Most of the people I see with psoriasis have had it for longer than I have been nursing. They know their plaques better than anyone. They know which elbow flares first, which knee cracks in winter, and which treatments they have quietly stopped using.
That last part is the one I have learned to ask about first. Not "how is your skin?", but "what are you actually putting on it, and how often?" The honest answer is often a long pause.
The tube in the drawer
A patient once brought in a carrier bag of half-used tubes. Every one of them had been prescribed in good faith. Every one of them had been abandoned, usually within a fortnight, usually for the same reasons: too greasy, too slow, stains the sheets, takes too long before work.
We tend to talk about adherence as though it were a character trait. In my experience it is mostly about the morning routine. If a treatment does not fit into ten minutes between the shower and the school run, it will not be used, however good it is.
- Ask what they are using, how often, and where they keep it.
- Ask which areas bother them most, not just which look worst.
- Ask what stopped them using the last thing.
Ask about the routine, not the regimen
When I describe a plan now, I describe it as a morning, not a schedule. Which bit of the day, which room, how long it takes, what they will wear afterwards. It sounds trivial. It is the difference between a plan that is followed and a plan that is filed.
The man with the carrier bag still comes in twice a year. He brings one thing now, and he uses it.