained well, and that we’re responsible. It’s exciting.

Melodie Young, MSN, RN, ANP-C: There are very few patients who you meet and start on a biologic therapy and they stay 100% clear for the entire relationship that you have with them. A lot of times, we start talking about, “Let’s get you diagnosed. Let’s figure out what the best therapy is at this point.” And then, with each subsequent visit—and we can talk about how we do those assessments initially and how we do those assessments as we move through the relationship. A lot of times you just see a patient a couple of times a year. Or you’re just making sure they don’t have skin cancer. There is an increased incidence in skin cancers, so you need to be able to find those and refer them out to the Mohs surgeon you work with.

But as the progression goes, people do have flares. They have things that happen in life. They have other illnesses. This is a disease that can be managed, but it’s always going to be a part of their life. All the other factors associated with their disease can also be issues. Some lifestyle things that we’ve mentioned can have an impact on health. We have to make sure we understand that it’s not 1 and done. You don’t just see them, write a script, and have them walk out the door.

NPs and PAs are the largest-growing segment-of-care providers for people with psoriatic disease. Whether it’s in the dermatology clinic or the rheumatology clinic, we are taking a bigger role. I love the role. I love the relationship building. I love seeing people at this point in my life. With all the work we did, and with the struggles and the battles in the early years, now they don’t have to experience that. We were talking about genetics earlier. We first had that big publication, and we told patients, “Hey, we found out there are these gene linkages to psoriasis.” I thought they would be excited, because that was new science that we were hoping would lead to a genetic cure. Unfortunately, it just showed that it was too complex at this point. But it did lead to the biologics and some of the therapies we have now. We had some ladies who would say, “I’m not going to have children because I don’t want to pass this on, because it’s so devastating.” Now when you see somebody who has it, you say, “The great thing is that even if your child does have psoriasis, this is a disease that we can almost always control and manage. It doesn’t have to impact you in that way anymore.” The progression of the disease and all the complexities are the things that you, as clinicians, need to mention.

Transcript edited for clarity.