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Running head: Critical Appraisal Topic
Critical Appraisal Topic: Psoriasis
NUR 568: Common Health Problems of Maturing Adults
Brooke A Evans RN, BSN, DNPs
University of Mary
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Critical Appraisal Topic: Psoriasis
Author: Brooke Evans
Case Scenario
J.L is a 35 year-old female patient who presents to the clinic today with a history of psoriasis.
She has been experiencing more frequent flare-ups. Treatment in the past has included the use of
emollient (Cetraben 13.2%), which has provided short-term relief but, she feels her flare-ups are
getting longer and closer together. Could the patient benefit from using more than one treatment
option?
PICO question
In adults with recurrent psoriasis; does the use of a topical treatment alone decrease the incidence
of flare-ups in comparison to using topical and oral treatments?
Summary and appraisal of key evidence
Article one:
Gooderham. M, Costello-Poulin, M, Shelton, J, Bayan, N, & Pappa, KA. (2016).
Predictors of topical use in psoriasis patients in the REFINE study. Journal of
Cutaneous Medicine and Surgery, 20(2), 106-112.
Psoriasis is a chronic conditions that is immune-mediated which is seen to affect 1-8% of
the adult population worldwide. The severity of psoriasis does not have a clear definitive
definition and there are several other factors that contribute to the complexity of the disease.
Using the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index
(DLQI) can assist in determining the appropriate treatment. The REFINE study showed safe and
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effectiveness in the use of topical therapy during the maintenance phase of Etanercept (ETN)
therapy.
The study population met criteria if they were at least 18 years old, had stable moderate
to severe plaque psoriasis for six months or longer, had BSA involvement of 10% or more, had a
PASI score of ten or greater, and had to qualify for systemic therapy or phototherapy. Enrollment
of participants spanned across 23 community dermatology practices in Canada. There were a
total of 310 patients enrolled in the study; 144 received ETN monotherapy and 143 receive
ETN+ topical and 23 opted out prior to week 12. Results of this study revealed that participants
who were involved in the ETB+ topical regimen had a higher likelihood (74.2%) of achieving
PASI 90 in 12 weeks than those who used ETN monotherapy.
Limitations to the study included the post hoc analysis which may not have considered
the use of other topical agents that were used during the study design. The outcome of this study
may not be representative for long-term therapy due to the study being 12 weeks and adherence
to treatment regimen may decline as time progresses. Lastly, the small numbers of patient at
specific locations and the small number that were using low-potency topical agents; this could
prevent the detection of correlation from other sources. This study was a level II evidence
because it consisted of one well-designed randomized controlled trial.
Article two:
Kofoed, K., Skov, L., & Zachariae, C. (2015). New drugs and treatment
targets in psoriasis. Department of Dermato-allergology. Acta Dermato
Venerologica, 95, 133-139.
Over of the years, there has been a better understanding of the pathophysiology that
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is involved in psoriasis; with this new understanding comes new treatment options. Psoriasis was
once looked at as a disease of an “intrinsic epidermal keratinocyte disease to a T-Cell mediated
disease to now being considered a systemic inflammatory disease with an evident role for the
immune system” p. 133. Treatment options have evolved with the recognition of change in the
pathophysiological process of psoriasis. New treatment options focus on the use of Interleukin
12/23 inhibitors, Interleukin-17 inhibitors, anti-tumor necrosis factor agents, phosphodiesterase
inhibitors, Janus kinase inhibitors, and A3 adenosine receptor agonists.
This study reviewed clinical trials that were published in peer-reviewed journals starting
in 2011-2014. The focus of the reviews centered on the mechanisms of action, efficacy, and
adverse effects of the new therapies. The study review concluded that there are multiple new
drugs that are in process for the treatment of psoriasis over the coming years. With that being
said there are limitations of drug safety that prescribers need to be aware of and the studies
reviewed were not of great length or population size. This study provided level III evidence
because the study obtained evidence from peer-reviewed articles.
Clinical Bottom Line
Both studies indicated that there are effective treatment managements for psoriasis. In
addition, with the evolving discovery in pathophysiology, there are several new treatment
options that will be available for future practice. Both studies emphasize the fact that multiple
treatment regimens are more effective than monotherapy in psoriasis. Dual treatment enables the
patient a higher chance of obtaining PASI 90.
Implications for Practice:
Psoriasis is a chronic skin condition that affects approximately two percent of the U.S.
population and there are 150,000 new cases each year (Goodman, et al. 2016). While studies
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have shown an improvement with dual therapy more research needs to be conducted on the
safety and efficacy of new treatment regimens available.
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References
Gooderham. M, Costello-Poulin, M, Shelton, J, Bayan, N, & Pappa, KA. (2016).
Predictors of topical use in psoriasis patients in the REFINE study.
Journal of Cutaneous Medicine and Surgery, 20(2), 106-112.
Feingold, K., & Grunfeld, Carl. (2012). Psoriasis: it's more than just the skin.
Journal of Lipid Research, 53, 1427-1429.
Kofoed, K., Skov, L., & Zachariae, C. (2015). New drugs and treatment targets in
psoriasis. Department of Dermato-allergology. Acta Dermato Venerologica, 95, 133-139.