Expert insight into the clinical management of psoriasis.

Question No. 1: "How is psoriasis diagnosed?"

The diagnosis of psoriasis is based on clinical assessment. No further investigations are necessary.

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Question no. 2: "How is the severity of psoriasis measured?"

"Beyond the patient interview, which assesses the impact of psoriasis on an individual’s life and its psychological burden, several severity scales are utilised:

the surface area of the affected skin;
the DLQI (Dermatology Life Quality Index) which objectively evaluates the dermatological repercussions on quality of life;
the PASI (Psoriasis Area and Severity Index) which is an internationally used composite score to objectively quantify disease severity.

Question No. 3: "How is the choice of treatment made? On what grounds does the physician base their prescription?"

The choice is determined by the severity, the pattern of involvement (guttate psoriasis, plaque psoriasis, inverse psoriasis, infantile psoriasis, etc.), the patient’s age, any plans for pregnancy, the patient’s medical history, potential drug interactions if the patient is already on treatment, the formulation acceptable to the patient (spray, cream, gel, etc.) and the need for systemic therapy.

In clinical practice, a score greater than 10 on any of the standard scales is regarded as justification to consider systemic therapy, that is, an affected body surface area exceeding 10%, and/or a DLQI over 10 and/or a PASI over 10. The initiation of this type of therapy is not, however, automatic. It is a decision made by consensus.

The treatment will depend on the severity of the condition and how it affects the patient. Treatment options include steroidal anti-inflammatory creams, medications, as well as phototherapy which is a light-based therapy.

Question no. 4: "If psoriasis goes untreated, what are the consequences?"

"Skin lesions, which can be cosmetically conspicuous, may have psychological repercussions for the patient and a social impact. Rare psoriatic erythrodermas (inflammations affecting 90% of the skin surface) expose patients to the risk of dehydration and infection, and may be life-threatening. Mild to moderate psoriasis may not be treated if the patient does not request it."

Question No. 5: "How is psoriasis treated in a pregnant woman and in a child?"

There are certain medications contraindicated in pregnant women and those of childbearing potential. One such example is acitretin, a retinoid that prohibits any pregnancy for two years after treatment cessation. The ciclosporin and the methotrexate are contraindicated during pregnancy. However, some topical therapies (topical corticosteroids, vitamin D3 analogues, etc.) are permissible during pregnancy.

Phototherapy can be considered during pregnancy depending on individual factors (skin phototype, risk factors for skin cancer, melasma). It should be emphasised that phototherapy is a medical treatment that must be prescribed and administered by a dermatologist.

Question No. 6: "Which medications can trigger a psoriasis flare-up?"

"Drugs reported to trigger or aggravate psoriasis include mainly beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and lithium, and less commonly non-steroidal anti-inflammatory drugs (NSAIDs). The list is not exhaustive. It is therefore essential to remain vigilant and report any suspected triggering event."

Question No. 7: “Do antidepressants have a positive impact on psoriasis?”

"Antidepressants are not treatments for psoriasis. However, patient management is comprehensive and multidisciplinary, involving multiple specialists as well as the general practitioner. Treating depression in a patient with psoriasis thus appears fundamental and may require the use of antidepressant therapy."