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.
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.