Tag: psoriasis

Treat Type 1 Diabetes with a Plant-Based Diet? | NutritionFacts.org

Is it possible to reverse type 1 diabetes if caught early enough?

The International Journal of Disease Reversal and Prevention has already had its share of miraculous disease reversals with a plant-based diet. For instance, one patient began following a whole food, plant-based diet after having two heart attacks in two months. Within months, he experienced no more chest pain, controlled his cholesterol, blood pressure, and blood sugars, and also lost 50 pounds as a nice bonus. Yet, the numbers “do not capture the patient’s transformation from feeling like a ‘dead man walking’ to being in command of his health with a new future and life.”

I’ve previously discussed cases of reversing the autoimmune inflammatory disease psoriasis and also talked about lupus nephritis (kidney inflammation). What about type 1 diabetes, an autoimmune disease we didn’t think we could do anything about? In contrast to type 2 diabetes, which is a lifestyle disease that can be prevented and reversed with a healthy enough diet and lifestyle, type 1 diabetes is an autoimmune disease in which our body attacks our pancreas, killing off our insulin-producing cells and condemning us to a life of insulin injections—unless, perhaps, it’s caught early enough. If a healthy enough diet is started early enough, might we be able to reverse the course of type 1 diabetes by blunting that autoimmune inflammation?

As I discuss in my video Type 1 Diabetes Treatment: A Plant-Based Diet, we know that patients with type 1 diabetes “may be able to reduce insulin requirements and achieve better glycemic [blood sugar] control” with healthier diets. For example, children and teens were randomized to a nutritional intervention in which they increased the whole plant food density of their diet—meaning they ate more whole grains, whole fruits, vegetables, legumes (beans, split peas, chickpeas, and lentils), nuts, and seeds. Researchers found that the more whole plant foods, the better the blood sugar control.

The fact that more whole fruits were associated “with better glycemic [blood sugar] control has important clinical implications for nutrition education” in those with type 1 diabetes. We should be “educating them on the beneﬁts of fruit intake, and allaying erroneous concerns that fruit may adversely affect blood sugar.”

The case series in the IJDRP, however, went beyond proposing better control of just their high blood sugars, the symptom of diabetes, but better control of the disease itself, suggesting the anti-inﬂammatory eﬀects of whole healthy plant foods “may slow or prevent further destruction of the beta cells”—the insulin-producing cells of the pancreas—“if dietary intervention is initiated early enough.” Where did this concept come from?

A young patient. Immediately following diagnosis of type 1 diabetes at age three, a patient began a vegetable-rich diet and, three years later, “has not yet required insulin therapy…and has experienced a steady decline in autoantibody levels,” which are markers of insulin cell destruction. Another child, who also started eating a healthier diet, but not until several months after diagnosis, maintains a low dose of insulin with good control. And, even if their insulin-producing cells have been utterly destroyed, individuals with type 1 diabetes can still enjoy “dramatically reduced insulin requirements,” reduced inflammation, and reduced cardiovascular risk, which is their number one cause of death over the age of 30. People with type 1 diabetes have 11 to 14 times the risk of death from cardiovascular disease compared to the general population, and it’s already the top killer among the public, so it’s closer to 11 to 14 times more important for those with type 1 diabetes to be on the only diet and lifestyle program ever proven to reverse heart disease in the majority of patients—one centered around whole plant foods. The fact it may also help control the disease itself is just sugar-free icing on the cake.

All this exciting new research was presented in the first issue of The International Journal of Disease Reversal and Prevention. As a bonus, there’s a companion publication called the Disease Reversal and Prevention Digest. These are for the lay public and are developed with the belief I wholeheartedly share that “everyone has a right to understand the science that could impact their health.” You can go behind the scenes and hear directly from the author of the lupus series, read interviews from luminaries like Dean Ornish, see practical tips from dietitians on making the transition towards a healthier diet, and enjoy recipes.

The second issue includes more practical tips, such as how to eat plant-based on a budget, and gives updates on what Dr. Klaper is doing to educate medical students, what Audrey Sanchez from Balanced is doing to help change school lunches, and how Dr. Ostfeld got healthy foods served in a hospital. (What a concept!) And what magazine would be complete without an article to improve your sex life?

The journal is free, downloadable at IJDRP.org, and its companion digest, available at diseasereversaldigest.com, carries a subscription fee. I am a proud subscriber.

Want to learn more about preventing type 1 diabetes in the first place? See the related posts below.

Michael Greger M.D. FACLM

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October 22, 2024
The Largest Study on Fasting in the World | NutritionFacts.org

The Buchinger-modified fasting program is put to the test.

A century ago, fasting—“starvation, as a therapeutic measure”—was described as “the ideal measure for the human hog…” (Fat shaming is not a new invention in the medical literature.) I’ve covered fasting for weight loss extensively in a nine-video series, but what about all the other purported benefits? I also have a video series on fasting for hypertension, but what about psoriasis, eczema, type 2 diabetes, lupus, metabolic disorder, rheumatoid arthritis, other autoimmune disorders, depression, and anxiety? Why hasn’t it been tested more?

One difficulty with fasting research is: What do you mean by fasting? When I think of fasting, I think of water-only fasting, but, in Europe, they tend to practice “modified therapeutic fasting,” also known as Buchinger fasting, which is more like a very low-calorie juice fasting with some vegetable broth. Some forms of fasting may not even cut calories at all. As you can see below and at 1:09 in my video The World’s Largest Fasting Study, Ramadan fasting, for example, is when devout Muslims abstain from food and drink from sunrise to sunset, yet, interestingly, they end up eating the same amount—or even more food—overall.

The largest study on fasting to date was published in 2019. More than a thousand individuals were put through a modified fast, cutting daily intake down to about ten cups of water, a cup of fruit juice, and a cup of vegetable soup. They reported very few side effects. In contrast, the latest water-only fasting data from a study that involved half as many people reported nearly 6,000 adverse effects. Now, the modified fasting study did seem to try to undercount adverse effects by only counting reported symptoms if they were repeated three times. However, adverse effects like nausea, feeling faint, upset stomach, vomiting, or palpitations were “observed only in single cases,” whereas the water-only fasting study reported about 100 to 200 of each, as you can see below and at 2:05 in my video. What about the benefits though?

In the modified fasting study, participants self-reported improvements in physical and emotional well-being, along with a surprising lack of hunger. What’s more, the vast majority of those who came in with a pre-existing health complaint reported feeling better, with less than 10 percent stating that their condition worsened, as you can see in the graph below and at 2:24 in my video.

However, the study participants didn’t just fast; they also engaged in a lifestyle program, which included being on a plant-based diet before and after the modified fast. If only the researchers had had some study participants follow the healthier, plant-based diet without the fast to tease out fasting’s effects. Oh, but they did! About a thousand individuals fasted for a week on the same juice and vegetable soup regimen and others followed a normocaloric (normal calorie) vegetarian diet.

As you can see below and at 2:54 in my video, both groups experienced significant increases in both physical and mental quality of life, and, interestingly, there was no significant difference between the groups.

In terms of their major health complaints—including rheumatoid arthritis; chronic pain syndromes, like osteoarthritis, fibromyalgia, and back pain; inflammatory and irritable bowel disease; chronic pulmonary diseases; and migraine and chronic tension-type headaches—the fasting group appeared to have an edge, but both groups did well, with about 80 percent reporting improvements in their condition and only about 4 percent reporting feeling worse, as you can see below and at 3:25 in my video.

Now, this was not a randomized study; people chose which treatment they wanted to follow. So, maybe, for example, those choosing fasting were sicker or something. Also, the improvements in quality of life and disease status were all subjective self-reporting, which is ripe for placebo effects. There was no do-nothing control group, and the response rates to the follow-up quality of life surveys were only about 60 to 70 percent, which also could have biased the results. But extended benefits are certainly possible, given they all tended to improve their diets, as you can see below and at 4:00 in my video.

They ate more fruits and vegetables, and less meats and sweets, and therein may lie the secret. “Principally, the experience of fasting may support motivation for lifestyle change. Most fasters experience clarity of mind and feel a ‘letting go’ of past actions and experiences and thus may develop a more positive attitude toward the future.”

As a consensus panel of fasting experts concluded, “Nutritional therapy (theory and practice) is a vital and integral component of fasting. After the fasting therapy and refeeding period, nutrition should follow the recommendations/concepts of a…plant-based whole-food diet…”

If you missed the previous video, check out The Benefits of Fasting for Healing.

Michael Greger M.D. FACLM

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October 8, 2024
The Importance of Access to Treatment

Historically, racial and ethnic minorities in the United States have lived with long-term disparities in both access to health care and the quality of care that they receive. These differences are improving thanks to laws like the Affordable Care Act. Still, some minority groups have higher rates of illness and death from many health conditions than white people. And they’re still more likely to face prejudice and other barriers to health care.

These differences in care also include treatment for plaque psoriasis, a skin disease that causes an itchy, scaly rash. Research shows racial minorities see a doctor less often for the condition than white people. Here’s a look at some reasons for these disparities and how the medical community can help.

What Are the Barriers to Psoriasis Care for People of Color?

The issue of insurance

Walking into the doctor’s office is the first step in getting care for your psoriasis. But you may not be able to make this step without health insurance coverage. This is a problem that impacts racial and ethnic minorities more often in the U.S. For Americans under age 65, Asian Americans are just slightly more likely to be uninsured than white people, while Hispanics, American Indians, and Alaska Natives are more than 2.5 times more likely to have no coverage. The uninsured rate for Black Americans is almost 2 times that of whites.

Without coverage, access to health care remains out of reach for many people of color.

Getting the right diagnosis

Once you’re able to see a doctor, the next step in treating psoriasis is getting a proper diagnosis. That’s not always easy for anyone – psoriasis is often mistaken for conditions like eczema or dry skin.

But it’s doubly hard for people of color. During medical training, many doctors don’t learn how to spot psoriasis on nonwhite skin. While the condition tends to look bright red on lighter skin, it often appears purplish, brown, or reddish-brown on darker skin tones. Some people of color may also have thicker psoriasis plaques and more scaling across more areas of their bodies.

A biopsy (a study of a small skin sample under a microscope) helps doctors figure out if you have psoriasis. Dermatologists suggest the procedure when it’s hard to tell plaque psoriasis from other conditions. They say it can be especially useful for people of color.

Access to treatment

Once you have a psoriasis diagnosis, you and your doctor will work together to figure out the best treatment options. But for some, access to a doctor and treatment is another hurdle in getting care.

One issue is a lack of dermatologists in underserved communities. This can be an issue with a treatment like light therapy, which calls for visits to the dermatologist two or three times a week.

Meanwhile, if you’re a person of color in the U.S., finding a dermatologist of the same race or ethnicity can also be a challenge.

While dermatologists of all backgrounds are qualified to treat skin of color, you may prefer care from a doctor who looks like you. In one study, Black people who visited skin-of-color clinics said dermatologists there had better training to address their concerns. They also felt the doctors showed them more respect and dignity and were more trustworthy.

Reena Ruparelia is a Toronto-based psoriasis advocate who has lived with the condition for nearly 30 years. She’s South Asian and has often visited older, white male dermatologists. Ruparelia says she felt intimidated by these doctors and uncomfortable asking questions. Today, her dermatologist is of the same background and gender.

“I feel like it’s much easier to speak with her because I can share my problems. She took time to listen, but also understood my unique situation. I know that she’s willing to find a treatment that supports me.”

Another barrier to care for people of color is undertreatment. Research shows Black people with psoriasis are less likely than white people to get biologics. These are treatments made from living organisms. You take them as a shot for moderate to severe psoriasis. But health insurance doesn’t always cover this type of treatment. Or your insurance company could require you to try another medicine first before covering it.

How Can Doctors Improve Psoriasis Care for People of Color?

Diversity in medical training and research

More inclusive medical training can help doctors better diagnose and treat people of color. There are now efforts to include a broader range of skin tones in educational courses, textbooks, and other resources.

Lynn McKinley-Grant, MD, a board-certified dermatologist, professor of dermatology, and president of the Skin of Color Society, suggests students learn to diagnose skin diseases face-to-face with people from different racial and ethnic backgrounds.

“If you’ve trained in the middle of Minnesota and you haven’t seen any brown skin, then there should be an effort to make sure people take a rotation or two in places where there are varying skin types,” she says.

There’s also a lack of diversity in psoriasis research. Studies show psoriasis treatments are safe and work well in people of all skin tones. The problem is researchers have mainly studied them in white people with the condition. One review found that 84% of people who join clinical trials for psoriasis are white.

The dermatology community has started to recognize the need for more racial diversity in clinical trials. Researchers are making more of an effort to include a wider range of people in dermatology studies to understand how treatments affect different groups.

‘Let the patient educate you a little’

McKinley-Grant and other dermatologists stress the importance of doctors listening to people of color, both during diagnosis and treatment.

“If a patient tells you, ‘This is where I itch,’ ‘This is what’s burning me,’ and the doctor can’t see it, and their training has been focused on one skin type, then they have to listen and trust what the patient is seeing,” McKinley-Grant says. “Let the patient educate you a little.”

Ruparelia says many health care professionals have compassion fatigue, brought on by a packed schedule.

“After you’ve seen 10 people who are complaining about their skin, maybe you’re tired of hearing it. But if there’s a way to listen to every patient like it’s the first time you’ve heard it – take time to look at their skin and really give them a chance to express what they’re experiencing – I think it would make a huge difference.”

The Skin of Color Society also encourages doctors to ask their patients which treatment they prefer. For instance, some people of color will want to avoid phototherapy because it causes temporary skin tanning. Black women with scalp psoriasis may have unique concerns about hair texture, how often they wash their hair, and hair styling.

When both people of color and their doctors are aware of how psoriasis affects this group, they can better work together to find the best treatment.

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February 17, 2023
The Importance of Access to Treatment

Plaque Psoriasis: Why Equal Access to Treatment Is Essential

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February 17, 2023
How to Tell If Your Psoriasis Treatment Is Working

There isn’t a cure for psoriasis yet. But if you have the condition, there are lots of treatment options available. The trick is to find one that works for you.

Different people respond to different treatments, says Ashley Jenkins, MD, a dermatologist and adjunct professor of dermatology at the University of Missouri in Columbia. In some cases, a medication may be effective for a while and then stop working. That’s when it’s time to try something new.

If you have psoriasis, here’s what you need to know about your treatment plan.

What Should Treatment Do?

The goal of psoriasis treatment is to have plaques on no more than 1% of your body. If you have symptoms in other areas of your body, such as pitted nails or inflamed joints, treatment should decrease those, too.

“It can take up to 12 weeks for a medication to work completely,” says Dendy Engelman, MD, a dermatologist at the Shafer Clinic in New York City. “If your symptoms aren’t [mostly cleared] in that time, let your dermatologist know.”

Most doctors start treatment with topical medications, like corticosteroids, that you put directly onto your skin. “They have fewer side effects and can be effective, especially if you have mild to moderate psoriasis,” Jenkins says.

But if you have a lot of scaling on your skin, joint pain, or don’t get relief from topicals, your doctor may recommend another treatment. That could include light therapy or “systemic treatments.” These are oral or injected medications that treat inflammation throughout your body. You can pair systemic medications with topical treatments or use them on their own. They should start working within several weeks.

No matter what your treatment, your doctor will examine your skin to determine whether it’s working, says Joshua Zeichner, MD, a dermatologist and director of cosmetic and clinical research in dermatology at Mount Sinai Hospital in New York City.

If you have psoriatic arthritis, “your doctor may also recommend tests like X-rays to see if you have joint damage,” Zeichner says.

Biologic medications, a type of treatment that suppresses your immune system, can help. Your doctor may put you on them for a few months to get your inflammation under control, Zeichner says, then switch to a different treatment, like light therapy and topical medications.

What Happens if Treatment Doesn’t Work?

Touch base with your doctor right away,” Zeichner says, if you notice your psoriasis is getting worse, or you’re having a side effect linked to your treatment. These are signs it may be time to try a new type of medication. Sometimes combining treatments, like a biologic and a topical ointment or cream, will give you better results.

“You want to have a conversation with your dermatologist or doctor about what results you want and how aggressive you’re willing to be with treatment,” Jenkins says. There are dozens of different options, so don’t be afraid to speak up if you don’t like the plan your doctor suggests for you.

Having psoriasis means seeing your dermatologist or another member of your health care team regularly, especially when your symptoms flare up. Make sure your doctor is looking at all aspects of your health, not just your skin.

“Psoriasis is a sign of inflammation in your body. That inflammation throws off your body’s ability to regulate your immune system,” Engelman says. The impact on your immune system can cause or contribute to many other health problems, including joint damage. Tests to measure your blood sugar, blood pressure, and weight can help your doctor spot and treat psoriasis-related health problems before they cause serious problems.

Effectiveness isn’t the only reason you may want to change medications. If you don’t like or can’t live with the side effects, or find a medication too hard to use, you may want to switch. Depending on your health insurance, cost may also be an issue. Know that it’s OK to stop using a medication, even if it’s working.

“It’s important to be your own advocate,” Engelman says. The key is to be willing to try something else.

“Left untreated, psoriasis can have a major impact on your health and day-to-day life,” Jenkins says. “It’s important to team up with your doctor and keep trying new approaches until you find a solution that works for you.”

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January 17, 2023
How Treating Psoriatic Disease Has Changed

By Nilanjana Bose, MD, as told to Susan Bernstein

I am an adult rheumatologist, so I see patients who are 18 and above, with the whole gamut of rheumatologic conditions. Every patient I see is different. For patients with classic psoriatic disease, skin psoriasis symptoms often occur before their arthritis symptoms happen. These two conditions could even develop years apart for some people. But that’s not absolute. You can develop arthritis, or joint pain and swelling, first and then later develop psoriasis.

Patients typically first come to see us for their joint swelling. Usually, psoriatic arthritis causes a peripheral joint swelling. They’ll have swelling of your fingers and toes, which can look similar to rheumatoid arthritis (RA). We do an initial workup and examine their skin, too. If they have psoriasis, including nail pitting or psoriasis plaques, or if they have a family history of psoriasis or psoriatic arthritis, this may suggest that they may have psoriatic arthritis.

COVID: Hello, Telehealth

Once the pandemic hit last year, for the first couple of months, we had to go into retreat mode at our clinic. We really had to scramble to adapt. We moved quickly into using telehealth to treat our patients. We didn’t have some of the telehealth technology, but once we understood that there were resources out there, like telehealth portals and online platforms we could use, we started adopting them.

I think our patients also adapted to telehealth fairly quickly. There were some challenges with older folks. Some didn’t have internet access or found it harder to work out the logistics of telehealth. But for those patients, we were able to conduct regular telephone visits as well.

Telehealth came with its own challenges. We had to learn how to “examine” a patient over the internet. It’s not easy, and it’s not optimal for joint or skin conditions. But a telehealth visit is any day better than a patient missing their appointment altogether and not accessing medical care.

For follow-up visits, telehealth is easy and works well. You can check in with patients and see how they’re doing on their current medications. Some of my patients really prefer telehealth for the convenience. Again, it’s not optimal. We still encourage our psoriatic disease patients to come into the office. It can be tough to see everything using the camera.

Overall, telehealth has been a fun experience, but if a patient needs to be examined in person, I ask them to come in. We’re all still masked up, practicing social distancing, and taking every precaution. We are very committed to the whole aspect of infection control with our patients.

I’ve even seen new patients using telemedicine, especially during the worse phases of the COVID pandemic. If they were referred to me by another physician because they have psoriasis, I can do the initial consultation remotely, but I still try to have them come in. Just getting in and seeing a rheumatologist to begin your treatment is ultimately the most important step with psoriatic disease. You can establish a rapport with your doctor and get the information you need.

Biologics: Game Changer for Psoriatic Disease

Biologics have totally changed the way we manage this disease. Once you’re diagnosed with psoriatic arthritis, there are great treatment options out there. In the past, we had steroids, DMARDs (disease-modifying antirheumatic drugs), and TNF inhibitors, but now, we have IL-17 and IL-23 inhibitors, and JAK inhibitors, too.

Initially, we evaluate our new patients with lab tests and joint imaging and go over all of their symptoms. Some people will have milder psoriatic disease, and some will have more systemic symptoms. With younger patients, we may try to be more aggressive at controlling their disease, because they’re at greater risk for joint damage.

When we go over treatment options, it’s really a two-way, fluid discussion. I talk with my patients about all the risks and benefits of each treatment. If my patient is doing better after a few months, we talk about it and may re-assess the treatment plan.

It’s very rare to see people with psoriatic arthritis these days who develop chronic joint deformities. It may happen if someone was diagnosed a long time ago, before there were better treatment options, or if they were unable to access care before they came to us. The improvements are mainly due to advances in drug treatment, but also because people are more conscious of rheumatic diseases. They Google it. They just have more awareness of rheumatic conditions and that they need to see a rheumatologist.

We screen every patient. Some of them have a true inflammatory, psoriatic disease, while some do not. They may have osteoarthritis or fibromyalgia causing joint pain. Every patient deserves a thorough, complete examination. We want to diagnose these patients as early as possible to begin treatment to control their disease and prevent damage.

COVID and Other Infections: Take Extra Precautions

We were having this exact discussion with our patients before COVID, too. They are at higher risk for serious infections – not just COVID, but also other types of pneumonia and other infections. We had already been encouraging these patients to wash their hands often, take commonsense precautions, avoid close contact with sick people, and to get all their vaccinations.

Once the COVID vaccines became available, I told them, “Please get vaccinated and keep wearing your mask.” People who are on a biologic to treat their psoriatic disease are by default more cautious. For new patients who were just starting their biologics, I advised them on how to take precautions to prevent infection. We told many of our psoriatic patients, “Stay home as much as you can right now, and avoid close contact with others.” Patients do listen to this advice because they trust us as their doctors.

Making Psoriatic Patients Feel Safer

Always have a backup plan with telehealth technology! Also, I have encouraged all of my patients to enroll in our online patient portal, so we can stay connected. They can send me messages, I can update their prescriptions, and we can share test result with them.

Technology is a beautiful thing. We need to use it to the fullest advantage in modern medical care. Technology can make it easier to stay in touch with patients with psoriatic disease, who need ongoing care. But some patients may not be used to telehealth, so they can experience some frustration at first. Be patient, take your time to learn to use these tools, and help your patients adapt. Don’t give up if something doesn’t work right at first.

Face-to-face interaction is still very important when you are working with patients with psoriatic arthritis. It can be difficult to form a new patient/doctor relationship without any in-person component.

After they’re diagnosed, some patients continue to see me virtually, and it seems like we are really able to get to know each other well. Telehealth is a safe, secure environment for patients. They’re in their home or office, or even in their car. Sometimes, when I’m talking with a psoriatic patient over telehealth, I see them taking notes. That’s good! Some people find that they’re less anxious when they’re in a telehealth appointment instead of being in their doctor’s office.

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December 19, 2022
The Future of Autoimmune Disorders: Psoriatic Disease
By Rebecca Haberman, MD, as told to Stephanie Watson

Psoriatic disease isn’t curable, but it is becoming more treatable. While not everyone can achieve clear skin or pain-free joints, things are improving with each new drug that we have to treat them with.

Our stable of drugs is growing exponentially, which is really important where one particular medication doesn’t treat everyone with the disease.

The diagnosis of psoriatic disease has also come a long way. It was under-recognized for a long time. It’s only been in the past 10 to 15 years that people have really begun to pay attention to it. Since then, it’s become easier to diagnose it.
Biologic Drugs

Psoriatic disease can be tricky to treat because it shows up in so many ways. Inflammation can affect:

Your joints

Where tendons and ligaments connect to bone (called the entheses)

Your fingers and toes

Your spine

Your skin

Your nails

While we think of psoriatic disease as one condition, it is possible that the diseases that make it up are a little different.
So it makes sense that we need different medicines to treat it. Older disease-modifying antirheumatic drugs (DMARDs), like methotrexate, target overall inflammation to slow the disease and prevent joint and skin damage.

A newer group of drugs called biologics has more specific targets within the immune system. They block certain proteins in your immune system that trigger inflammation. There are a growing number of these treatable targets, including ones called:
Trial and Error

No test can show which of these targets is best suited for you. So your doctor won’t know which of these drugs will work best against your disease until you try it.

The severity of your disease and which parts of your body it affects most (skin, joints, etc.) will help determine which medicine the doctor gives you first. For example, IL-17, IL-23, and IL-12/23 inhibitors seem to work especially well against plaque psoriasis.

Also important is whether you have other medical conditions that might make one biologic riskier for you than another.

But overall, prescribing these drugs can involve some trial and error.

The ultimate goal is to put you into remission, where you have no symptoms. But if you’ve lived with the disease for a long time, less pain, fewer swollen joints, and fewer skin plaques may be more realistic things to shoot for.

The Future of Treatment

Today’s treatments for skin lesions are more effective than the ones available for joint inflammation. Thanks to the wide range of topical medicines, biologics, and other therapies, we can get almost 100% clearance of the skin much easier than before.

It’s hard to achieve that with the joints. So we’re trying to come up with new ways to make people feel better.

The outlook for joint involvement may change as companies discover new drugs and they become available.

Drug companies are on the hunt for new ways to block inflammation in psoriatic disease. Some ideas involve combining biologics or targeting more than one inflammatory pathway at once. For example, a drug in development, bimekizumab, targets two inflammatory proteins, IL-17A and IL-17F. In studies, it helped some people’s symptoms improve by as much as 90%.

Researchers are also working on more personalized approaches to diagnosing psoriatic disease.

The ultimate goal is to get to precision medicine, where I can do a blood test and say, “This is how the patient is presenting and this is the medication that’s going to work.”

Rebecca Haberman, MD is a rheumatologist with NYU Langone Health in New York. She’s also a clinical instructor at NYU’s Grossman School of Medicine.

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December 19, 2022
Being a Young Adult With Psoriatic Disease

By Amber McKnight, as told to Shishira Sreenivas

The first time I started to notice white flakey patches, it kind of almost burned a little bit on the back of my ear. It was March 2019, and I was 24 at the time. I was working at Disney World and I had to wear a hair net and a fun hat. I thought it must be the sweat and irritation from wearing them because the hat and net sat right on that spot. I just thought they were rubbing me the wrong way.

I went to urgent care and showed it to them. I was hoping for a cream or an ointment to put on it. They gave me topical steroids and told me it should go away in a bit. I thought, “great!” I had eczema for a while so I thought it might be a flare-up. But I decided to keep an eye on it.

The steroid cream helped. The patches went away.

In 2020, I started physical therapy school in Atlanta, GA. By the end of the year, the eczema-like patches started to pop up all over my body: stomach, back, breasts, arms, and legs, especially in the crooks of my elbows and the backs of my knees. However, the patches from my neck up were the most severe — the crown of my head, behind my ears, and the nape of my neck.

But every time I showed it to a doctor, they just kept brushing it off. They said, “oh that’s just eczema.”

Psoriasis Can Affect Your Quality of Life

I looked like a scaly lizard. And I was both embarrassed and frustrated. Basically, you could see everything, so I had to cover up everything. The summer heat in Atlanta did not help the situation, either.

For school, especially during PT labs, I had to wear my hair up and have a mask on. This meant everyone could see my scaling, plagued skin. They could see huge chunks of white stuff fall off of my skin. In fact, I had some people come up to me and say I had rice in my hair.

PT school required a lot of hands-on touching and therapy. For the lab, we would have to take off our clothes. I simply couldn’t. It was so uncomfortable for me. So I wore full-length leggings and a sweatshirt in the middle of summer. Plus, the patches were either flaking, itching, or painful. I started to skip some of my labs.

I have had a ton of skin issues in the past, but these patches looked different and new to me. It looked similar to the patches I had in 2019. It just couldn’t be eczema. These patches had a different texture, largely connected, were very flakey, and peeled a lot. It was awful.

At this point, I decided to see a dermatologist.

Getting a Psoriasis Diagnosis Can Be Tricky

I went to a number of doctors – primary care doctors and dermatologists. They all said it didn’t look good or it was just eczema. One even sent me to a wound care specialist. And they said they couldn’t fix it. Some of the spots were starting to get infected with staph infections.

At this point, I was going in for two appointments a week for a month. I tried a few medications, but nothing helped.

One dermatologist decided to do an allergy test to see if I was reacting to something. When I went back to have my results read, it was a different dermatologist from the one I normally saw. She happened to be covering for the other doctor.

She took one look at my scalp and said, “that’s 100% psoriasis. I have no idea why no one has said this to you.”

They biopsied a couple of different spots. Some were eczema, but others, it turns out, were psoriasis. The type I had was called guttate psoriasis.

It can happen after you’ve had strep throat. And I commonly get strep throat and staph infections. It’s what apparently caused the confusion about differentiating eczema from actual psoriasis. The patches on my scalp, however, were plaque psoriasis.

I finally got a diagnosis in January 2022.

Find Ways to Control Stress and Manage Psoriasis

After I was diagnosed with psoriasis, they put me on injection medications, which helped a lot. All of the doctors said it was important to manage stress.

I didn’t realize I was stressed. I mean, I was working at Disney World when it all started. I thought it was the happiest place on Earth. But I took some measures to change a few things about my lifestyle.

The big thing I did that helped was I stopped using any lotion or cream with petroleum jelly in it. I believe it caused some of the irritation. I swapped to cleaner products and it has made a world of difference.

I regularly feel my scalp or my elbows for psoriatic patches. If I feel patches beginning to form, I immediately increase my sleep, drink more water, and figure out what might be stressing me out. I basically pulled back from constantly being on the go. Now, I love to take long nature walks. It helps me stay calm.

I also think I tend to scratch my arms more when I’m stressed. I think it’s my body’s subconscious reaction to distract me from whatever is stressing me. But scratching makes psoriasis worse. So, I do whatever it takes to stop myself from scratching. I wear long sleeves or a jacket. Sometimes, I’ll just sit on my hands and remind myself to stop it.

But overall, once I started treatment and made changes to my lifestyle, my skin has been relatively calm. If I notice the patches getting worse, I’ll see a doctor.

Find a Good Support System

Dealing with an autoimmune condition like psoriasis in your 20s can be hard. If I could talk to my younger self, I would say, “It is ok. You’ll be fine. Stop scratching, stop looking, and stop obsessing.”

Obviously, it’s hard to deal with it but it’s important to stay calm, take a step back, and reassess the situation.

It’s important to find a good support person or system. I was lucky to have a really good friend with me in Atlanta when all of this happened. She always let me vent.

It helps to have someone go to the doctor with you because it can be intimidating. I’ve had times when I lost hope. It’s always good to have someone who knows what’s going on or who can just be there for you if you start to shut down or spiral.

And keep advocating for yourself. At the end of the day, you know your body more than anybody else.

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December 16, 2022
Psoriatic Disease: An Autoimmune Disease Expert’s Point of View
By Brett Smith, DO, as told to Rachel Reiff Ellis

Psoriatic disease is a condition you have your whole life. Skin plaques are the main symptom, but many people also get joint pain. It requires lifelong observation by medical professionals. Although there isn’t a cure for psoriatic disease, there are great medications to help control the symptoms.

The news that you have it can sometimes come as a surprise. You may see your primary care doctor because you’re having joint pain, but be unaware of plaques because they’re hiding on your backside, scalp, chest, or groin.

If your psoriasis is mild enough, a primary care doctor should be able to prescribe topical steroids or other topical medications to help, depending on how much of your body is involved.

But many people with psoriasis require more than just topical therapies, especially if they have joint pain and swelling. If your psoriasis care goes beyond the scope of a primary care doctor, you’ll need to see other specialists to get the treatment you need.

Your Health Care Team

After you’re diagnosed, you’ll primarily see a dermatologist. If you have joint pain, you’ll see a rheumatologist. As a rheumatologist myself, I get referrals from primary care doctors, dermatologists, and sometimes pediatricians.

About 30% of people with psoriasis go on to have joint inflammation. On average, that inflammation comes about 10 years after a psoriasis diagnosis. When people with psoriasis have joint pain, a dermatologist refers them to me. A collaborative approach with a dermatologist gives people the best care.

You may have to see other specialists along the way, depending on how your psoriatic disease affects you. There are people with joint inflammation who get inflammatory eye problems or intestinal problems later. You’ll need an eye specialist or a gastroenterologist to help you with that.

Make the Most of Your Appointments

When you meet with your doctor, especially for your first visit, come with questions and details that cast a wide net. Talk about any symptoms you’re having, even if they don’t seem related to psoriatic disease. Your doctor will want to know if they should look anywhere else for information, like your eyes, gastrointestinal tract, or nails. If you’re having joint or back pain, ask about an evaluation by a rheumatologist.
Find out about the specific medications you’ll be taking:

How often will I take it?

How will I take it?

What are the possible side effects?

What are the goals of treatment?

How soon should I expect to see a difference in my symptoms?

Treatment will vary, depending on your diagnosis and condition. But in general, everyone with joint inflammation from psoriatic disease should be taking medication unless there’s a specific reason that it would be risky for you. Most people are going to feel at least 50% to 75% better within the first 3-6 months of therapy, and even better beyond that.

Remission — meaning no joint swelling, no pain — isn’t possible for everybody, unfortunately. But we shoot for that goal, because if you’re that person, we want to have you there.
Stay in Touch

Check in with your doctor every 6 months or so. When psoriatic disease affects the joints, it’s chronic and can be quite aggressive in terms of damage and chronic pain, so you want to make sure your joints are OK.

Aside from that, you should make a visit to your doctor if your pain gets worse, you notice a swollen joint, you feel stiffer, or your back hurts more.

Your doctor will also want to know if you have inflammation or pain in one or both of your eyes, or if you have diarrhea or blood in your stool. This could be a sign that your disease is affecting more of your body. In that case, you might need a new therapy that can treat all those things better.

Don’t underestimate how aggressive the disease can be. You’re more likely to have problems from the disease than you are from the medications you take. Psoriasis can come on at a fairly young age — many people are between 20 and 30 years old when they find out they have it. So that can be a long time for the disease to be active in your body.

We can always change therapies and find one that works best for you.

The goal is to find medication that will help you be comfortable. I know that sometimes the medication can seem intimidating or scary, but we have a lot of experience with them. These medicines can really help.
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November 21, 2022
Feature: Answers to Your Psoriasis Questions

If you’ve just been diagnosed with psoriasis, you may have a few questions about it. Here are answers to some of the more common ones people ask.

What’s the difference between psoriasis and eczema?

To an untrained eye, these conditions may seem alike. But while they’re both skin diseases, they’re not the same. In fact, “They’re 100 percent different,” says Whitney High, MD, an associate professor of dermatology and the director of the Dermatopathology Laboratory at the University of Colorado Anschutz Medical Campus.

Psoriasis doesn’t usually affect children, High says. But eczema, or atopic dermatitis, is a childhood disease. Eczema also tends to be itchier than psoriasis. Only about a third of people who have psoriasis say they have itchiness.

And the conditions are likely to appear in different places. Eczema often shows up on kids’ faces and buttocks and the inside of their knees and elbows. Psoriasis isn’t typically found in those places.

Plus, “The same person that has childhood eczema doesn’t get psoriasis. And the person who has psoriasis as a young adult usually didn’t have childhood eczema,” High says.

What causes psoriasis?

Doctors aren’t exactly sure. “I get that a lot of times; ‘Why do I have it?’” says Melvin Chiu, a doctor of dermatology at the David Geffen Medical Center at the University of California, Los Angeles. “I don’t really … have a good answer for that. It’s a big mystery, I think, right now.”

Chiu says researchers believe the two main culprits behind psoriasis are your genes and your environment. Scientists are still tracking down which genes are to blame, but they think that about 1 out of every 10 people got at least one of the genes that can lead to psoriasis from their parents. But only about 3% of people who have those genes get psoriasis. That’s where the environment comes into play.

Researchers think things like infection (especially strep throat), an injury to the skin, certain medications, smoking, and other things may trigger the condition.

What’s the cure?

“There is no cure at this point,” Chiu says. “It’s a chronic condition. … You may have times when it’ll be worse, and there may be times when it’ll get better.” He also says there may be some lucky people in whom it’s very minimal. Or it gets better and doesn’t get worse again. But, he says, most people “can expect it will be persistent.” Treating it can make it better. But when treatments stop, it often comes back.

“There are some really excellent treatments,” he says. “There are newer treatments in the pipeline, and many treatments [that] are available currently … work very well.” Those treatments don’t cure the disease, he says. “But they significantly improve the disease and make [people] feel better.”

What are the treatments?

The most common ones are medicines prescribed by your doctor. They include foams, solutions, ointments, or creams, called topicals, that you put on your skin, along with drugs you take that affect your whole body. Your doctor also may recommend light therapy.

“Consult with a board-certified dermatologist, and they’ll be happy to discuss any and all of these options, including over-the-counter options when they’re appropriate,” High says.

What works for one person may not work for another. That’s why you and your doctor need to talk about what your treatment plan should be.

Chiu says that with the treatments available now, “we can get skin a lot better.” He says that 20 to 30 years ago, psoriasis patients had much worse options and many fewer ones than people do now. “I tell people, it’s kind of an exciting time in psoriasis.”

Can the sun help?

Some research says a little every day can help with your symptoms. But, as always, you have to be careful not to overdo it. A sunburn may lead to a flare-up.

Is psoriasis contagious?

You can’t “give” it to anyone, and no one can “catch” it from you.

“You can touch psoriasis all day long,” High says. “As a dermatologist … I see at least one person if not a few people with psoriasis [every work day], and I don’t have it.” High adds, “My wife doesn’t have it. I didn’t bring it home. I don’t do special laundry. I don’t undress in the garage or anything like that.”

What is psoriatic arthritis?

Up to 30% of people who have psoriasis get this condition as well. It causes inflammation and swelling in your joints that can lead to pain and stiffness.

If you have psoriasis and feel any discomfort in your joints, tell your doctor. It’s important to treat it quickly so your joints don’t get damaged.

Are any other conditions linked to psoriasis?

Research is still under way, but scientists think people with psoriasis and psoriatic arthritis may be more likely to have other serious diseases.

“There’s an increasing appreciation that psoriasis can manifest in other ways: increased risk of cardiovascular disease, increased risk for obesity … a natural risk for diabetes,” High says. “It might impact your life in ways that you can’t even really fully predict now.”

Besides cardiovascular diseases and obesity, psoriasis also has been linked to cancer, Crohn’s disease, depression, and liver disease, among others.

That’s even more reason to stay in touch with your doctor and make sure you have a plan.

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October 24, 2022
Living Your Best Life With Psoriatic Arthritis

By Brenda Kong, as told to Shishira Sreenivas

I developed psoriasis and psoriatic arthritis (PsA) at the same time when I was 12 years old. I’m 41 now. My psoriasis diagnosis was easy, but the PsA diagnosis was not. Because I played sports as a teenager, doctors attributed my aches and pains to that. Unfortunately, I wasn’t fully diagnosed until I was 21.

By then, we couldn’t turn back time on all the joint mutilation I already had. For example, something that had bothered me since I was 12 was my middle finger joint on my left hand. I said, “Hey, this is really bad. It shouldn’t be this swollen for this long.” But I kept being told, “You’re playing too much sports,” and “If you rest it and ice it, It’ll be fine.”

It’s not fine. It became my first mutilated joint. Now I literally have full-body arthritis, from my jawline all the way down to my toes.

The Hardest Time

My late teens into my early 20s was the hardest time for me. When I was a college student, 18 years old, I tried out for the school’s volleyball team. But because of my pain, I never got to play. The stress I had after starting college was horrible. It all just went from 0 to 60. And the nature of PsA is that it responds to stress.

Most of my joint damage happened when I was between the ages of 18 and 20. At times, I couldn’t get out of bed. I couldn’t go downstairs without gripping the handrails. I wanted to go clubbing, wear heels, and all of that. I didn’t get to do that.

When I was around 21, both my psoriasis and PsA flared up and I was bedridden for 2 months. I had to use a wheelchair or cane to move. I went in and out of the hospital around three times in 3 weeks because we couldn’t regulate my body temperature. The inflammation was everywhere. I couldn’t even make a fist.

At the time, I very much hated my life. I’d never even heard of a rheumatologist until finally, a dermatologist who was treating my psoriasis urged me to see one.

Find the Right Rheumatologist

I think my biggest regret was not getting to a rheumatologist sooner. I could have taken care of a lot of the joint pain that later on became damage.

In fact, my advice for anyone else going through this would be to see a rheumatologist — not just any doctor — as soon as you can. Also, be consistent about seeing your doctor.

I actually went through three rheumatologists before I found one that really clicked. The first one, who diagnosed me, I just didn’t like very much. The second one didn’t take my insurance. But the third one, I loved. He was my rheumatologist up until I lost my insurance a few years ago and had to switch.

The first thing that rheumatologist prescribed for me was a steroid. It was a very strong steroid.

The first time I took it, I fell asleep on the couch because I was so tired. When I woke up, I sat up on the couch, then put my legs down and stood up. I didn’t even register how easy it was. The drugs had reduced my inflammation that much. I didn’t take deep breaths and brace myself as I usually did. I thought, “Oh my God! What just happened?”

But my biggest improvement didn’t come until a year and a half later, when my doctor started me on biologics.

Try Different Treatment Options

The first time took a biologic for PsA, I was around 24. I’d just bounce out of bed. I was like, “What are we doing?” “Where are going?” I just wanted to go do something, because I was able to. My friends and I went traveling. We went to Las Vegas six times in one year just to do it. My skin was good and my joints were amazing.

This was my first biologic for the arthritis, but my third overall. I’d tried others for my skin only and my joints only. But this worked for both. I went from being covered in psoriasis, barely able to walk, using a wheelchair, and taking 1,800 milligrams of ibuprofen daily to not needing painkillers at all.

I’ve used a number of biologics since. Funny enough, I’m now using that first biologic I took for my psoriatic arthritis. I got back on it 3 years ago when my arthritis was getting pretty bad again.

I’ve also tried complementary treatments like yoga and meditation in addition to the biologic. Also things like diet — losing weight just gave me a lot less to carry around.

Even on a biologic, you can have a flare-up. And there’s always a fear that your treatment will stop helping you. That does happen with biologics. After a certain point, it may lose efficacy and you have to figure out a new treatment.

If this biologic ever stops working for me, I would take the steps to try to find another one. I know how bad my body can be and how painful it can be without medication.

Manage Your Stress

Stress is a major contributor to PsA. So mental health is a big thing for me. Now when I have a flare-up, I actually relax a lot more. I know that if I stress out about it, it’s going to be worse for me.

I do mental health exercises now. This helps keep me from overthinking, going down rabbit holes, and stressing myself out like I’ve done before.

When I was in my early 30s, I told myself that I couldn’t keep doing that. So I started therapy and made managing stress part of my routine. I started doing calming meditation exercises. I started doing yoga. Even now, when I feel really stiff, I sit and do some light yoga poses until I can function a little bit more.

It’s impossible to be stress-free. But now I do things to help manage it, and I have a much better mental outlook.

Try Activities That Make You Happy

In my early 20s, I couldn’t cook because my hands hurt so much. Now I can. I do hand exercises to keep my hands loose and happy.

I cook massive amounts of food when I need to feel better. I just get in the kitchen, I turn on music, and I don’t talk to anyone. No one talks to me. Everyone in my house knows this. I stay in the kitchen and get all my frustrations out, and it always turns out beautifully. I redirect so much of my emotion and stress into cooking.

The psoriatic arthritis life is a roller coaster, for sure. There are going to be many highs and there are going to be many lows, unfortunately. You just have to focus on the highs, and you’ll get through the lows.

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October 20, 2022
Should You Stay or Go? When to Change Treatments

Treating psoriatic arthritis (PsA) isn’t like treating strep throat. You don’t just take one medicine for a few days and feel better. PsA is a complex, chronic disease that stays with you and affects many parts of your body — skin, joints, nails, heart, and lungs.

Many medications slow PsA and relieve symptoms, but the first treatment you try won’t always be the right one for you.

“There is no one-size-fits-all, and there is no one medication for psoriatic arthritis,” says Saakshi Khattri, MD, assistant professor of dermatology and rheumatology at the Icahn School of Medicine at Mount Sinai in New York. “So often there are patients who do not respond to their medication.”

There are a couple of reasons you might need to switch to a new treatment, says Ethan Craig, MD, assistant professor of clinical medicine at the University of Pennsylvania and rheumatologist at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.

“One is intolerance — the patient has a side effect of some sort. The second is ineffectiveness. Either the medication doesn’t work in the first place, or it works for a period of time and then it stops working,” he says.

When your medicine doesn’t tame your symptoms, it’s time to regroup with your rheumatologist or dermatologist and talk about other treatment options.

Signs That It’s Time to Change

The clearest signs that you need a medication switch is a new flare-up of symptoms.

Worsening joint pain and stiffness, increased fatigue, and sudden trouble doing activities that were easy for you are some of the most obvious symptoms. More subtle signs like difficulty sleeping and mood changes also suggest the medication you’re on isn’t controlling your PsA well enough.

If you’ve just started on a treatment, you do need to give it time.

Sometimes you can have a partial response — maybe the swelling comes down in some of your joints but not in others. Then your doctor might suggest that you wait it out for 4 to 6 months to give the drug more time to work. During that time, steroids or nonsteroidal anti-inflammatory drugs (NSAIDs) can help bridge the gap until your medication kicks in.

Once you’ve been on a treatment for several months with no improvement, or if you’re no longer getting relief from a drug you’ve been taking for a while, “that’s often an indication that we need to think about switching things up,” Craig says.

Advice for Switching Meds

PsA treatment comes in many forms. Often anti-inflammatories and conventional disease modifying drugs are used (DMARDS). Biologic DMARDS are also often used; they target different pathways in the immune system. There are other options for treatment as well, including targeted synthetic DMARDS and newer oral agents.

Your doctor will take a few factors into consideration when recommending your next step, including:

Your symptoms. PsA causes a variety of symptoms. Your choice of medication may hinge on the type of symptoms you have, how much they bother you, and which drug targets them best.

For example, one of Craig’s patients worked at a ticket window. “Because he had to hand out tickets, he was very self-conscious about the appearance of his nails,” Craig says. “He was willing to be on a drug that helped his nails, even if it didn’t help his arthritis.”

The drug’s side effects. Each type of medication comes with a set of side effects, which you need to balance against its benefits. For example, methotrexate can irritate your stomach, while biologics increase the risk for infections. It’s important to think about which side effects you can tolerate and which ones you definitely don’t want.

How you take the drug. Many PsA meds come as an infusion or an injection. If you’re not a fan of needles, you might prefer a pill.

What other conditions you have. Methotrexate can damage your liver. NSAIDs are linked to heart problems. So if you already have liver or heart disease, these medications may not be safe for you.

Your insurance coverage. Ultimately, your insurance company could decide which treatment you get next. “The sad fact of the matter is that our choice of medication is often substantially constrained by insurance approval,” Craig says.

Some insurance companies will expect you to try a certain drug first and prove it doesn’t work before they’ll let you switch to the medication that you and your doctor want to use.

How to Ask Your Doctor for a New Treatment

You might already see your doctor every 3 to 4 months if you take medication. During those visits, the doctor can examine your joints, do imaging tests, and check your lab test results to see whether your PsA is under good control.

But tests don’t always tell the whole story. Your point of view is important, too. Let the doctor know if you’re having any problems with your medications, including side effects or breakthrough symptoms.

If you’re not due for a visit yet, call the office or send your doctor an email about your concerns through the patient portal.

Don’t be afraid to speak up. “A lot of patients are hesitant. They don’t want to take up the doctor’s time,” Craig says. “It’s helpful for us if they come in. I hate to see someone suffer for months. And it’s often easier to intervene earlier in the course of the disease, when things are less active.”

If your doctor isn’t on board with you switching medications, don’t be afraid to push back to get on the right treatment. “Sometimes it’s a matter of miscommunication,” he adds. “We need to be on the same page as to what the expectations are, what we’re treating, and what effect we expect.”

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October 17, 2022
My Journey to Treating With a Biologic

By Julie Greenwood, as told to Keri Wiginton

Biologics gave me my life back. Once I took the medicine, my skin became human again. And I changed from a person who couldn’t function at all to someone who’s been able to work for years.

I tried my first biologic in 2003. But that’s not where my story begins.

When my psoriatic disease started in 1991, my dermatologist put me on methotrexate right away. That’s a drug used to treat joint inflammation, but I didn’t know anything about it. I was only 23, and they gave me this pill with no mention of side effects. It made me so sick that I decided to stop taking it.

But I have severe psoriatic disease. Over the years, it continued to progress. My fingers swelled up like sausages. I couldn’t step off a curb unassisted or stand up straight. I was hunched over like a little old woman because my back hurt so bad.

My skin symptoms got worse, too. My psoriasis started in my scalp, then showed up in my ears and went down my back to just below my knees. My skin was so tight that just moving would make it crack and bleed.

It felt like I was wearing reptile skin.

Years of Frustration

I tried all kinds of things to make my skin more human. I even ordered a product from the back of a magazine. It was banned in the U.S, and it burnt my skin. But it also got rid of my plaques. I have scars under my breasts from it.

But I was desperate. I would’ve put acid on my skin if it would’ve worked.

I also tried messy steroid creams. But I could only get them with a prescription. My doctor would give me this tiny little tube for a whole month. I have psoriasis all over my body, so that tube would last maybe a few days.

I also tried something called Goeckerman therapy. They put me in a UVB-light machine in the mornings. Then they’d slather me in coal tar and cover me in plastic wrap and I’d sit in a room all day. And this was before we had smartphones to entertain ourselves.

That worked, but only for a few weeks.

Then, when I was 31, I got pregnant. My symptoms went into complete remission. I hoped my body would forget I had psoriatic disease. But everything started up again a couple of months after my daughter was born.

Finding a Biologic

I thought that if pregnancy could put me into remission, there must be something that could help me feel better. I was determined to find that treatment. My dermatologist put me in a study where they gave me a diabetic medicine. It was amazing. But then they changed me to a different study drug, and my symptoms came back.

I went back to my doctor and asked, “What else do you have?” Then he told me about a biologic drug. At first, I said no. I wasn’t interested in giving myself a shot. I was terrified of needles.

That’s when my doctor gave me some tough love. He said I’d have to go to someone else if I wasn’t willing to try it and that there wasn’t anything else he could do for me.

That sounds really harsh when I say it out loud. But I understand why he said it like that.

My doctor went over all the pros and cons of biologics. I didn’t have the same kind of fear about this drug that I did about methotrexate. I think the main reason was because I’d gone through so much pain during the previous 10 years. What’s more, I’d had those months of remission, so I knew what it felt like to feel good again.

When My Symptoms Improved

I found it very hard to give myself that first shot. But I did it in my doctor’s office. A couple of days after that first shot, I remember saying to my parents, “I might be crazy, but I think I’m starting to feel better.”

Within a couple of weeks, my skin started to clear up. And it was completely clear after about 6 weeks. But what was really noticeable was that after only 2 weeks, I could walk like a normal person. My constant pain eased.

Biologics helped me do everyday things that people without psoriatic disease might take for granted. I could do normal mom things, like pick my daughter up and put her in the sink to take a bath. Not long after that, I could lean over to put her in the bathtub. I could bend and stretch my body without cracking my skin.

And then there were my sheets. I’d always treated them as disposable. I’d bleed on them, and all the stuff I put on my skin would rub off. I could only keep them for a few months before throwing them out. Now I only have the best sheets.

Considering Side Effects

I know that biologics raise your odds for infections. But I wasn’t really worried about that. I was more concerned that’d I’d get cancer or have a seizure. My doctor reassured me and helped me feel better.

My teenage daughter also has psoriatic disease and is on a biologic. She was very comfortable starting her treatment, partly because I’ve been on them for so long. Plus, I do a lot of advocacy work. I’m always telling people they should be more afraid of the progression of psoriatic disease than of the biologics themselves. She’s heard that so many times that she knew not to let her disease go untreated.

Now when I look at it, my thought is: If I do have a higher chance of health problems after taking a biologic for so long, at least I’ve boosted my quality of life for all of these years. It would have been so poor without the medicine. That wouldn’t have been a life worth living.

Changing Biologics

I’ve been on a different drug for a little more than a year now. I’m always afraid of trying a new medication. It’s the most stressful part about my treatment. I’ve had pretty serious allergic reactions to infusions with biologics before.

My doctor is very cautious about changing my medicine. They only do it if I stop responding to treatment — my joint inflammation gets worse, for example. When I do make a switch, I’ll ask my husband to check on me through the night.

Going Forward

Only recently has my disease made it so I can’t keep working. I was really hard on myself about that. I felt like a failure. But then I remembered something: I worked for three decades beyond my diagnosis. I have to stop and remind myself of what a major achievement that is. I’m actually a badass who’s pretty amazing.

I still have a moderate level of pain that’s only gotten worse with my age. I’m 52 now. But it’s unbearable to think about what my life would’ve been like without these drugs. I’ve gone through hard times, even recently, with my mental health. But if somehow all of the biologic companies shut down tomorrow, I don’t know what I’d do.

It takes a lot of effort and energy to live with psoriatic disease. And it’s because of this medication that I can do it. I’m so incredibly thankful.

Julie Greenwood is an advocate and volunteer with the National Psoriasis Foundation, National Patient Advocate Foundation, and Patient-Centered Outcomes Research Institute. She lives in Cary, NC, with her husband, Scott, daughter, Nora, and their two puggles, Molly Malone and Cassie.

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October 10, 2022
Finding Success When Managing Psoriatic Disease

By David Rosmarin, MD, as told to Stephanie Watson

Treating psoriatic disease is very different from what it was 10 or 20 years ago.

We have a lot of great treatment options that are extremely effective. So we’re usually able to meet a vast majority of people’s goals.

When someone first comes to me with a diagnosis of psoriatic disease, I’m very interested to learn what their goals are. It’s important for them to communicate to me what they want to accomplish with their treatment, and how quickly they want to get there. That way, I can deliver the right treatment to them.

So I ask questions like:

How quickly do you need clear skin? Do they have a big event coming up? Do they want to be clear for a vacation? Whether they need to see a response in a month, or they aren’t interested in a quick fix will help guide the treatment we choose.

For example, if somebody wants a very rapid response, then we can use a medicine that suppresses the immune system, or a biologic that works quickly. When we do that, on average, people can see a 50% improvement in their skin within 2 weeks, and a 75% improvement within a month.

How clear do you want it? Do they want to have their legs clear so they can wear shorts in the summer? Do they want to get their scalp cleared so they don’t have to deal with flakes? Do they want to get rid of the itch?

We also talk about their nails if they’re a concern. That’s helpful to know upfront, because nails can take longer to clear than skin.

What is your treatment tolerance? Biologics are targeted treatments that have revolutionized how we help people with moderate to severe psoriasis. The ones we use to ease inflammation come as injections or infusions. So, are they fearful of needles? If so, it may be better for them to go on a treatment that involves an injection once every 3 months, rather than once a week. We also have other alternatives like oral medications, phototherapy, and topicals.

Overall, the side effects of biologics aren’t too bad. Infection is a little bit more likely, as is a reaction near the injection site. But compared to the first biologics we had, the newer ones work better with fewer injections, and they don’t hurt as much.

They’re safer, too. For example, newer biologics don’t raise your chances of cancer.

Still, it’s important for me to know a person’s concerns and their medical history before I prescribe them a drug.

Are your joints involved? I ask all of the people I treat if they have joint pain or stiffness. If they do, they might have psoriatic joint disease. That means I need to give them a plan that will treat both skin and joints. I may collaborate with a rheumatologist on their care.

Roadblocks to Relief

One of the biggest barriers we face in getting people the right treatment is insurance. Some of these medications can be quite expensive. Insurance plans may prefer that we start with a certain treatment. They want “treatment A” first, even though we want “treatment B.” Most times, that’s based on cost.

For example, for people who are insured through an employer plan, many pharmaceutical companies have programs in place to get them directly to the medicine they need. Other than a small copay, they’ll cover the entire cost of the medicine. For people of low income, foundations can help them afford their meds.

Weight can be another stopper to relief. Some people with psoriasis are overweight. Those who are heavier may have more severe disease. Sometimes, weight loss can help their treatment work better.

Be Honest

The more open you are about your disease and how it affects you, the more productive your doctor visits will be. Come to each appointment ready to share your concerns. That includes talking about sensitive subjects like how your psoriasis affects your genitals. It’s important to realize that these visits are confidential. You can’t get relief if you don’t tell your doctor about the problems you’re having.

If your disease is starting to get worse, don’t wait until your follow-up visit to tell your doctor. Let them know right away. You might want to send in photos to show what you’re going through.

If people have side effects from their medication, like coughing or shortness of breath, any recent infections, or anything they’re unsure of related to their medication, I always prefer that they call and ask. We can either reassure them or take steps to treat the problem.

For example, if your skin is getting worse right before you’re due for your next injection, your doctor might need to bump up the dose. If you’re no longer responding to your meds or you never reached your initial goal, your doctor might add a topical or switch you to a different medication. Some of these drugs can lose effectiveness over time.

Stick With Your Plan

We can’t cure psoriasis, we can only control it. It’s like having high blood pressure or high cholesterol. You need to stay on your regimen. If you go off your psoriasis medication, the disease will come back.

You don’t want to start and stop your medicine, because that will lead to poorer control of your disease. And it becomes more likely that the drug will stop working for you. It can be hard to think about staying on a medicine indefinitely, but these drugs are safe over the long term.

Psoriasis medications are very effective. Some of them improve the disease an average of 90% after 4 months, and 95% after a year. Some can even get people completely clear.

It’s great to be a physician treating these people, because I can make a big impact on their quality of life.

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October 10, 2022
Why Some Psoriatic Disease Symptoms Are Unreported

By David Chandler, as told to Kara Mayer Robinson

I’ve seen hiccups in the process of diagnosing psoriatic disease. I also know about it firsthand. I’m 62 years old, and I’ve had psoriasis since I was a teenager.

I first got it when I was 15. Not too long after that, when I was 17, I started to have pain in my lower back. I had years of appointments, doctor visits, and tests, but I didn’t discover that psoriatic disease had affected my joints until I was 30.

Once, when my psoriasis flared, I decided to see a dermatologist. They recognized I had joint inflammation and then referred me to a rheumatologist. It was then that I found out I had psoriatic disease involving my joints. So it took more than 10 years to get a proper diagnosis once I started to have symptoms.

My doctor didn’t connect my skin problems with the joint trouble I was having.

If you have psoriatic disease, the sooner you can get an accurate diagnosis, the better. In my case, the slow diagnosis meant I didn’t get the right treatment right away. That left me with joint changes and fused bones, mainly in my feet, back, and neck. Early diagnosis might have helped me avoid the disability that stemmed from that.

With psoriatic disease, it’s common for symptoms to be missed and diagnoses to take a long time. Symptoms often go unreported or overlooked for a variety of reasons.

I’ve learned that often comes from a lack of awareness about the link between the skin and joint involvement. You may think of skin lesions as an external disease and joint inflammation as an internal one. But actually, they’re both autoimmune disorders related to your immune system.

Why Psoriatic Disease Symptoms Get Missed

It’s common to misunderstand skin issues. You may think you have dandruff when it’s really scalp psoriasis. It’s also common not to report problems with your nails, which may be nail psoriasis. Your medical chart may reflect dry skin or eczema. If you see a new doctor, they might not think to ask about signs or symptoms of psoriatic disease.

You also may not think symptoms like joint pain, swelling, and fatigue have anything to do with your skin issues. That’s especially common with younger people, who are less likely to think that joint pain is something that can happen to them.

It’s best to let your doctor know about all symptoms you have.

Other Reasons Symptoms Get Missed

Symptoms of psoriatic disease also go unreported because they can often be vague. Test results or X-rays may not show anything. What you feel may not seem to change much over time. You might dismiss or doubt your symptoms because they’re not obvious or consistent.

Symptoms might also be intermittent — they may come and go. If you go to the doctor when things like joint pain or swelling aren’t happening, you may not think to tell your doctor about them.

What You Can Do

Report all symptoms to your doctor, regardless of whether you think they’re connected to your psoriasis. Make sure you consider symptoms you’ve had before, even if you don’t have them when you go to your appointment.

Think about your family history. Do any family members have conditions that might have gone misdiagnosed? Do they have symptoms that could relate to psoriatic disease?

Remember that psoriasis skin symptoms are a visual sign that something may be wrong with your immune system. So it’s possible you may have other issues, like joint pain and fatigue. If you’ve had these, talk to your doctor about the possibility of psoriatic disease.

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October 10, 2022
Lowering the Expense of Psoriatic Disease Treatments

By Steve Feldman, MD, as told to Kendall Morgan

For the last 29 years, I’ve specialized in treating patients with psoriatic disease, a chronic immune condition that includes psoriasis. I’ve been involved in studies where new drugs are being tested and in the development of new treatment guidelines. There were changes and new developments in treatment right from the beginning. There’ve been various topical treatment options, oral drugs, and then, more recently, the development of biologic treatments.

Biologics have revolutionized the management of moderate to severe psoriasis and other psoriatic conditions including psoriatic arthritis, but they also can cost tens of thousands of dollars per year. I’ve done a lot of research into these costs, and what I came to realize is that it’s hard to know how much any particular patient actually will pay for a particular drug. That’s because of contracts with insurers and other programs. So, keep in mind that the retail price of a drug isn’t an accurate reflection of how much you (or your insurer) will pay.

Still, these costs can be intimidating. I’ve had patients who lost their insurance not come to see me because they felt they couldn’t afford it. But there are lots of ways to get to low-cost or even free medications for those who can’t afford it otherwise. Health insurers often will specify which drugs they’re willing to pay for. If you don’t have insurance coverage, you might actually have more treatment options, not fewer. Many drug companies offer financial assistance through special support programs. You can look into financial assistance through nonprofit or government organizations, too. There may be a process involved, but you should never assume that treatment is out of reach simply based on your income or insurance status. Even if you think your household income is too high, you still might qualify for financial assistance or price breaks. It never hurts to ask.

If your symptoms are mild, you can save on costs even before you go to see a doctor. For mild psoriasis on the face or other sensitive parts of the body, for example, you can try over-the-counter treatments such as hydrocortisone ointment. It’s a relatively weak topical, but it may be strong enough. Topical tars can be messy and smelly, but they also can be effective if you’ll use them. Scalp psoriasis is common, and over-the-counter medicated shampoos can be useful there. Also, getting sun on psoriasis is a good way of treating it. We do phototherapy in the office, and that’s costly. But just spending time in the sun can make your psoriasis symptoms better.

When you go to the doctor, finding one who takes your insurance will keep your copays lower. If the doctor prescribes medications, I recommend going to GoodRx.com to see what the medicines cost at different pharmacies and what breaks are available. Even generics can be expensive, so it’s always a good idea to check and compare prices first. Sometimes there can be vast differences between pharmacies. Check if the medication is one that your insurer will cover.

If your doctor recommends phototherapy (also called ultraviolet light) treatments, these can cost a lot less than many of the biologic medications used for severe psoriasis. But, depending on your insurance coverage, it may actually cost you more in copays. As an alternative, see if you can find a tanning bed at a gym or somewhere else in your community. Oftentimes it’s possible to get unlimited access for a low monthly fee. It’s a good idea to talk with your doctor about any treatment you use, but home phototherapy, sunlight, and tanning beds can be reasonable ways of reducing costs even if your psoriasis is severe.

Another thing patients with psoriatic disease can do if they are doing well on a drug taken every 2 weeks is to try taking it every 3 or 4 weeks instead and see what happens. It might work to stretch the dosing this way, and that can lower the cost. However, if your prescription copay is low anyway, this may not affect your cost all that much. It’s best to let your doctor know if you are adjusting your medications and spreading the doses out this way, as it could make it more likely the treatment will stop working over time. This said, there are now lots of treatment options, so I don’t worry about this as much as I used to.

Keep in mind that you will need to see a specialist to get these prescription medications. Your primary care doctor most likely won’t have access to biologics. When you choose a specialist, make sure they have experience treating psoriatic disease and let them know about any financial concerns you have. I give patients my phone number and tell them that if they get to the pharmacy and the drug costs a lot, they can call me and see if there’s an alternative treatment or a financial assistance program available to lower the cost. I’ve seen too many patients who blindly filled a high-cost prescription when there was a way to pay less. I’ve also seen too many patients suffer by delaying needed treatment.

This doesn’t need to happen. There are many steps you can take, and help is available to lower your costs while ensuring that you get the treatment and care you need.

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October 10, 2022