A rapid access clinic for psoriasis: first experiences

Dear Editor, Psoriasis is a complex, immune-mediated inflammatory disease associated with several important medical conditions including arthritis, cardiometabolic disease and mood disorders. The mean age of onset of psoriasis is 33 years,1 and early adulthood is a particularly formative time when the impact of being diagnosed with a chronic and stigmatizing skin condition can have far-reaching consequences. The term 'cumulative life course impairment' describes how the chronically relapsing nature of psoriasis can lead to negative social, psychological, educational and economic functioning, the impacts of which accumulate over time.2 Devolution of the health and social care budget in Greater Manchester through the Greater Manchester Health and Social Care Partnership (GMHSCP) has created an opportunity to revisit the management of long-term conditions such as psoriasis.3 In the GMHSCP model, investment in a service whereby people with a new diagnosis of psoriasis are referred to secondary care early in their disease may enable allocation of the correct treatment pathway, screening for and prevention of comorbid disease with onward referral for management, and reduction of cumulative life course impairment overall, thereby reducing pressure on the social care budget. We recognized the potential for early intervention in psoriasis both to improve patient care and to integrate service delivery.4, 5 This led to the development of the Psoriasis Rapid Access Clinic (PRAC), an innovative consultant-led, multidisciplinary clinic based within a community setting in Salford, North West England. We aimed to recruit patients who were ≥ 16 years old, were systemic treatment naive and had developed psoriasis within the previous 2 years. Intervention combined specialist dermatology and health psychology management. The objective of this pilot implementation study was to identify and recruit this target population to the PRAC. We describe the baseline characteristics and clinical needs of participants attending this specialist clinic. The pilot clinic was fully operational for 7 months prior to the onset of the COVID-19 pandemic. Fifty-three patients were reviewed, of whom 39 met the target characteristics. Of these, 54% (21 of 39) were female; the median age was 34 years and the median disease duration was 21 months at recruitment. The mean Psoriasis Area and Severity Index was 6·4 (SD 4·5) and 90% had psoriasis affecting a high-impact site. Screening for comorbidities revealed hypertension (blood pressure ≥ 140/90 mmHg) in 36% (14 of 39), total cholesterol > 5 mmol L−1 in 50% (17 of 34) and glycated haemoglobin > 41 mmol mol−1 (high risk of developing diabetes) in 6% (two of 34). Hospital Anxiety and Depression Scale scores ≥ 8, consistent with possible mental health impairment, were reported by 36% (14 of 39) for anxiety and 23% (nine of 39) for depression. Overall, 18% (seven of 39) had a Psoriasis Epidemiology Screening Tool score ≥ 3 when screened, warranting investigation for psoriatic arthritis. The mean body mass index was 28·5 kg m−2 (SD 6·5). Additional baseline characteristics are summarized in Table 1. These data reveal that the majority who attended the PRAC were young adults within 2 years of developing psoriasis. Most demonstrated high disease burden and considerable comorbidity risk, making them suitable for early and more effective therapies such as systemic treatment and illness prevention behavioural support to minimize long-term psychological and physical consequences of psoriasis. Almost half of those in employment felt that psoriasis had impaired productivity at work. This highlights the impact of psoriasis on physical, mental and socioeconomic wellbeing and further reinforces the need for strategies to reduce delays in referring for specialist management. The analysis of longer-term outcomes of attendees at the PRAC and results of a psychoeducational intervention will form the basis of a subsequent manuscript. Although to the best of our knowledge this is a world-first multidisciplinary early access clinic for psoriasis, the benefits of early intervention are well established for other immune-mediated inflammatory diseases such as rheumatoid arthritis and Crohn disease, for which early targeted treatment can potentially modify the disease course.6 This has not yet been proven for psoriasis but has been hypothesized·6 A recent priority setting partnership facilitated by the UK Psoriasis Association resulted in the creation of the psoriasis top 10,7 a list of current research priorities for psoriasis, to which the PRAC closely aligns. In parallel, national and international healthcare policymakers emphasize the importance of policy change to keep pace with scientific developments and innovative therapies. There is an urgent need to integrate such recommendations into practice. In the case of psoriasis, this means early access to specialist care, at which point more vulnerable patients can be identified and their care escalated, while integrating primary and secondary care services to optimize disease management for individual patients. This approach is exemplified by the PRAC model. Following on from the success of this pilot study, the PRAC has been included in the recently published Dermatology Getting it Right First Time report.8 Early access clinics for psoriasis may prevent long-term sequelae, as the disease is better controlled, and comorbid conditions are screened for and acted upon. Investing in the PRAC model has the potential to save future health and social care costs, something more easily achieved in the GMHSCP with devolved health and social care budgets. Claire Reid: Conceptualization (supporting); data curation (equal); formal analysis (equal); investigation (lead); methodology (lead); project administration (lead); software (supporting); supervision (supporting); writing – original draft (lead); writing – review and editing (lead). Charlotte Welsh: Data curation (supporting); formal analysis (supporting); software (supporting); writing – review and editing (supporting). Soney Dharmaprasad: Data curation (supporting); investigation (supporting); project administration (supporting); resources (supporting). Holly Martin-Smith: Data curation (supporting); investigation (supporting); project administration (supporting). Richard B Warren: Resources (supporting); supervision (supporting); writing – review and editing (supporting). Lis Cordingley: Conceptualization (lead); data curation (supporting); formal analysis (supporting); methodology (supporting); project administration (supporting); supervision (lead); writing – review and editing (supporting). Christopher Ernest, Maitland Griffiths: Conceptualization (lead); funding acquisition (lead); project administration (supporting); supervision (lead); writing – review and editing (supporting). Author elects to not share data