A chronic, systemic inflammatory skin disorder, psoriasis is often recognised by the telltale scaly patches of skin that are typical of this immune condition. It is thought that at least 73,000 people in Ireland have psoriasis, yet myths and misperceptions abound when it comes to its diagnosis and treatment.
Psoriasis is typically recognised and diagnosed by a patient’s GP, but only the mildest cases can be treated with topical creams.
For those with moderate to severe psoriasis, where a significant proportion of the body is covered in patches, the barrier to effective treatment comes when trying to access specialist care.
With dermatology services in high demand and limited availability, waiting lists can be more than 18 months in some parts of the country, acknowledges Prof Brian Kirby, consultant dermatologist at St Vincent’s University Hospital.
Prof Kirby features in the first episode of a new video and podcast series from Janssen Sciences Ireland UC.
Ireland does not have sufficient full-time posts for dermatology consultants
PsO Let’s Talk Psoriasis aims to support and empower people living with psoriasis as they await access to specialist dermatology care. “Ireland does not have sufficient full-time posts for dermatology consultants,” he says. “One dermatologist per 62,500 people is the benchmark requirement we need to get to.”
Up to 40,000 people in Ireland are currently waiting for a specialist dermatology appointment, he adds.
This means that by the time they reach his clinic, patients can often be in a “bad way”.
“They are usually pretty miserable. Psoriasis is itchy, very uncomfortable, can be painful, and this has major implications for sleep, for example. It’s very distressing for someone if they can’t sleep every night because they are so uncomfortable, and this in turn can affect their social functioning, where they are tired and cranky or can’t work properly."
The distinctive red scales of psoriasis can also be unsightly; Prof Kirby says his patients are often most concerned with their appearance. “It uncommonly affects the face, but even on the body it means people are very careful about what they wear. They may avoid changing rooms and swimming pools and places like that. Many people with psoriasis don’t wear dark clothing because the telltale scales show up more. It can be very stigmatising."
He explains that psoriasis scales are due to the body making more skin than it needs as the immune system turns on itself. But psoriasis is much more than just a rash, and the concept of it as a systemic inflammatory disease is still not well understood.
The amount of inflammation that is in your system causes a lot of fatigue, and this has knock-on effects and can lead to depression
“The amount of inflammation that is in your system causes a lot of fatigue, and this has knock-on effects and can lead to depression. It’s a lot better understood than it was before, but it’s still not always the case, even among healthcare professionals.”
A diagnosis of any chronic illness is a major blow, and learning that you have psoriasis can deliver an emotional sucker punch, says Paul D’Alton, a clinical psychologist and head of the Department of Psychology at St Vincent’s. Dr D’Alton, who also features in the PsO Let’s Talk Psoriasis video and podcast series, says it can take months for someone to truly accept they have the condition.
“People find it difficult to take it on board,” he says. “It’s an enormous thing to take on and coming to terms with living with a chronic illness takes a long time.”
The six-month period is one of adjustment, he notes. “When we get a diagnosis of an illness like psoriasis it can take up to six months to adjust to it and get your head around it. This will include periods of denial and internal bargaining, people will think ‘maybe they got that wrong’ or ‘if I do x, y and z it will go away’. The acceptance will come later, but it takes time to make those adjustments.”
He adds that people should use their “support system” – family, friends and work colleagues – as they navigate their diagnosis and their feelings around it. “People tend to isolate themselves when it comes to a diagnosis like this, but a problem shared is a problem halved.”
Indeed, an illness such as psoriasis has a significant emotional component, and Dr D’Alton echoes Prof Kirby when he talks about the higher incidence of anxiety and depression seen in patients with the condition.
“It’s really important to say that it’s not your mind that has caused your psoriasis. That’s not the case, but we do know that these physical illnesses, these chronic conditions, have significant emotional and psychological ties.”
Stress is a common trigger for a flare-up of psoriasis. “If you don’t take care of that burden, the emotional and psychological consequences, it’s very often the case that the disease will get worse,” Dr D’Alton says.
Anxiety, depression and stress are really common in psoriasis, but they are really treatable; you don’t have to suffer in silence
“Anxiety, depression and stress are really common in psoriasis, but they are really treatable; you don’t have to suffer in silence. In my view, your treatment for this is just as important as for the psoriasis itself.”
The good news for patients is that with the right treatment for psoriasis, Prof Kirby predicts they will see significant clearance of the skin within four months. Light therapy, where ultraviolet light is shone on the skin, is still effective for less severe disease but oral medications or medications known as biologic therapies have proven results, he says.
“Although UV light works very well, it is limited by the fact that patients have to come three times a week every week, and it isn’t practical for everybody depending on where they live or their lifestyle. Biologics became available in the mid-2000s, and they only require an injection once a month. They have transformed the treatment of psoriasis.”
Prof Kirby says patients often come to him believing there is no cure for their psoriasis. "But if you think about it, most medical conditions have no cure, like asthma or high blood pressure, and most people with them lead high functioning lives. They just take medication to control their condition, and it is the same with psoriasis. And fortunately, in 2022 the vast majority – 99 per cent – of people will experience an improvement.
“With the medications now available, it’s a rarity that we don’t achieve improved control in our patients. We can offer them hope.”
PsO Let’s Talk Psoriasis is available free online, with the four episodes released on a weekly basis throughout May, at www.janssenwithme.ie/pso/resources/pso-lets-talk-psoriasis. The audio versions are available on all popular podcast platforms.
References relating to this article are available upon request.