Tag: Psoriatic disease

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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December 19, 2022
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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December 19, 2022
Being a Young Adult With Psoriatic Disease

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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
Lowering the Expense of Psoriatic Disease Treatments

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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