The RACGP (2012) advise: GPs need not raise this issue, but if men ask about prostate screening they need to be fully informed of the potential benefits, risks and uncertainties of prostate cancer testing. Their high PSAs might be due to: 1. Welcome to AusDoc.Plus, the new home of Australian Doctor, Medical Observer, 6minutes and How to Treat. This follows a public college statement that pharmacy-run health checks are money grabs that risk patients’ health. doi: 10.1080/09546634.2017.1329511. Ann Rheum Dis 2005;64(Suppl 2):ii14–17. 2 Moll et al described five types of PsA, namely oligoarticular asymmetrical arthritis, symmetrical polyarthritis, distal arthritis, arthritis mutilans and spondyloarthropathy (which can affect the spine and sacroiliac joints). is associated with a reduction in scalp psoriasis, but to date there is no correlation with the severity of psoriasis. Br J Dermatol 2020;182(4):840–48. www.racgp.org.au Healthy Profession. doi: 10.1007/s40257-017-0337-2. Christmas and New Year shutdown. Higher incidence rates of comorbidities in patients with psoriatic arthritis compared with the general population using US administrative claims data. PsA questionnaires include but are not limited to Psoriatic Arthritis Quality of Life (PsAQoL) and Psoriatic Arthritis Impact of Disease (PsAID). The pathogenesis occurs via a dysfunction of the skin microbiome and impaired tolerance, resulting in abnormal immune activation.25. The guidelines have also received formal endorsement from the Urological Society of Australia The risk of lymphoma – in particular, Hodgkin’s lymphoma and cutaneous T-cell lymphoma – is at least three times greater in patients with severe psoriasis than the general population.21 The relative risk of any lymphoma in patients with mild psoriasis is 1.34. J Manag Care Spec Pharm 2019;25(1):122–32. doi: 10.1016/j.clindermatol.2019.01.011. The risk of lymphoma in patients with psoriasis. longer recommended in addition to PSA testing. Psoriatic arthritis (PsA) is a chronic inflammatory spondyloarthropathy that affects up to 42% of patients with psoriasis1 and up to 1% of the general population.2 Moll et al described five types of PsA, namely oligoarticular asymmetrical arthritis, symmetrical polyarthritis, distal arthritis, arthritis mutilans and spondyloarthropathy (which can affect the spine and sacroiliac joints).1, PsA affects men and women equally; in contrast, rheumatoid arthritis has a female preponderance.2 In the majority of cases, psoriasis precedes PsA; however, PsA can occur concomitantly or precede the cutaneous signs. Suicidal ideation occurs in 7–17% of patients with psoriasis. Many patients don’t have a regular GP and pharmacy checks lead to a referral back to their doctor, whom they may not have seen for a long time. The coroner called for the two professions to trust and respect each other while maintaining their independence after an elderly man died after being prescribed the wrong dose of methotrexate. RACGP Victoria chair Dr Cameron Loy urged patients to stay away from pharmacy health checks, telling Fairfax media they were a lure to get patients into the store to buy products. doi: 10.1111/jdv.13619. Psoriatic arthritis (PsA) is a chronic inflammatory spondyloarthropathy that affects up to 42% of patients with psoriasis 1 and up to 1% of the general population. Lewis DJ, Chan WH, Hinojosa T, Hsu S, Feldman SR. Mechanisms of microbial pathogenesis and the role of the skin microbiome in psoriasis: A review. The prostate specific antigen (PSA) test is a blood test to see if you might have prostate cancer and to monitor treatment for prostate cancer.. Although many believe the skin is the only organ involved in psoriasis, more recent advances have shown a predilection for other diseases and comorbidities (Table 1), likely due to a proinflammatory state with excess circulating cytokines. Gelfand JM, Shin DB, Neimann AL, Wang X, Margolis DJ, Troxel AB. doi: 10.1016/j.det.2014.09.004. But both the PSA and Pharmacy Guild believe the RACGP is provoking a turf war that is putting patients at risk. He says the RACGP’s stance is out of step with what’s happening on the ground and in his experience, GPs welcome pharmacist health checks, as long as they are evidence-based, delivered to PSA standards and there is a clear referral pathway. The pathophysiology of depression and psoriasis may be similar, with elevation of proinflammatory cytokines interleukin (IL)-1 and IL-6 suggesting biochemical and physiological interdependence rather than physical consequence.13, The prevalence of depression in patients with psoriasis has been reported as high as 18% in some studies,5,14 although anxiety has been reported in up to 30% of patients.6 Anxiety does not correlate with the severity of the skin disease. Clin Dermatol 2019;37(2):160–66. doi: 10.1016/j.jaad.2017.03.037. Veale DJ, Fearon U. Counsel a patient with newly diagnosed type 2 diabetes. PsA typically starts as a mild oligoarticular disease, although for 20% of affected patients it progresses to a severe form that comprises polyarticular disease and joint destruction.2 It is more asymmetrical than rheumatoid arthritis.2 Symptoms include pain and stiffness at rest that improve with movement, and morning stiffness that lasts for longer than 30 minutes.3 Enthesitis represents inflammation around the insertion of the tendon or ligament into the bone. Therefore, it is important to screen for conditions such as tuberculosis, hepatitis B and C, HIV, syphilis and strongyloidiasis before commencing and, if at high risk, during such therapies. It is common for older men to have some cancer cells in their prostate glands. These cancers are usually slow to grow. But both the PSA and Pharmacy Guild believe the RACGP is provoking a turf war that is putting patients at risk. Management of psoriasis as a systemic disease: What is the evidence? Br J Dermatol 2017;177(3):837–44. Fry L, Baker BS, Powles AV, Fahlen A, Engstrand L. Is chronic plaque psoriasis triggered by microbiota in the skin? Purchase the AMH Book direct from the college. Inflamm Bowel Dis 2017;23(10):1783–89. Psoriasis and smoking: A systematic review and meta-analysis. Guild Victoria president Anthony Tassone says pharmacies work closely with local GPs and health checks are an important way to identify at-risk patients. Recent sexual activity. Infections can induce psoriasis or be associated with or caused by medications that treat psoriasis.24 Chronic plaque psoriasis and guttate psoriasis are both associated with Streptococcus pyogenes infection activating T cells through superantigens. Prostate cancer resource Prostate cancer accounted for the second highest number of male cancer deaths in Australia. doi: 10.1111/bjd.18245. Joint damage starts early in the disease, manifesting in dactylitis, enthesitis and spondylitis.3 Tendons, ligaments, joints, synovium and bone can all be inflamed in PsA.3. Kaine J, Song X, Kim G, Hur P, Palmer JB. QoL scores such as the Dermatology Life Quality Index (DLQI), Health-related quality of life (HRQOL), Psoriasis Disability Index (PDI) and Skindex can be used to assess the impact of psoriasis. The Royal Australasian College of Physicians. 1 Summer long reads: 6 of our best in-depth stories from 2020. Most men with high PSAs don’t have prostate cancer. Live vaccines must also be avoided given the risk of dissemination. Epidemiology of mental health comorbidity in psoriasis. Dactylitis, which is inflammation of the entire digit, can present as a ‘sausage finger’ because of inflammation of the joints and tendons.2,4 Both enthesitis and dactylitis are common in PsA. But most of these cancers do not cause problems. Eppinga H, Poortinga S, Thio HB, et al. It is needed to confirm whether prostate cancer is present. Psoriasis is a common immune-mediated skin condition that affects at least 2% of the Australian population. doi: 10.1136/ard.2004.032482. Shah K, Mellars L, Changolkar A, Feldman SR. Psoriasis: Classical and emerging comorbidities. Practice, Formerly Australian Family Physician (AFP). Depression scoring systems also exist. A higher-than-normal PSA level doesn’t automatically indicate prostate cancer either. Despite treatment-attributable risk, there seems to be a moderately increased risk of NMSCs but not melanomas,22,23 so regular skin checks and vigilance are prudent, especially for patients who have had immunosuppressive therapy or phototherapy. Real-world burden of comorbidities in US patients with psoriasis. General Alcohol intake is an independent risk factor for the development of psoriasis and PsA.17 One study found that high-risk drinking occurred in 24% of the study population, compared with 14% of the general population. Preus HR, Khanifam P, Kolltveit K, Mørk C, Gjermo P. Periodontitis in psoriasis patients: A blinded, case-controlled study. Biochemical recurrence (BCR) occurs in 27–53% of patients after primary curative therapy and is defined differently depending on the modality of primary treatment: following radiotherapy, PSA needs to be >2 ng/mL higher than the PSA nadir level; after prostatectomy, any detectable PSA represents the presence of disease. The economic burden of psoriasis is accentuated by the presence of psychiatric disorders when taking into account emergency department and outpatient visits, time off work and prescription costs.15. The guideline recommendations must be referenced and graded to help guide clinical management, in the context of the patient’s setting. doi: 10.1111/ajd.12895. Depression and suicidality in psoriasis: Review of the literature including the cytokine theory of depression. Moll JM, Wright V. Psoriatic arthritis. doi: 10.1097/MIB.0000000000001169. J Am Acad Dermatol 2017;77(2):287–92.e4. RACGP Victoria chair Dr Cameron Loy urged patients to stay away from pharmacy health checks, telling Fairfax media they were a lure to get patients into the store to buy products. Psoriatic arthritis for the dermatologist. High prevalence of alcohol use disorders in patients with inflammatory skin diseases. email@example.com, Inflammatory bowel disease and coeliac disease, Substance abuse (including alcohol and smoking). RACGP is the latest medical college to endorse the guidelines, which provide health professionals with evidence-based recommendations for using the prostate specific antigen (PSA) blood test to assess prostate cancer risk and manage test-detected patients. PsA is considered a spondyloarthropathy because of the extra-articular features and spondylitis that occur in up to 40% of patients.2 It is also associated with HLA-B27.2 Nail involvement affects approximately 87% of patients with PsA.3 Typical changes include pitting, crumbling, onycholysis, leukonychia, subungual hyperkeratosis and splinter haemorrhages. The PSA blood level is also increased in other conditions. It is possible, although rare, to have prostate cancer without raised PSA levels in the blood. doi: 10.1080/09546634.2017.1395800. Like acute rheumatic fever ( arf ), psa is a reactive arthritis characterized by a pharyngeal streptococcal infection, a symptom-free interval and subsequent aseptic inflammation of one or more joints. 18 A proportion of men with BCR will progress to metastases and death; others will have … The PSA said the changes mean electronic prescriptions are quickly expected to be in wide use across the whole metropolitan area by prescribers and pharmacies. doi: 10.1016/S0140-6736(18)30830-4. With the advent of newer biological and immunosuppressive agents in the armamentarium to treat psoriasis, it is essential to monitor for other infections, malignancies and side effects. Though some of these comorbidities occur commonly in clinical practice, they should not be overlooked in a patient with psoriasis as they may cause a psychological and physical impact if left untreated. PSA screening. doi: 10.1016/j.det.2014.09.010. A prostate infection. Australas J Dermatol 2019;60(2):91–98. PSA president Shane Jackson says recent findings by a Victorian coroner highlighted the importance of pharmacists and GPs working together. “So we’d like to see this kind of rivalry put aside so we can all be making the best possible contribution to our health system.”. These comorbidities may be missed unless specifically looked for. The association between psoriasis and hypertension: A systematic review and meta-analysis of observational studies. Korman NJ. PsA is often underdiagnosed, with a delay in therapy resulting in morbidity and impaired quality of life (QoL). For this test, a blood sample is sent to a laboratory for analysis. J Med Econ 2019;22(12):1290–97. Harmful, hazardous and dependent drinking can lead to increased morbidity and mortality. 2. As an example, he says local GPs supported his pharmacy’s involvement in the recent diabetes screening trial. These toxins are associated with a more severe type of psoriasis.25 There is no evidence to date to support tonsillectomies to reduce the incidence of guttate psoriasis. Patients with psoriasis are more likely to have cardiovascular mortality than patients without psoriasis,6 so it is important that risk factors are screened for and treated. GPs are in a prime position to screen, diagnose and manage comorbidities in a patient with psoriasis. Serum rheumatoid factor is elevated in 13% of patients with PsA, compared with 80% of those with rheumatoid arthritis.2 Radiographic changes include pencil-in-cup deformity, with digit shortening and bone lysis.2 These changes can occur within two years of disease onset. Egeberg A, Thyssen JP, Gislason GH, Skov L. Skin cancer in patients with psoriasis. A case control study found that after accounting for confounders (eg cardiovascular risk factors including hypertension, hyperlipidaemia and income status), patients with dementia had an odds ratio of 1.46 of having previous psoriasis when compared with the control group.16 Other studies have implied cognitive decline, poor QoL and earlier death for patients with psoriasis.16, Alcohol consumption may be elevated in patients with psoriasis. J Invest Dermatol 2006;126(10):2194–201. Of the 80 people screened, five were ultimately referred and started treatment for diabetes. This article outlines the common comorbidities of psoriasis in the hopes of facilitating discussion between general practitioners (GPs) and patients. There is an increased risk of herpes zoster with tumour necrosis factor–a inhibitors and Candida spp. In addition to treating the skin, it is important to assess patients for psoriasis-related comorbidities by taking a simple history (eg asking about arthralgia and arthritis, alcohol and drug intake/abuse, sexual dysfunction), performing clinical examinations (eg measuring waist circumference, weight, body mass index), performing QoL scales (eg depression and anxiety scales) and ordering laboratory investigations (eg lipid profile, blood sugar levels, liver and renal function).6 A multidisciplinary team approach to patients with psoriasis may include non-GP specialists such as dermatologists, rheumatologists, cardiologists, endocrinologists, gastroenterologists and psychiatrists as well as allied health practitioners (eg psychologists and dietitians). The risk of cutaneous malignancies in psoriasis is difficult to measure given treatments such as phototherapy and immunosuppressive medications may increase the risk. Candida superimposed on flexural psoriasis makes treatment difficult, resulting in persistent and severe plaques. Should I have prostate cancer screening? Prevalence and phenotype of concurrent psoriasis and inflammatory bowel disease. Though psoriasis was often considered a cutaneous condition alone, more recent literature has shown other organ involvement. It is therefore important to identify patients with psoriasis at risk of mental health issues and monitor them for anxiety, seclusion, depression and suicidal ideation. A holistic approach to a patient with psoriasis that includes evaluating and assessing comorbidities and risk of morbidity is essential, as psoriasis should be considered a systemic disease rather than cutaneous condition alone. This increases to 1.49 times in patients with severe disease.7 The risk of T2D is almost two times greater in patients with psoriasis when compared with patients without psoriasis.8 Proinflammatory cytokines and systemic inflammation compounded by lifestyle and social circumstances are thought to be responsible for the increased risk.8 Obesity alone with inflammatory cytokines increases the risk of developing and worsening psoriasis.6 Weight loss can therefore improve psoriasis and the effect of therapies. Int J Dermatol 2016;55(2):e72–78. Dermatol Clin 2015;33(1):41–55. The PSA test measures the level of PSA in a man’s blood. AMH is jointly owned by the Royal Australian College of General Practitioners (RACGP), the Pharmaceutical Society of Australia (PSA) and the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT). Lønnberg AS, Skov L, Skytthe A, Kyvik KO, Pedersen OB, Thomsen SF. Refer a patient to an allied health professional as part of a care plan and team care arrangement Complete a diabetes annual cycle of care. General practice management of type 2 diabetes https://www.racgp. Although these QoL tools are time consuming to complete and analyse, they provide important current and evolving information about the impact that psoriasis has on a patient. The management of the comorbidities is not discussed as it is beyond the scope of this article. There are several reasons for this. Geller S, Xu H, Lebwohl M, Nardone B, Lacouture ME, Kheterpal M. Malignancy risk and recurrence with psoriasis and its treatments: A concise update. doi: 10.1038/sj.jid.5700410. J Eur Acad Dermatol Venereol 2017;31(8):1308–15. Beta-haemolytic streptococcus is known to trigger and exacerbate psoriasis. Prostate-specific antigen, or PSA, is a protein produced by normal, as well as malignant, cells of the prostate gland. Because psoriasis precedes PsA by approximately 12 years,3 there is ample time to ask patients about symptoms of PsA and investigate and treat early in the disease process before permanent joint destruction occurs.3 This primary prevention is not undertaken in almost 60% of patients with PsA, who do not have their joints treated.3 When assessing a patient with psoriasis, no matter how severe, it is important to examine their nails and joints, ask about symptoms of PsA and provide analgesia and early referral to a rheumatologist. Br J Dermatol 2013;169(1):47–52. J Dermatolog Treat 2018;29(1):13–18. Chelsea Felkai MPS usually balances a busy life of university teaching, PhD study and community pharmacy locum shifts in Newcastle, NSW. doi: 10.3109/00016350903583678. doi: 10.1016/0049-0172(73)90035-8. Am J Clin Dermatol 2019;20(3):457–63. The Royal Australian College of General Practitioners has released new guidelines for prostate cancer screening in General Practice. Do you know the symptoms of spinal muscular atrophy? Treating a patient with psoriasis should encompass education about lifestyle changes and evaluating their risk of other comorbidities. Lin C-C, Lin H-C, Chiu H-W. Association between psoriasis and dementia: A population-based case-control study. Hohenberger M, Cardwell LA, Oussedik E, Feldman SR. Interleukin-17 inhibition: Role in psoriasis and inflammatory bowel disease. Hepatitis C virus and Candida albicans are known triggers of psoriasis. The pathogenesis of psoriatic arthritis. Am J Clin Dermatol 2018;19(3):363–75. To ensure you get the right membership, please select your vocation: Login or join to access theAusDoc website, They say the doctors' college is putting patients at risk, © Australian Doctor 2021 - All Right Reserved. doi: 10.1111/ijd.13073. Zink A, Herrmann M, Fischer T, et al. An Bras Dermatol 2015;90(1):9–20. Malassezia spp., a common yeast, is associated with scalp psoriasis, seborrheic dermatitis and sebopsoriasis. It is characterised by salmon pink plaques with adherent scale, and the most common locations include the elbows, knees, intergluteal cleft, nails and scalp. Patients with severe psoriasis were more likely to have suicidal ideation, suicide attempts and completed suicide than the general population.13,14 Clinical trials evaluating the efficacy of newer medications for psoriasis typically incorporate QoL and depression questionnaires to assess the impact on psychiatric health. RACGP President Dr Frank R Jones says the list was created as part of Choosing Wisely Australia to encourage GPs and their patients to think about and discuss medical tests, treatments and procedures where evidence shows they provide no overall benefit and, in some cases, may lead to harm. Mr Tassone says there was similar push-back when pharmacy-based flu vaccinations — now an “accepted and beneficial” part of the health system — were introduced. The results are usually reported as nanograms of PSA per milliliter (ng/mL) of blood. The PSA blood test alone cannot diagnose prostate cancer. The Pharmaceutical Society of Australia (PSA) is the peak national professional pharmacy organisation, representing Australia's 32,000 pharmacists in all sectors and across all locations, working in or towards a career in pharmacy. Br J Dermatol 2014;170(2):304–14. Ryan C, Kirby B. Psoriasis is a systemic disease with multiple cardiovascular and metabolic comorbidities. doi: 10.1080/13696998.2019.1638788. There is a higher incidence of lymphoproliferative malignancies and non-melanoma skin cancers (NMSCs) in patients with psoriasis when compared with the general population. 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