What Do Primary Care Providers Need to Know About Psoriasis?
In a presentation at Practical Updates in Primary Care, Annie Truss, MD, and Joel M. Gelfand, MD, provided and in-depth overview of psoriasis care for primary care providers, emphasizing early recognition, comorbidity management, and evolving therapeutic strategies.
In this interview, Dr Gelfand outlines psoriasis as a chronic, immune-mediated inflammatory disease, with significant systemic implications including cardiovascular disease, diabetes, and depression. He discusses the role primary care providers play in psoriasis care and how to implement a holistic strategy when diagnosing, treating, and educating patients.
Key Highlights
- Primary care providers must be able to distinguish psoriasis from other autoimmune diseases, skin cancers, and infection.
- Psoriasis and cardiovascular disease often have a bi-directional relationship.
- Comorbidities such as obesity, diabetes, and depression are commonly managed by primary care providers.
Reference:
Gelfand JM, Truss A. Cracking the Psoriasis Code: What Primary Care Providers Need to Know Now. Practical Updates in Primary Care. Presented at: Practical Updates in Primary Care; 2025.
Consultant360: What role do you envision primary care playing as the front line in identifying and managing inflammatory diseases like psoriasis?
Dr. Joel Gelfand, MD: I think the first role is being able to diagnose it, to be able to look at the rash and say, I feel confident this is psoriasis, and not something else, like an autoimmune disease, such as lupus, or an isolated skin cancer, or some other skin disease or drug reaction, or an infection. It is a clinical diagnosis. It's not like a test you order. When we do a skin biopsy, it's because it doesn't look like psoriasis, so it will rule out other things. We make sure it's not lupus or infection or something like that.
Being able to recognize is number one. Number two is to be able to initiate the conversation with the patient. You can explain that this is not a contagious disease; this is an immune disease that's affecting you, and that we have a lot of ways to treat it effectively. If patients are bothered by the disease, feel stigmatized by it, it affects their emotional life or well-being, we should work together to get their skin clear.
It's also important to be aware that psoriasis is a marker of other internal diseases related to chronic inflammation. That includes psoriatic arthritis and cardio metabolic disease. They have more atherosclerosis, more insulin resistance, more obesity, more diabetes, more dyslipidemia. Those aspects of disease need to be tended to as well.
And finally, knowing when to refer. If the patient is not doing well on the therapies you have available, if they have localized disease but are not responding, the disease is more extensive, then they really should see a dermatologist.
I think it's helpful for the patients to know ahead of time that we have very effective treatments for them that are very safe and well tolerated because our patients come to the office with their own preconceived notions. Maybe they read online that a friend took this drug and died, or something like that and all these anecdotes that are probably false. I think understanding there is a lot of reason for optimism and that we can help people with this disease is really important for helping a patient be successful in managing this chronic condition.
C360: For a primary care provider seeing a newly diagnosed psoriasis patient, what are the first-line steps before referring to a dermatologist?
Dr Gelfand: I think the main one is initiating the education for the patients. Make sure they're aware that this is inflammatory disease, it is not contagious, and there'll be a lot of good treatment options.
I think if the primary care doctor has a sense that this patient may need systemic agents, initiating the workup for that will make sense. Starting with a blood count, liver and kidney function, electrolytes, getting testing for HIV, hepatitis B and C, because those tests need to be done if we're going to use systemic agents, especially from an insurance point of view. Maybe they should look for causes of arthritis if they have joint symptoms such as a rheumatoid arthritis test, like a rheumatoid factor, CCP antibody, uric acid for gout, which could look like psoric arthritis, markers of inflammation, like a C reactive protein, and that they have hands and feet involved. Getting X rays of those joints can be helpful to distinguish and see if there's any evidence of erosions. If they have erosions that's going to buy them more aggressive management of their psoriatic disease. And then, of course, making sure that they have been screened for cardio metabolic disease, their blood pressure, the hemoglobin, 1c their lipids, treatment, statins, early if they need them, if they're maybe considering a coronary calcium score, if there's any question about the trying to risk stratify the patient, and then also try and make sure to up to deal with their age appropriate medical care, like cancer screening and vaccination. Some of the therapies make people a little more prone to infection, so it's nice if they're vaccinated to lower their risk of Covid and flu.
C360: Many of the comorbidities you discussed—such as obesity, diabetes, and depression—are conditions that primary care providers already manage. How can these physicians best coordinate with dermatologists to deliver comprehensive, patient-centered care?
Dr Gelfand: Patients sometimes are reluctant to treat these comorbidities, and it's important that they and their care team are aware that these things are all interrelated in a lot of ways, and that sometimes treating the comorbidity could help improve the psoriatic disease. So for example, if someone is obese, there is evidence that weight loss improves psoriatic disease. That would be an extra reason to use a GLP-1 or another therapy to try and help them lose weight. We talked a little bit earlier that it's a sign of dyslipidemia and metabolic disease and atherosclerosis, so it's a reason to use statins earlier.
I think those are some important aspects as well as anxiety and depression that often go along with psoriasis. Once a patient is already super anxious or dealing with depression, it could often be hard to manage it with just CBT or other counseling therapies. They may need SSRIs or other psychiatric medications to help them and clearing their skin will often improve their mood, but not always. Sometimes it can be paradoxical: people have become so anxious and withdrawn or depressed that when the skin improves and they still feel terrible, it's even harder for them, and so it is important to be aware of the full impact on their well-being. Helping to manage those symptoms goes a long way to having a better outcome holistically.
C360: In your presentation you discussed the “bi-directional relationship” between psoriasis and cardiovascular disease. How should clinicians integrate this understanding into their routine cardiovascular risk screening?
Dr Gelfand: When you walk in that room, if they have increasingly extensive disease, you know there are higher risks of having a major adverse health outcomes, and so those are people that you want to spend a little extra time think about things like how do we prevent morbidity and mortality in this patient? That usually revolves around the things that we're trying to do anyway, which is helping people lose weight, treating diabetes aggressively, controlling lipids aggressively, but we know many of our patients are just not at goal or not appropriately screened or diagnosed with these risk factors. That’s a big component of the bi-directional relationship that you need to know that when you see psoriasis, it's a flag that something may be wrong from a cardio-metabolic perspective, and on the flip side of it, although we don't know for certain that treating psoriasis lowers risk of cardiovascular disease and diabetes, generally speaking, we know that people's well-being is improved when they get their skin clear. We sort of think about it as holistically. We want to lower their LDL. We want their blood pressure to be normal. We want their A1C to be normal. We want their skin to be clear, if possible, because that's a reduced metabolic load in that patient, and so trying to clear skin is another goal that we have for our patients, to restore them to sort of a normal physiology.
C360: What is the most important message you hope physicians will take away from your talk?
Dr Gelfand: The most important takeaway is that we've had so much progress in this disease in the last 10 years that knowing about psoriasis is more important than ever. By knowing about it, we could really help people get clear skin and not have to live with the heartbreak of psoriasis as well as be alerted to the serious health problems that are often underlying psoriatic disease.
C360: Is there anything else you would like to add?
Dr Gelfand: Patients are often interested in diet, and we recently published an article suggesting the Mediterranean diet has some benefits in psoriasis compared to regular diet. I think it's helpful for clinicians to know about that because patients are often interested. The Mediterranean diet is one that's relatively easier to follow and has a variety of benefits beyond just helping the skin, and so for people looking for dietary advice, that's usually where I point them.