Failure to Counsel Patients With Psoriasis to Decrease Alcohol Consumption (and Smoking)

Abstract

Most dermatologists appreciate that psoriasis is a chronic, systemic, inflammatory disorder, multifactorial in etiology, with a complex interplaybetweengeneticpredispositionandenvironmental and behavioral factors (such as alcohol intake, obesity, and smoking). Behavioral factors appear to play a role in the development of psoriasis as well as affect the clinical severity of disease. 1,2 As such, the awareness and ascertainment of these risk factors would be an importantaspectofpsoriasismanagement.Hereinliesthepractice gap for most dermatologists: Inattention to alcohol andsmokingbehaviorsprecludestheopportunityfortheir modification (by reduction or even cessation). To better understand the barriers to changing clinical practice, let us briefly examine the impact of these factors on psoriasis. Qureshi et al provide evidence suggesting that alcohol is a risk factor for the development of psoriasis, with a particular increase in risk for those with the greatest intensity and severity of use. Patients with a genetic predisposition (HLA-Cw6 and HLA-B57) to developing psoriasis have this risk compounded by smoking,stressfullifeevents,andevenobesity. 1 Datafor HLA types and alcohol does not yet exist, but a similar relationship seems plausible. This increased risk of developing psoriasis from smoking was normalized for individualswhohadquitsmokingforatleast20years,suggesting that modification of behavioral factors may play aroleinprimarypreventionofpsoriasis.Withthisknowledge, does reduction in alcohol and smoking lead to an improvementinpsoriasis?Abstinencefromalcoholseems to lead to a reduction in disease severity 2 (and similarly for smoking cessation) and an improvement of palmopustular psoriasis. Barriers to incorporating and applying this knowledge into clinical practice remain. Many dermatologists do not routinely ask about smoking and drinking behaviors. In part, dermatologists may be reticent to discuss smoking and alcohol modification because they are not familiar with current practices and treatment options to aid in cessation. By having patients in the waiting room complete a psoriasis questionnaire designed to identify these health risk factors or by using a template of a set ofquestionswhentakinghistoriesfrompatientswithpsoriasis,collectionofinformationcanbestreamlined.With basic education, dermatologists may be able to develop their skills in counseling these patients regarding behavior modification. Regardless, it is essential for dermatologists to address this issue, since this provides an opportunity for patient education. Educational materials such as pamphlets and brochures can be provided, and patients can be directed to experts in lifestyle modification. Current patient education materials, such as those from the American Academy of Dermatology, can be modified to include information related to alcohol intake and smoking. Other lifestyle factors such as weight loss can be promoted and monitored as methods of risk reduction. Simply educating patients on these benefits may encourage them to make changes. While targeted therapeutics are honed, opportunity exists to intercede on modifiable risk factors and comorbidities that are commonly encountered. Patients with psoriasis should be educated regarding the impact of behavioral factors on their disease and the purported benefitsfrommodificationofthesefactors.Collaborationwith primary care physicians may allow for further reinforcement and greater modifications of these factors.