Introductory Chapter: New Challenges for Practionners, New Roads for Patients

1. Psoriasis: A common multifaceted disease

Psoriasis is an autoinflammatory skin disease that can be defined by an accelerated rate of epidermal turnover including hyperproliferation and defective maturation of epidermal keratinocytes [1]. It is a chronic disease that first occurs more frequently in the second and third decades of life but can be observed at any age. Its prevalence reaches 2% in northern countries, North America, and Europe, probably less in southern countries. It seems important to review what the practitioners can find in psoriatic patients, from the classical chronic plaque psoriasis, with well-demarcated thickened and scaly plaques, often symmetrically distributed, to the other presentations namely guttate psoriasis, flexural or inverse psoriasis, palms and soles hyperkeratosis, nails distorted by thimble pits, nail plate thickening, and detachment. Recognizing all these signs allows rapid relief for the patient and surely the best support. Too many patients will still come lately after years of suffering.

2. Behind the skin lesions

In up to 30% of patients with psoriasis, arthritis can be associated, a seronegative for rheumatoid factor. The prevalence of arthritis among psoriatic patients emphasizes the need for a multidisciplinary approach with assessment of both skin and joints by general practitioners, dermatologists, and rheumatologists.

Psoriasis is also associated with comorbidities such as Crohn’s disease, obesity, diabetes, hypertension, and even cancer. Moreover, studies found higher degrees of depression in patients with a greater percentage of their skin affected with psoriasis. This is one more proof that multidisciplinarity is important in our daily practices. According to the WHO, the management of psoriasis does not only correspond to the treatment of skin or joint lesions but also deals with these different comorbidities [2].

3. New roads

Much is known about the epidemiology of psoriasis, but the interplay between the disease itself, the effects of the treatments, and the behavior of patients should be better investigated [3].

We have to recognize that our purpose is not only to explore all the fields of this frequent disease and to give to readers an exhaustive material but well to provide very important and practical aspects for all practitioners following psoriatic patients. This current book claims to be a practical and perspective tool.

Because most patients will not be free of disease for the rest of their lives, biological therapies are the most important information regarding a new therapeutic option [4]. These targeted and tailored therapies are able to modulate the immunity of patients and enable to define of new therapeutic aims: proportions of patients achieving clearance or near clearance are high, with excellent outcomes and patient satisfaction. Cost-effectiveness studies remain important to define the position in the therapeutic strategy. This strategy emphasizes now the concept of “hit hard and hit early” which means that every practitioner has to recognize all forms of psoriasis and to rapidly treat them with a tailored approach. Biological treatments could take a major place in the treatment of patients with psoriasis since the option could be to reduce and to space out the doses.

On the other side, there is an effort to find new treatments and other approaches than the “classical” evidence-based therapy. Many patients ask for these new and other approaches. There are more proofs of evidence that supports to explain that curcumin should help patients for instance presenting with arthritis. Curcumin is a phytopolyphenol pigment isolated from the plant Curcuma longa known for its anti-inflammatory properties as a result of the inhibition of cyclooxygenases (COX inhibition). It also disrupts cell signal transduction by different mechanisms including inhibition of protein kinase C. The idea is not to forget this traditional Indian spice and to remember that many therapies came directly or indirectly from perennial plants. Of course, more investigations are necessary to bring evidence-based proof and to investigate other new roads.

By the way, many studies underline the effect of the environment on patients and their diseases. This will help the patients to choose a well-balanced lifestyle, making them actors and decision-makers. This is surely the beginning of the idea of “patient empowerment” which changes the paradigm of medical approach. If the patients recognize triggering factors, the medical team will help them control their impacts on the natural history of their diseases. Studies on the impact of psoriasis have corroborated clinicians’ feeling that psoriasis has a major impact on social and psychological functioning [5]. It is one more argument to regularly assess a patient’s quality of life, not only by asking the patient “How are you?” but by using a multidimensional model, such as the Dermatology Life Quality Index (DLQI). No matter how much or little of the skin is involved, patients can experience deep effects from the physical, mental, or social point of view.

There is a lack of long-term studies on patients with severe chronic plaque psoriasis, despite the fact that most of the treatments show good evidence of risk of harm and side effects from most of the treatments, such as skin cancer for phototherapy, cutaneous atrophy from chronic dermocorticosteroids use, hepatic fibrosis and myelosuppression from methotrexate, renal impairment and hypertension from ciclosporin, teratogenicity from systemic retinoids, paradoxical effects or tuberculosis reactivation from biological therapies. These facts are a reminder to focus on the future of new therapies and to help the patients to control their own lives. A balance must always be found between patients’ individual perceptions, constraint and side effects of the treatments.

This book will give readers, whatever the specialty of the practitioner, the opportunity to consider differently the psoriatic patient, because the patient needs more than pharmacological treatment.