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3 21 Case discussion

Mrs Jane Smith is 36 years old. She is a teacher and married to a computer engineer. They have two daughters, aged ten and eight. Apart from psoriasis she says she enjoys good health, apart from borderline hypertension (not currently on treatment) and a high BMI.

She has had psoriasis since her early teens. Initially this presented with guttate psoriasis after a sore throat, but that soon evolved into chronic stable plaques of psoriasis on the back of her elbows, front of her knees and scattered plaques on her torso – some quite small, others up to the size of the palm of her hand. From time to time she has less scaly, almost shiny, sore areas under her breasts and in her groin and umbilicus. In her scalp she has areas of very thickened scale, and she has a few plaques of psoriasis on the nape of her neck and behind her ears. She keeps her hair long to hide these. Her face, hands and feet are clear. Her nails are ‘quite brittle’ with a few areas of heaped-up scale under a few of them (especially her right index and middle fingers). She denies any joint pain or stiffness.

In the past she has noticed a significant deterioration in her psoriasis after a sore throat, and she continues to have a bad sore throat at least four or five times a year. Both Mrs Smith and her husband smoke up to 20 cigarettes a day. She rarely has any alcohol. She is on no medication other than the mini pill (her BMI is 31), which she continues, largely as it has stopped her periods.

She previously had about five courses of light therapy (as a teenager PUVA, but subsequently UV-B). The last course was at least five years ago.

She has tried steroids creams (up to Betnovate® strength), which have helped. More recently she has been using a vitamin D analogue ointment, but she says she finds this quite ‘irritant’ and so has abandoned it. She tells you that a further course of light therapy would be very inconvenient as she works all week. During the holidays she needs to be with the children.

As her GP you are aware that their marriage has been unhappy from time to time. Mrs Smith recently told you they were now sleeping in different bedrooms. They have not had a family holiday for some years.

You ask her how having psoriasis makes her feel and she bursts into tears. ‘No one has ever asked me that before,’ she says. She goes on to say it makes her feel dirty, uncomfortable and she is desperately embarrassed about it. It looks awful and she is aware she leaves a trail of skin scales wherever she goes. She refuses to take her daughters swimming and the idea of a beach holiday (which her daughters have been begging for) appals her. She is so unhappy about exposing her body that she cannot even get undressed in front of her husband. They have not made love for years. Recently she struggled to hide her tears when her daughter said, ‘Why do you never wear pretty skirts like my friend Kirsty’s mum?’

Questions for reflection

To help you understand how the GP curriculum can be applied to this case, ask yourself the following questions:

Fitness to practise

  • How hard should I work to help Mrs Smith if she seems unmotivated?

Maintaining an ethical approach

  • How can I balance my patients’ needs with the availability of commissioned services?

Communication and consultation

  • Are there any lifestyle or complementary therapies that she might ask me about?

Data gathering and interpretation

  • What tools could I use to measure severity (DLQI / PDI)? [1] [The best access to the Dermatology Life Quality Index (DLQI) and Psoriasis Disability Index (PDI) is via the Cardiff University Department of Dermatology website.]

Making decisions

  • Am I confident I can diagnose psoriasis and distinguish it from other common skin conditions?

Clinical management

  • What topical treatments might I prescribe for the various affected areas?
  • How would I approach discussions about the inheritance of psoriasis?

Managing medical complexity

  • Should I consider referring her for consideration of oral second-line therapies (e.g. methotrexate / ciclosporin)?
  • If so, what advice would I give (note she is a smoker and has borderline hypertension)?
  • If her treatment is going to be topical, how is she going to treat her back?
  • How will I manage the complexity in this case?

Working with colleagues and in teams

  • What resources might be available in the primary health care team to help me manage this patient?

Maintaining performance, learning and teaching

  • What do I know about ‘complete emollient therapy’ and its place in the management of psoriasis?
  • What advice would I give regarding the use of topical steroids in psoriasis (refer to NICE / SIGN guidelines 2012)

Organisational management and leadership

  • What advice might I give about a pre-payment prescription?
  • How can I record the distribution of her skin condition on the computer software?

Practising holistically and promoting health

  • What are her priorities for treatment?
  • Mrs Smith is a smoker. Should I use this opportunity to discuss this with her?
  • What is the additional risk of chronic, moderate or severe psoriasis accelerating atherosclerosis? How will I discuss CVS risk factors?
  • Psoriatic arthritis is often unrecognised, but it is essential to manage this actively, as it is common and destructive (NICE / SIGN guidelines). How would I evaluate the presence of this in Mrs Smith’s case?

Community orientation

  • Do we provide sufficient support in the community for lifelong dermatological conditions?

 

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