Last month I discussed the interpersonal elements of the initial exam room encounter with psoriasis patients. The next step after establishing a relationship with your patient is gaining an understanding of the degree of psoriasis in order to establish a treatment plan. Calculating body surface area (BSA) is not an exact science, but there are a few basic principles that help guide the screening. For example, one patient palm (not including the thumb) should be considered one percent BSA. You should then rank erythema, induration, and scale on a zero to four scale, with zero being clear and four being severe. Also, take note of scalp, palm, and sole involvement.
Once these details have been determined and the patient has gotten dressed, sit down with her or him and get a thorough history, as this will help to determine the appropriate therapy. This includes any history of joint pain or stiffness in fingers or toes when waking up, history of an entire finger or toe swelling up (dactylitis), any painful soles (plantar fascitis), achilles swelling and/or tenderness, costochondral junction pain, swelling and or pain of elbows or knees. These questions help to establish the potential for psoriatic arthritis.
Along with asking how long the patient has had psoriasis, it is also important to ask the patient on a scale of one to 10 how bad her or his psoriasis is today. This re-enforces your desire to help and makes the process feel less cumbersome and “listy” for the patient. After this, it is appropriate to ask what treatments the patient has undergone, for how long, and how well each therapy worked. The last part of the patient history is the medical history. Here you must acquire the patient’s history of recurrent infections, bronchitis, urinary tract infections, photosensivity. If the patient has had cancer, when and what type, as well as treatment they have received. Also ask for a history of lymphoma, leukemia, TB, hepatitis, demyelinating disease, MS, Bells palsy, CHF, and cardiac history. Importantly, do not forget to take note of the patient’s height and weight.
Once these factors are ascertained it is necessary to discuss the various therapeutic options with the patient, including each therapy’s risk/benefit ratio. With a relationship established and a thorough history documented, patients will likely be more open about their concerns and questions and will feel included in the decision of therapy selection.
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