Explaining a Diagnosis of Psoriasis – OSCE Guide

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Being able to share information in a clear and concise way is an essential skill in all fields of medicine. This can range from simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis. Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format in order to communicate more effectively.

This guide provides a step-by-step approach to explaining a diagnosis of psoriasis. You should also read our overview of how to effectively communicate information to patients.


Structuring your explanation

Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.

BUCES
Figure 1. BUCES structure for information sharing

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better understanding of their problem. After introducing yourself, it is important to take a brief history (this is the first part of the BUCES structure):

  • What has brought the patient in to see you today?
  • What are their symptoms?
  • Are there any risk factors that can be identified? (e.g. lifestyle/family history)

For example, a patient with psoriasis will likely mention itchy, red lesions with an overlying scale on areas such as the scalp and extensor surfaces. They may also mention precipitating factors such as recent infections or exacerbating factors like smoking and alcohol.

Tip: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction and brief history between 1-2 minutes maximum.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

What does the patient understand?

Following a brief history, it is important to gauge the patient’s knowledge of their condition. Around one-third of patients with psoriasis will have a family history of the condition, so the patient may already have a lot of knowledge and experience regarding it, or it may be their first encounter with a dermatological condition.

Due to these reasons, it is important to start with open questioning. Good examples include:

  • “What do you think is causing your symptoms?”
  • “What do you know about psoriasis?”
  • “What has been explained to you about psoriasis so far?”

Open questioning should help you to determine what the patient currently understands, allowing you to tailor your explanation at an appropriate level.

At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks (i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal communication such as nodding).

Checking the patient’s understanding should not be solely confined to this point of the consultation but should be done throughout by repeatedly ‘chunking and checking’.

Tip: Try using phrases such as: “Just to check that I am explaining psoriasis clearly, can you repeat back to me what you understand so far?”. This is far better than only saying “What do you understand so far?” as the onus is placed upon the quality of your explanation rather than there being an issue with the patient’s ability to understand.


What are the patient’s concerns?

The patient’s concerns should never be overlooked. Asking the patient if they have any concerns before beginning your explanation allows you to specifically tailor what is most relevant to the patient, placing them at the centre of the explanation. The “ICE” (ideas, concerns and expectations) format, can provide a useful structure for exploring this area further.

ICE

Ideas:

  • What does the patient think is causing their symptoms?
  • What is their understanding of the diagnosis?

Concerns:

  • What are the patient’s concerns regarding their symptoms and diagnosis?

Expectations:

  • What is the patient hoping to get out of the consultation today?

Explanation

After determining the patient’s current level of understanding and concerns, you should be able to explain their condition clearly

You should begin by signposting what you are going to explain to give the patient an idea of what to expect.

“I’m going to begin by talking about the normal function of the skin and then move on to discuss what psoriasis is, what causes it and how we can manage it together.”

Tip: Use the mnemonic “Normally WCan Probably Manage” to help you remember the structure of explaining a disease.

Normal anatomy/physiology

“The normal function of the skin is to act as a barrier. We can imagine the skin to be layers of bricks stacked on top of each other. In normal skin, the mortar between the bricks prevents irritants from getting in and prevents water from getting out which stops the skin from drying out.”

What the disease is

Psoriasis is a chronic inflammatory skin condition characterised by clearly demarcated red, scaly plaques. It affects around 2-4% of the population and while it is more common in Caucasian patients it can affect patients of all backgrounds.

The most frequently affected areas are the scalp, elbows and knees and the lesions tend to appear symmetrically. 

Patients will typically report developing itchy, red rashes on the skin, that tend to be symmetrically distributed. They may also have pain/burning sensations around the rashes, joint pain and nail changes such as pitting.

Cause of the disease

“The development of psoriasis is very complicated and a lot of different factors contribute. It is thought to be due to a problem with parts of the immune system becoming overactive, which leads to inflammation in the skin.

We don’t know the exact cause of psoriasis but know that it is due to a combination of genetic, immune and environmental factors. There is a genetic component, and the disease will often run in families. There is often no clear trigger in most cases of psoriasis.

There are some things that can precipitate psoriasis, for example, infections, hormonal changes and certain medications such as lithium. Additionally, some things can make psoriasis worse once it has developed, these include skin trauma, smoking, alcohol and stress.”

Problems/complications

Outlining potential complications of psoriasis is necessary so that the patients can identify problems early and seek medical advice. Being aware of common problems will also encourage patients to adhere to their treatment.

Explain that you are outlining the potential risks so that they are aware of them. When discussing potential complications explain that you and the patient will need to work together as a team to reduce the likelihood that they’ll occur.

Complications of psoriasis include:

  • Persistent disease and symptoms
  • Anxiety and depression due to the psychosocial burden of the disease
  • Reduced quality of life
  • Development of associated conditions, such as psoriatic arthritis

Patients can also experience flares of severe forms of the disease, such as pustular and erythrodermic psoriasis, which can be fatal in rare cases.

“A rare complication of psoriasis is the development of a severe flare, known as either pustular or erythrodermic psoriasis. These flares are serious and require emergency medical treatment. If you notice that you begin to develop multiple pus-filled blisters on your body quickly, or that you begin to develop painful and itchy rashes all over your body then you should seek urgent medical advice.”

Management

Reinforce to the patient that they need to work with you as a team to achieve a good result. 

Patients should be advised to avoid any exacerbating factors/triggers such as smoking and alcohol. 

The management of psoriasis follows a stepwise approach, which allows room for increasing the strength and effectiveness of treatments in patients that do not respond to first-line therapy. Patients will initially be given topical therapies and then may require additional systemic therapies or other therapies such as phototherapy if they do not respond to initial treatment.

Emollient therapy

Emollients should be used regularly regardless of how well-controlled psoriasis is (up to 8 times a day) and regular application has been shown to reduce the number of flares. Advise the patient to apply emollients gently to the skin in the direction of hair growth (to help prevent folliculitis).

Ointments:

  • paraffin based
  • oily/greasy, thick
  • can stain clothing
  • the most effective emollient if used properly

Creams:

  • water-based
  • soak in and disappear

Lotions:

  • water-based
  • replacement for soaps and shampoos
  • not used as an emollient alone

Topical corticosteroids

Topical corticosteroids are the most commonly prescribed topical therapy for psoriasis. The strength of the preparation can be adjusted depending on the severity of the disease (plaque thickness), skin sensitivity and the site of the disease.

Other topical therapies

Tar preparations are anti-inflammatory and help with symptoms of itching. They are often combined with keratolytics (e.g. salicylic acid) to help lift scale. This is the preferred topical therapy for psoriasis on the trunk and limbs.

The most common tar preparation is liquor picis conbonis (LPC, coal tar).

Calcipotriol is a vitamin D analogue that can be used as a topical therapy as it has an anti-proliferative effect on keratinocytes. It is generally given alongside topical corticosteroids.

Systemic therapies

If a patient’s psoriasis is not controlled by topical treatment alone then they may require systemic therapy, which is generally immunosuppressive treatment.

Methotrexate is frequently used as an oral therapy for severe unresponsive psoriasis, due to its ability to slow epidermal cell proliferation. It is effective but has a wide range of potentially severe side effects that must be monitored for, including liver dysfunction and pulmonary fibrosis.

Acitretin is an oral retinoid that is anti-inflammatory and affects cell proliferation and differentiation. It has the same side effect profile as many other oral retinoids, including cheilitis and dryness of the skin and mucosal membranes. It is a potent teratogen.

Cyclosporin is highly effective at controlling psoriasis but is not recommended for continuous therapy due to its adverse side effect profile (hypertension, renal dysfunction and derangement of liver function, among many others). Additionally, psoriasis frequently recurs quickly after cessation of treatment.

Biologic therapies may be used in patients with treatment-resistant psoriasis (mostly restricted to severe disease due to the expense associated with biologic agents). They may also be effective in improving psoriatic arthritis if present. Treatment targets include TNFα (infliximab, etanercept), IL-23 (ustekinumab) and IL-17a (secukinumab). 

Other therapies

Psoriasis often responds well to narrowband UVB phototherapy, which down-regulates the immune and inflammatory pathways of the skin. This is the phototherapy of choice for plaque psoriasis, but other forms of phototherapy may be used for different phenotypes.

Example of how you might explain the management of psoriasis

“The symptoms of psoriasis can be very unpleasant and disruptive to your life so it’s important that we work to try and get them under control.”

“The mainstay of treatment will be topical creams. You will have one type called an emollient. Emollients work by filling the cracks between the dry bricks, which stops irritants from getting in and prevents water from escaping, which helps to moisturise the skin. This can also reduce the number of flare-ups and improve your general symptoms. There are lots of different types of emollients such as creams, ointments, and gels, so we can pick ones that are most effective and work best for you. This can sometimes be a case of trial and error at the beginning. I can give you some samples of the different types of emollients, and ask a specialist nurse to speak to you about them today if you would like?”

“You will also have another type of topical treatment to use alongside the emollient to help manage your symptoms. This will generally either be a steroid cream or a coal tar preparation. We tend to try topical steroids first as they are very effective but can change to an alternative if they don’t help. Steroids should not be used on the face as they can cause thinning of the skin and other serious side effects. You should always wash your hands after applying steroid creams.”

“In most people, the treatments we have discussed will control your psoriasis extremely well. However, we do have other options for treatment if these are not successful and we can discuss those if it becomes appropriate.”


Closing the consultation

Summarise the key points back to the patient.

“In summary, psoriasis is a long-term condition that affects that skin. Your symptoms may get worse or improve over time, depending on lots of different factors. We have lots of treatment options available to manage your psoriasis, starting with an emollient and a topical steroid today, but if these don’t help then there are lots of other things we can try. If your psoriasis starts to get worse very quickly or you’re concerned about infection then you should see a doctor the same day. You are going to meet the specialist nurse today to talk about the emollients which will suit you best, and then we can meet again in a few weeks to see how things are going.”

Ask the patient if they have any questions or concerns that have not been addressed.

“Is there anything I’ve explained that you’d like me to go over again?”

“Do you have any other questions before we finish?”

Arrange appropriate follow-up to discuss their psoriasis further. Acknowledge that you have discussed a large amount of information and it is unlikely that they will remember everything.

Offer the patient some leaflets on psoriasis and its management, and direct them to some reliable websites which they can use to gather more information (examples include patient.info and NHS Choices).

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


References

  1. DermNet NZ. Psoriasis. 2014. Available from: [LINK]
  2. British Association of Dermatologists. Handbook for Medical Students and Junior Doctors. 2020. Available from: [LINK].
  3. Patient.info. Chronic Plaque Psoriasis. 2020. Available from: [LINK].
  4. NICE. Psoriasis assessment and management. 2017. Available from: [LINK].

 

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