Is psoriasis getting under your skin?

By Matthew McClelland, M.D., dermatology, Providence Medical Group-Bridgeport

The most troubling thing about psoriasis, for most people, is its appearance. Red, scaly patches often appear on the skin in very noticeable places such as the hands, elbows, knees, and even sometimes on the face. We don’t want people feeling uncomfortable in their skin, and there are many treatments that help with this common condition.

Beneath the skin, however, there is a systemic component to psoriasis that’s more important to be aware of. In people with psoriasis, a misdirected, overactive immune system sparks a lot of inflammation where it doesn’t need to be. On the surface, that inflammation causes rapid turnover of skin cells, creating those red, scaly patches. Below the surface, chronically inflamed blood vessels and joints puts people with psoriasis at higher risk for heart disease, diabetes and a form of arthritis called psoriatic arthritis.

One in five people with psoriasis develops psoriatic arthritis, an inflammatory joint disease similar to rheumatoid arthritis. Failure to treat the arthritis can result in progression and permanent joint damage. That’s why I ask all of my patients with psoriasis how their joints are feeling. If a joint feels stiff in the mornings but gets better as the day goes on, that’s usually an indicator of psoriatic arthritis in an individual with psoriasis; age-related osteoarthritis usually feels worse as the day goes on. Psoriatic arthritis commonly affects the hands and wrists, and can affect any joint, including the joints of the spine.

Deciding whether or not to treat your skin symptoms is a personal choice – if you’re uncomfortable with the possibility of treatment side effects, it’s perfectly valid to opt not to treat mild flare-ups. The fact that this is a systemic disease that can cause arthritis, heart disease and diabetes, however, is an important reason not to ignore it completely.

Treatment options

We can’t cure psoriasis yet, but we do have a lot of good treatments available. Your primary care provider or dermatologist can go over all of the options and recommend one based on the extent of your skin issues and whether or not you also have arthritis.

Treatments for skin issues:

• Over-the-counter treatments: Products that contain salicylic acid can remove the dead skin that is so characteristic of psoriasis. However, the low concentrations available over the counter don’t usually work very well. Higher concentrations, available by prescription, are more effective.
• Topical steroids: These prescription creams and ointments can clear up skin patches somewhat and make your skin look better if you use them consistently. They’re usually our first line of treatment when people are newly diagnosed, as long as the psoriasis doesn’t cover a large portion of the body.
• Phototherapy: I don’t recommend sun exposure or tanning beds due to the risk of skin cancer; medical phototherapy is a safer option that can work very well for the skin. Like the other treatments mentioned so far, however, it doesn’t affect the systemic disease.

Systemic treatments:

• Pills: If you have a lot of psoriasis that’s not responding to treatment, or you have it on your face or other cosmetically sensitive areas, oral medications may help. Methotrexate, a first-line systemic agent, has been used for decades and works pretty well, but has potential side effects that require careful monitoring of the liver, bone marrow and other organs. A new pill, called Otezla, may be safer and equally effective, but cost will be an obstacle until a generic form becomes available. Like all systemic treatments, both of these treat arthritis to some degree as well.
• Injectable targeted medications: Some of the newest options are targeted much more precisely to the specific immune system problem that causes psoriasis. These targeted therapies, theoretically, work better and cause fewer side effects than methotrexate and other traditional treatments. Injected medications such as Enbrel, Humira and Stelara are extremely effective. Another new medication, Cosentyx, was also recently approved. These clear the skin better than any other medication – in some patients, they clear it completely – and they also treat psoriatic arthritis. Some shots need to be administered twice a week; Stelara is given every three months, and a new medication is being developed that will need to be injected just once a year. These and the other systemic medications may weaken the immune system and increase the risk of cancer and infection, but the increase is very slight. Cost is the main issue – most of these average about $20,000 per year.

New treatments are being developed all the time, and a lot of research is going on that may lead to a cure, or at least to the next best thing: a treatment that provides long-term clearance.

Self-care

In addition to medical treatment, there are several things you can do to minimize psoriasis flare-ups and lower your systemic risks:

• Reduce stress: Stress can trigger flare-ups, so learning to manage stress better may improve your psoriasis.
• Protect your skin: About 50 percent of patients experience what’s called the Koebner phenomenon, which is psoriasis that shows up in areas of trauma to the skin, such as sunburns, bug bites, scrapes and other injuries.
• Don’t smoke: Cigarette smoke may worsen both skin psoriasis and the systemic diseases.
• Live a healthy lifestyle: Exercising, eating nutritious foods and losing weight if you’re overweight often improve psoriasis.
• See your primary care provider regularly: Make sure your primary care provider knows that your psoriasis puts you at higher risk for heart disease and diabetes, so he or she can monitor these risks at every checkup. If you do not have a primary care provider, find one today.

If you are motivated to keep psoriasis under control, there are plenty of tools that can help you. This is a condition that you’ll probably be living with for a long time, so keep exploring options until you find an approach that you feel good about.

For more information

• The National Psoriasis Foundation, located in Portland, offers an online community for people with psoriasis, plus research updates, treatment information, a blog, expert webcasts and other resources.
• The Oregon Medical Research Center often offers the latest psoriasis treatments at no charge to qualifying study participants.