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Tag: psoriatic arthritis

  • How Treating Psoriatic Disease Has Changed

    How Treating Psoriatic Disease Has Changed

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    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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  • The Future of Autoimmune Disorders: Psoriatic Disease

    The Future of Autoimmune Disorders: Psoriatic Disease

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    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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  • How Science Has Transformed What We Know About Psoriatic Disease

    How Science Has Transformed What We Know About Psoriatic Disease

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    By Alice B. Gottlieb, MD, PhD, dermatologist, as told to Kristen Fischer

    Certain things, like your genes, can increase your risk for psoriatic arthritis. If you have a first-degree relative with psoriatic arthritis, you have 39 times the risk of developing it. 

    Other risks for psoriatic arthritis include psoriasis on the scalp and nails. Inverse psoriasis, or intertriginous psoriasis, also raises your risk for psoriatic arthritis. (Inverse psoriasis occurs in folds of the body, such as in the armpits or groin area.)

    A common misconception is that only people with moderate to severe psoriasis get psoriatic arthritis. You can get psoriatic arthritis even if you have mild psoriasis. Early detection is key. If you can manage psoriasis, you may be able to stop psoriatic arthritis from getting worse – maybe prevent it completely. 

    Why Does Early Diagnosis of Psoriatic Disease Matter?

    Family doctors – especially dermatologists – need to spot psoriasis so they can prevent disabilities caused by psoriatic arthritis. Once detected, we can do something about it.

    That’s a paradigm shift from when I was a rheumatology fellow at the Hospital for Special Surgery. Back then, we had nothing that could keep the disease from getting worse. Doctors didn’t even control signs and symptoms that well.

    Now there are several medications on the market to treat psoriatic arthritis . Some are tumor necrosis factor (TNF)-alpha inhibitors blockers, Interleukin inhibitors, and JAK inhibitors.

    There’s also research that found people who took medication had less damage, compared to those who didn’t. That suggests that you may even prevent psoriatic arthritis.

    How Can Dermatologists Detect Psoriatic Disease?

    Dermatologists may not know how important their role is in detecting psoriatic arthritis. They don’t have to be experts in diagnosing it, but they must check for it. Then they can refer you to a rheumatologist. They need to ask you about joint pain. Many people don’t realize that aches and pains can be a disease. It has to be brought up.

    Missing a diagnosis can be serious. Research tells us that a delay in diagnosis and treatments causes increased joint erosion, deformity, and arthritis mutilans (a form of psoriatic arthritis where bone degeneration shortens your fingers and toes).

    In dermatology practices, people usually have signs of enthesitis before they have a psoriatic disease. Enthesitis is inflammation where tendons and ligaments insert into bone. It can cause joint pain, stiffness, and mobility problems. Some ultrasound evidence shows that enthesitis increases the risk of a future psoriatic arthritis diagnosis by five times.

    How Is Psoriatic Disease Care Improving?

    Doctors have simple, quick screening methods to spot psoriatic diseases. We need to get these in the hands of more general practice doctors and dermatologists – and they have to use them.

    I’m working with a team to encourage more doctors to use these screening tools. Mount Sinai recently started a new program that integrates psoriatic disease screening tools with our electronic medical records (EMRs). 

    Here’s how it works: People who come to us will respond to the five-question Psoriasis Epidemiology Screening Tool (PEST) while they’re in the waiting room. When they see their doctor, their PEST results will come up on the EMR. If they answer three or more questions positively, the EMR application alerts the doctor that the score shows possible psoriatic arthritis. It will give the doctor a prompt to refer the patient to a rheumatologist. It couldn’t be easier.

    They’re also integrating the industry-standard Psoriatic Arthritis Impact of Disease (PsAID) Questionnaire into EMR. People with an existing psoriatic disease, or those who are PEST-positive, will have to respond to 12 questions. If they have a certain score, it will alert the doctor that the case is not controlled. It will then prompt the doctor to set up an appointment with a rheumatologist. The EMR will also suggest medications.

    These screening tools are available in some other EMR systems, but my project is different because I will measure how well it works.

    At the end of 18 months, I’ll see if the percentage of cases goes up. The system will be able to tell if people are managing their psoriatic diseases, and we will be able to assess how treatments work.

    If all goes well, this will make it easy for doctors to give patients better care. It will help them to be more aware about diagnosing psoriatic diseases, and to know if people have their disease under control. 

    The screening tools are available on the GRAPPA app, which is produced by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.

    What’s New in Psoriatic Disease Medications?

    There are some advances in medications to treat psoriatic arthritis. TNF blockers are the gold standard to treat psoriatic diseases. But they don’t work for everyone. 

    Deucravacitinib is a newer FDA-approved drug for psoriasis – but not for psoriatic arthritis. There is some evidence that it can improve psoriatic arthritis. Clinical trials look good for bimekizumab, an oral medication that clears skin for 3 years, but it is not yet approved in the U.S.

    In 2023, adalimumab (Humira) will be available in generic form. I don’t think the price will come down much.

    I give preference to treatments that stop psoriatic arthritis from getting worse, even in patients that only have psoriasis. That’s because there’s some evidence that the drugs may prevent psoriatic arthritis. 

    For now, the combination of working treatments – and getting more people diagnosed so we can prevent disabilities from psoriatic diseases – is a priority.

    We have great treatments for psoriatic diseases, but many are expensive. Many people can’t afford them, even people with supplemental insurance. 

    What’s Next for Psoriatic Arthritis and Psoriasis?

    Overall, people need to know that psoriasis is much more than something that affects their skin. It can cause lasting damage and complications.

    That’s why screening for psoriasis and psoriatic arthritis is so important, and why I’m dedicated to making sure everyone gets checked.

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  • Psoriatic Disease: An Autoimmune Disease Expert’s Point of View

    Psoriatic Disease: An Autoimmune Disease Expert’s Point of View

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    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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  • It’s Gotten Awkward to Wear a Mask

    It’s Gotten Awkward to Wear a Mask

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    Last week, just a couple of hours into a house-sitting stint in Massachusetts for my cousin and his wife, I received from them a flummoxed text: “Dude,” it read. “We are the only people in masks.” Upon arriving at the airport, and then boarding their flight, they’d been shocked to find themselves virtually alone in wearing masks of any kind. On another trip they’d taken to Hawaii in July, they told me, long after coverings became optional on planes, some 80 percent of people on their flight had been masking up. This time, though? “We are like the odd man out.”

    Being outside of the current norm “does not bother us,” my cousin’s wife said in another text, despite stares from some of the other passengers. But the about-face my cousin and his wife identified does mark a new phase of the pandemic, even if it’s one that has long been playing out in fits and starts. Months after the vanishing of most masking mandates, mask wearing has been relegated to a sharply shrinking sector of society. It has become, once again, a peculiar thing to do.

    If you notice, no one’s wearing masks,” President Joe Biden declared last month on 60 Minutes. That’s an overstatement, but not by much: According to the COVID States Project, a large-scale national survey on pandemic-mitigation behaviors, the masking rate among Americans bounced between around 50 and 80 percent over the first two years of the pandemic. But since this past winter, it’s been in a slide; the project’s most recent data, collected in September, found that just 29 percent have been wearing masks outside the home. This trend may be long-standing on the population level, but for individuals—and particularly for those who still wear masks, such as my cousin and his wife—it can lead to moments of abrupt self-consciousness. “It feels like it’s something that now needs an explanation,” Fiona Lowenstein, a journalist and COVID long-hauler based in Los Angeles, told me. “It’s like showing up in a weird hat, and you have to explain why you’re wearing it.”

    Now that most Americans can access COVID vaccines and treatments that slash the risk of severe disease and death, plenty of people have made informed decisions to relax on masking—and feel totally at ease with their behavior while paying others’ little mind. Some are no longer masking all the time but will do so if it makes others feel more comfortable; others are still navigating new patterns, trying to stay flexible amid fluctuating risk. Saskia Popescu, an infectious-disease epidemiologist at George Mason University, told me that she’s now more likely to doff her mask while dining or working out indoors, but that she leaves it on when she travels. And when she does decide to cover up, she said, she’s “definitely felt like more of an outlier.”

    For some, like my cousin and his wife, that shift feels slightly jarring. For others, though, it feels more momentous. High-filtration masks are one of the few measures that can reliably tamp down on infection and transmission across populations, and they’re still embraced by many parents of newborns too young for vaccines, by people who are immunocompromised and those who care for them, and by those who want to minimize their risk of developing long COVID, which can’t be staved off by vaccines and treatments alone. Theresa Chapple-McGruder, the public-health director for Oak Park, Illinois, plans to keep her family masking at least until her baby son is old enough to receive his first COVID shots. In the meantime, though, they’ve certainly been feeling the pressure to conform. “People often tell me, ‘It’s okay, you can take your mask off here,’” Chapple-McGruder told me; teachers at the local elementary school have said similar things to her young daughters. Meghan McCoy, a former doctor in New Hampshire who takes immunosuppressive medications for psoriatic arthritis and has ME/CFS, has also been feeling “the pressure to take the mask off,” she told me—at her kid’s Girl Scout troop meetings, during trips to the eye doctor. “You can feel when you’re the only one doing something,” McCoy said. “It’s noticeable.”

    For Chapple-McGruder, McCoy, and plenty of others, the gradual decline in masking creates new challenges. For one thing, the rarer the practice, the tougher it is for still-masking individuals to minimize their exposures. “One-way masking is a lot less effective,” says Gabriel San Emeterio, a social worker at Hunter College who is living with HIV and ME/CFS. And the less common masking gets, the more conspicuous it becomes. “If most people met me, they wouldn’t know I was immunocompromised,” McCoy told me. “There’s no big sign on our foreheads that says ‘this person doesn’t have a functioning immune system.’” But now, she said, “masks have kind of become that sign.”

    Aparna Nair, a historian and disability scholar at the University of Oklahoma who has epilepsy, told me that she thinks masks are becoming somewhat analogous to wheelchairs, prosthetics, hearing aids, and her own seizure-alert dog, Charlie: visible tools and technologies that invite compassion, but also skepticism, condescension, and invasive questions. During a recent rideshare, she told me, her driver started ranting that her mask was unnecessary and ineffective—just part of a “conspiracy.” His tone was so angry, Nair said, that she began to be afraid. She tried to make him understand her situation: I’ve been chronically ill for three decades; I’d rather not fall sick; better to be safe than sorry. But she said that her driver seemed unswayed and continued to mutter furiously under his breath for the duration of the ride. Situations of that kind—where she has to litigate her right to wear a mask—have been getting more common, Nair told me.

    Masking has been weighed down with symbolic meaning since the start of the pandemic, with some calling it a sign of weakness and others a vehicle for state control. Americans have been violently attacked for wearing masks and also for not wearing them. But for a long time, these tensions were set against the backdrop of majority masking nationwide. Local mask mandates were in place, and most scientific experts wore and championed them in public. With many of those infrastructural supports and signals now gone, masking has rapidly become a minority behavior—and people who are still masking told me that that inversion only makes the tension worse.

    San Emeterio, who wears a vented respirator when they travel, recently experienced a round of heckling from a group of men at an airport, who started to stare, laugh, and point. Oh my god, look at what he’s wearing, San Emeterio recalls the strangers saying. “They clearly meant for me to hear it,” San Emeterio told me. “It didn’t make me feel great.” Alex Mawdsley, the 14-year-old son of an immunocompromised physician in Chicago, is one of just a handful of kids at his middle school who are still masking up. Since the start of the academic year, he’s been getting flak from several of his classmates “at least once a week,” he told me: “They’re like ‘You’re not gonna get COVID from me’ and ‘Why are you still wearing that? You don’t need it anymore.’”

    Alex’s mother, Emily Landon, told me she’s been shaken by the gawks and leers she now receives for masking. Even prior to the pandemic, and before she was diagnosed with rheumatoid arthritis and began taking immunosuppressive drugs, she considered herself something of a hygiene stan; she always took care to step back from the sneezy and sniffy, and to wipe down tray tables on planes. “And it was never a big deal,” she said.

    It hasn’t helped that the donning of masks has been repeatedly linked to chaos and crisis—and their removal, to triumph. Early messaging about vaccines strongly implied that the casting away of masks could be a kind of post-immunization reward. In February, CDC Director Rochelle Walensky described masks as “the scarlet letter of this pandemic.” Two months later, when the administration lifted its requirements for masking on public transportation, passengers on planes ripped off their coverings mid-flight and cheered.

    To reclaim a mask-free version of “normalcy,” then, may seem like reverting to a past that was safer, more peaceful. The past few years “have been mentally and emotionally exhausting,” Linda Tropp, a social psychologist at the University of Massachusetts at Amherst, told me. Discarding masks may feel like jettisoning a bad memory, whereas clinging to them reminds people of an experience they desperately want to leave behind. For some members of the maskless majority, feeling like “the normal ones” again could even serve to legitimize insulting, dismissive, or aggressive behavior toward others, says Markus Kemmelmeier, a social psychologist at the University of Nevada at Reno.

    It’s unclear how the masking discourse might evolve from here. Kemmelmeier told me he’s optimistic that the vitriol will fade as people settle into a new chapter of their coexistence with COVID. Many others, though, aren’t so hopeful, given the way the situation has unfolded thus far. “There’s this feeling of being left behind while everyone else moves on,” Lowenstein, the Los Angeles journalist and long-hauler, told me. Lowenstein and others are now missing out on opportunities, they told me, that others are easily reintegrating back into their lives: social gatherings, doctor’s appointments, trips to visit family they haven’t seen in months or more than a year. “I’d feel like I could go on longer this way,” Lowenstein said, if more of society were in it together.

    Americans’ fraught relationship with masks “didn’t have to be like this,” Tropp told me—perhaps if the country had avoided politicizing the practice early on, perhaps if there had been more emphasis on collective acts of good. Other parts of the world, certainly, have weathered shifting masking norms with less strife. A couple of weeks ago, my mother got in touch with me from one such place: Taiwan, where she grew up. Masking was still quite common in public spaces, she told me in a text message, even where it wasn’t mandated. When I asked her why, she seemed almost surprised: Why not?

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    Katherine J. Wu

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  • Should You Stay or Go? When to Change Treatments

    Should You Stay or Go? When to Change Treatments

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    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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  • Finding Success When Managing Psoriatic Disease

    Finding Success When Managing Psoriatic Disease

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    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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  • Why Some Psoriatic Disease Symptoms Are Unreported

    Why Some Psoriatic Disease Symptoms Are Unreported

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    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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