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We talk to prof. dr hab. n. med. Eugeniusz J. Kucharz and prof. dr hab. n. med. Joanna Maj.
Joanna Lewandowska: Psoriasis is a very mysterious disease. What causes it and who is at the highest risk?
Prof. Dr. n. with. Joanna May: The etiology of psoriasis remains unknown to this day, and numerous studies indicate that its development is influenced by many factors. We know that it is a familial disease with a polygenic nature of inheritance. We already know the regions on the chromosomes in which the genes involved in its development have been selected. The risk of developing the disease is approximately 14%. if one of the parents has psoriasis; 41 percent if both parents are sick; 6 percent if psoriasis has occurred in siblings; but also 2 percent. when no one in the family is sick. It should be remembered that psoriasis is not only a skin and joint disease, but also an inflammatory systemic disease. People with psoriasis are at risk of more frequent than the average cardiac incidents, atrial fibrillation, the development of hypertension and atherosclerosis. For this reason, education and prevention as well as early diagnosis are very important in order to eliminate the risk factors of atherosclerosis and obesity. In recent years, it has been shown that obesity predisposes to psoriasis, and psoriasis predisposes to obesity. The factors that trigger the disease in predisposed persons include infections, smoking, alcohol abuse, stress, burns, the use of certain drugs, e.g. beta blockers in the treatment of hypertension, doxycycline, non-steroidal anti-inflammatory drugs. Often, the first appearance of skin lesions occurs after an upper respiratory tract infection. In turn, smoking can trigger the onset of psoriasis or an exacerbation of psoriasis. The risk increases proportionally to the number of cigarettes smoked, and in menopausal women, smoking is an additional factor that provokes pustular psoriasis of the hands and feet.
Psoriasis manifests its presence by changes on the skin, which often has a huge impact on the daily life and psoriasis of the patient – becoming also, in extreme cases, the cause of suicide. Can we talk about the stigmatization of patients with this disease?
Prof. Dr. n. with. Joanna May: Psoriasis lesions are often localized in visible places, on the scalp, nails, backs of the hands, which makes the disease visible to the environment. Due to, among other things, the lack of infectivity of psoriasis, patients tend to be isolated by communities. The feeling of stigmatization in patients leads to isolation and avoidance of social contact. Psoriasis reduces the quality of life to a greater extent than diabetes, heart attack or cancer, and psoriasis in children reduces the quality of life to a greater extent than bedwetting, epilepsy or diabetes. Therefore, psychological support is necessary in general and local treatment of the disease.
Patients with psoriasis are also characterized by an increased risk of developing not only obesity, atherosclerosis and diabetes, but also depression, which may contribute to suicide attempts. It has been shown that psoriasis significantly reduces the possibility of performing paid work, contributing to increased absenteeism from work or even leading to disability. According to the data of the Social Insurance Institution, in the first quarter of 2017, the total number of days of sickness absence places psoriasis in the second place among all skin diseases in Poland in this respect. This is one of the reasons why effective treatment and patient comfort are so important.
What factors can cause psoriatic arthritis to develop or worsen?
prof. dr hab. n. med. Eugeniusz J. Kucharz: The cause of psoriatic arthritis remains unknown. Also, little is known about how the disease develops. It is hypothesized that the onset of the disease is the result of an accumulation of genetic and environmental factors, but this general statement does not translate into practical recommendations. Similarly, little is known about the factors behind the worsening of symptoms in a patient. It can be assumed that all kinds of injuries and stress, infections as well as smoking are factors that aggravate psoriatic arthritis.
What are the symptoms of psoriatic arthritis? When is an appointment with a specialist necessary?
prof. dr hab. n. med. Eugeniusz J. Kucharz .: We do not know a simple test for the diagnosis of psoriatic arthritis. The disease is characterized by arthritis with a slightly different profile from other types of polyarthritis, and the patient has psoriasis of varying severity (it may also appear earlier or later than arthritis). The skin involvement may be limited to small areas of the skin or to the nails only (in which case psoriasis is often confused with onychomycosis). Arthritis may involve several asymmetrical joints, may be limited to the joints of the spine, and sometimes it is polyarthritis with a high degree of damage to the joint structures. These symptoms may be accompanied by inflammation of the fingers (sausage fingers) and enthesitis. All these changes do not have to occur simultaneously. The criteria known under the acronym CASPAR (CASPAR = Classification Criteria for Psoriatic Arthritis) are helpful in diagnosing, assigning a specific number of points to individual symptoms and lesions. The final decision, however, is always that of a specialist doctor. Suspicion of psoriatic arthritis requires referral to a specialist rheumatologist.
What are the current standards of therapeutic management in patients with tears?
prof. dr hab. n. med. Eugeniusz J. Kucharz: Treatment should be comprehensive, combining pharmacological and non-pharmacological methods (e.g. education of the patient and his family, treatment of comorbidities, etc.). It should be individualized and discussed with the patient. This is a common rule, but in psoriatic arthritis, which is a disease with high variability in the clinical picture (and possibly also pathogenesis), “matching” the therapeutic strategy to the patient is very important. Undoubtedly, pharmacotherapy is the main focus. In 2016, the therapeutic recommendations known as GRAPPA (from the Group for Research and Assessment of Psioriasis and Psoriatic Arthritis) were announced. These recommendations consist of the 6th so-called general assumptions, defining the goals and principles of treatment and the treatment regimen, also divided into six parts, depending on the symptom or change predominating in the patient’s clinical picture (peripheral arthritis, axial arthritis, enthesitis, inflammation of the fingers, skin and nail lesions) .
Within each group, specific groups of drugs are prescribed. It may seem that the recommendations contain a very wide range of medications recommended to patients. This is not the case, because many groups of drugs are repeated. In most of the first stages of therapy, the so-called traditional drugs (non-steroidal anti-inflammatory drugs, synthetic drugs modifying the course of the disease, drugs applied topically to skin lesions). At the second stage, biological drugs are indicated to reduce the concentration of TNF-alpha. These drugs have the most versatile application in all of the above-mentioned groups of symptoms. Of course, the above description is not a complete treatment regimen, but only a signal of the current state of knowledge on this subject.
What new treatment options have emerged in the fight against this disease?
prof. dr hab. n. med. Eugeniusz J. Kucharz: Recently, two new treatment options have been added to the list of medications used in patients with psoriatic arthritis. Their feature is the mechanism of action, different for each of them and different from the mechanisms of action of previously used medicinal substances. These are secukinumab and apremilast. Secukinumab is a biological drug, a human monoclonal antibody directed against interleukin 17A. The second, small-molecule phosphodiesterase inhibitor is called apremilast and is a synthetic preparation. It acts on the intracellular transduction of receptor signals, modulating the transmission of pro-inflammatory signals, thereby inhibiting inflammation. These therapies are already initially included in the latest GRAPPA recommendations (from 2016). Their essence is a different mechanism of action, although unfortunately this treatment is symptomatic and not removing the cause or causes of the disease, which are still unknown. They may prove effective in the subgroups of patients who are intolerant or not responding to the drugs used so far. Thus, they are not “better” or “worse” than others, but broaden the treatment options for more patients, especially those who were “resistant” to other therapeutic methods.
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