What doctors wish patients knew about managing psoriasis

Living with psoriasis can be incredibly frustrating and challenging. That’s because dealing with itchy, scaly skin can hinder daily activities, affect emotional well-being and diminish overall quality of life. The encouraging news is that there are strategies to ease the challenges of living with psoriasis. Knowing what to keep in mind can help patients gain better control over their symptoms and improve their overall well-being.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two dermatologists took time to discuss what patients need to know about psoriasis. They are:

• Anthony P. Fernandez, MD, PhD, director of medical dermatology and W.D. Steck Chair of Clinical Dermatology at Cleveland Clinic. He is also assistant professor of clinical medicine at Cleveland Clinic Lerner College of Medicine.
• Jenny Murase, MD, director of medical consultative dermatology at the Palo Alto Foundation Medical Group and associate clinical professor of dermatology at the University of California, San Francisco.

“Psoriasis is a very common chronic inflammatory disease that predominantly affects the skin, but it can affect other organ systems as well,” Dr. Fernandez said, noting “it affects about 2% to 3% of the world’s population.”

“The most common manifestation of psoriasis is a rash that patients will have,” he said. “There are also different subtypes of psoriasis. So, the rash may look different in different individuals, but about 90% of patients develop plaque psoriasis, which appears as thick, pink-to-red plaques that often have very thick silvery white scales.”

For psoriasis, “the classic areas would include places like the elbows, the knees, the back of the scalp,” Dr. Murase said, noting “the most unusual areas—but also the areas that really indicate it’s psoriasis—would be the sideburn area, the belly button or the top of the gluteal cleft, which is the buttock area.”

Additionally, “there’s a pattern called inverse psoriasis where it occurs in the armpits and in the groin area,” she said. “But you can get erythrodermic psoriasis where it covers the entire body, and you can get certain patterns like a palmar plantar psoriasis where it just occurs on the soles of the feet and the hands.”

“It can have a pustular look to it with pustules that are little spots filled with puss. Or it can be guttate, which is a pattern that is scattered all over the body in these tiny little papules. It has a very distinct look to it,” Dr. Murase said. “You can also have nail psoriasis where the nails are affected and are growing out funny. It could just be a part of having chronic plaque psoriasis that your nails are affected or it can be just the nails” alone which are affected by the psoriasis.

Psoriasis affects everyone “roughly equal—it doesn’t favor one gender or one ethnicity,” Dr. Fernandez said, noting “we do think all patients who develop psoriasis have a genetic predisposition to it.

“But regardless of ethnicity or gender, patients need some additional trigger that serves as the spark for dysregulation of the immune system, which leads to this chronic inflammatory state,” he added. “And even that can be different in different individuals. In some people, it may be a bacterial infection. In others it can be a life stressor like the loss of a loved one that creates tremendous stress.”

Additionally, psoriasis “can occur at any age,” said Dr. Murase, noting psoriasis can appear in “a newborn baby and the oldest person who developed new onset psoriasis was 103 years old.”

“There’ve been a variety of genes that have been studied with genetic association, but it’s in the bone marrow,” Dr. Murase said. “It’s your genetic tendency for your inflammatory cells in your bone marrow where they will come to the skin and then cause psoriasis to form.”

“For example, if you get a bone-marrow transplant from someone who has psoriasis, then you will develop psoriasis once you receive their bone marrow,” she said.

“Ultimately, psoriasis leads to this chronic inflammatory state and the inflammatory molecules that are produced in this setting produce these skin lesions that people chronically have from that point forward,” Dr. Fernandez said, noting “we think of psoriasis as a chronic disease and, as of now, we do not have a cure.”

“Once you have psoriasis, we don’t have cures. We just have treatments,” Dr. Murase said. “Although, sometimes psoriasis can go into remission. It can stay away and stay quiet even when therapy is tapered off. But that's definitely more unusual when that happens.

“Usually, it's something that's being treated long term with the therapies and kept at bay with the therapies, and it's hard to taper off and have it not come back,” she added.

“Because it’s a chronic inflammatory disease, patients with psoriasis are at significant increased risk to develop numerous comorbid diseases over the course of their lifetime,” Dr. Fernandez said. “Arguably the most important of those is cardiovascular disease.”

“It’s been very well established with research over the past several decades that patients with moderate-to-severe psoriasis have increased risk for heart attack, stroke, peripheral arterial disease, even high blood pressure over time,” he said. “We also know patients with psoriasis are at an increased risk for developing other chronic inflammatory diseases.”

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“Inflammatory bowel disease is one example. So, things like Crohn’s disease, ulcerative colitis and eye inflammation, which is typically called uveitis,” Dr. Fernandez said. Additionally, patients with psoriasis are “at increased risk for psychological disorders—most commonly depression, but also anxiety.”

“In general, we want patients to eat a healthy diet. But in the setting of a chronic inflammatory disease like psoriasis, we think it’s especially important,” Dr. Fernandez said. “Of the diets that are out there, the one that is usually recommended most often—and where there’s the best evidence—is the Mediterranean diet, which includes foods that have anti-inflammatory properties.”

“Our goal is to eat foods that, if anything, will help calm down an overactive immune system,” he said. “The other important thing about diets like the Mediterranean diet is they’re low in fat, high in protein, high in nutrients.

“If people can stick to diets like that … they tend to lose weight. And we know that losing weight, losing body fat, in and of itself has anti-inflammatory properties,” Dr. Fernandez added. “On the flip side of that, the foods that we want them to avoid are fats that are high in calories, high in fat content, because those promote inflammation more than decreasing inflammation.”

While “diet is important in general, for patients with moderate-to-severe psoriasis, we never expect that all you need to do is eat your Mediterranean diet and the psoriasis will go away and you won’t need any medication,” he said. Diet is not the answer, “but we do think at minimum it can decrease the severity of their psoriasis and may allow them to be on less potent medications, lower doses or less medicines in terms of the overall number.”

Lifestyle change is a “very big area of not only research, but of clinical practice right now,” Dr. Fernandez said. “In general, for most chronic inflammatory diseases, we are recommending strategies to promote overall wellness for patients.”

“Part of the wellness strategy, of course, includes a good diet, but it also includes exercise,” he said. But it is especially important to try “to work on strategies to manage stress in your daily life. We all have it. No one escapes stress.

“So, if you can really figure out ways that work for you to manage that stress—to minimize the stressors in your life—it can really help to calm down an overactive immune system,” Dr. Fernandez added.

“The last big category for lifestyle change is sleep. Getting adequate, restful sleep is really important in terms of creating a nice, calm immune system,” Dr. Fernandez said. “A lot of us struggle in our own lives with getting that adequate, restful sleep.

“And we’re constantly reminding patients about that. Sleep can make a big difference for psoriasis,” he added.

“Psoriasis exhibits koebnerization, meaning in areas of trauma where you don’t have psoriasis, if skin is traumatized—including rubbing too hard—you can develop psoriasis in those areas,” said Dr. Fernandez.

“For example, you’re running and you fall. You develop a scab and a lesion on the front of your leg. Psoriasis can appear in those areas of trauma,” Dr. Murase said. Another example is with breastfeeding. An “infant who is breastfeeding and it’s rubbing and kind of rough. Psoriasis can appear on the nipple in breastfeeding women.

“So, limiting trauma to the skin can also be helpful in preventing psoriasis flareups,” she added.

“In terms of baths and showers, part of it is more individual. There may be some patients with psoriasis, for example, who feel like warm water is something that triggers itching in their skin plaques whereas for somebody else it may be cool water,” Dr. Fernandez said. “So, we would encourage our patients to choose a water temperature that doesn’t aggravate symptoms in their skin—pain or itching.”

“When washing, we never want people to scrub. You’re not going to scrub away psoriasis plaques,” he said. “If anything about baths and showers, it’s to remind our patients that they should wash gently and that’s the best strategy to make sure they don’t trigger more or worsen their own psoriasis.”

“There’s definitely an association with what we call the metabolic syndrome—which would be hypercholesterolemia or high cholesterol, obesity and diabetes—so it’s important for a patient with chronic plaque psoriasis to get their lipid panel, their cholesterol results and triglycerides, which is the fat in the blood, under control,” Dr. Murase said. That’s “because they’re more at risk of having a cardiovascular disease event like a heart attack or stroke.”

Dr. Murase added that she has patients get “their lipid panel checked at least once a year—fasting lipids—so that I can make sure that those are within the normal limits,” she said. “And if they’re not, I ask them to work with their primary care doctor to get that under control.”

“If the metabolic syndrome is an issue, we depend on our primary care colleagues to work with the patients to get them feeling the best they can,” Dr. Murase said.

“In terms of controlling the condition with over-the-counter treatments, that’s going to be really challenging to do just given that what’s over the counter for this is pretty limited,” Dr. Murase said, noting “there is an over-the-counter tar preparation called MG217 or crude cold tar that can be purchased. Hydrocortisone creams can also be purchased over the counter.

“But the vast majority of topical medication treatments and different oral and injectable treatments are only accessible through a clinical care team that includes a dermatologist,” she added. “So, it’s going to be challenging to treat this on your own without access to those therapies.”

“With so many different treatments for psoriasis, patients should visit the National Psoriasis Foundation website,” Dr. Murase said. “They have descriptions of all of these different options because of the fact that there are so many options out there for patients to read through and decide what they think they’d like to pursue.”

“We’re very lucky in today’s world with all of the weapons that we have to treat psoriasis and they range from phototherapy—or light therapy—to topical agents to oral pills that we take to injectable or infused biologic medications,” Dr. Fernandez said. “And the regimen that we choose for our patients is really going to depend on the severity of their disease.”

“For patients who have very mild psoriasis—maybe a few plaques here and there—we’re going to try to be conservative and use topical medicines or light therapy to control their disease,” he said. “Whereas patients who have moderate-to-severe psoriasis, we’re going to go with systemic medicines.”

“Our goal isn’t simply to address the rash, the skin lesions, we are really trying to address that systemic inflammation,” Dr. Fernandez said. “By doing so, we’re hoping that we can mitigate some of the risk of developing those other important comorbid diseases psoriasis patients are prone to develop in the future.”