Gaps and Barriers

Psoriatic patients receive less screening and treatment for CV risk factors and counseling regarding lifestyle modification than the general population. One barrier is the lack of clear definition regarding the specific roles of dermatologists and primary care physicians. Moreover, many providers are not aware of the CV risk associated with psoriasis. Lack of time, ambivalence about the need for CV screening, and lack of integration of screening into the electronic medical record also play a role.

Recommendations for Improvement


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  • An “organized collaborative approach between dermatologists, primary care physicians, cardiologists, and endocrinologists” should be implemented.
  • Electronic medical records that incorporate screening questions and measurement for counseling and routine testing should be developed.
  • A “systematic protocol” for screening and management of CV risk factors should be implemented.

Screening for Psoriatic Arthritis

Standards

Inflammatory arthritis affects up to 40% of patients with psoriasis. Seventy percent of these patients experience skin manifestations before joint signs and symptoms. Therefore, all patients diagnosed with psoriasis should be routinely screened for arthritis, as early diagnosis and treatment of psoriatic arthritis improves clinical outcomes, limits pain, and prevents irreversible joint disease through suppression of pathogenic inflammatory signaling.1

Patients should be questioned about prolonged morning stiffness, joint swelling, erythema and pain, and should be examined for signs of active synovitis and nail pitting. Patients should be screened for arthritis at the time of psoriasis diagnosis and at least annually thereafter. The most commonly used screening tool is the Classification of Psoriatic Arthritis (CASPAR).5

Gaps and Barriers

The underdiagnosis of psoriatic arthritis can be attributed to infrequent screening, improper use of screening tools, and limitations of the currently available tools. Economic disincentives decrease detection, since diagnosis of psoriatic arthritis increases overhead and the risk for an unfavorable tier rating.1   

Recommendations for Improvement

  • Creation of a “time-effective, validated screening tool” for the detection of psoriatic arthritis
  • Initiatives for patients and dermatologists
  • Limiting economic disincentives for the diagnosis and treatment of psoriatic arthritis
  • Adopting an interdisciplinary approach between rheumatology and dermatology clinics

Access to Biologic Agents

Standards

Compared with traditional systemic agents (eg, methotrexate or cyclosporine), biologics have a more effective and improved safety profile and are associated with increased patient-reported satisfaction and superior patient- and physician-measured outcomes.1 The six biologics approved by the US Food and Drug Administration (FDA) are etanercept, adalimumab, infliximab, alefacept, secukinumab, and ixekizumab. Golimumab and certolizumab are also approved for psoriatic arthritis, and ustekinumab is approved for psoriasis and psoriatic arthritis.