The Secret to Managing Psoriasis

WebMD Live Events Transcript

Working closely with your doctor is the best way to manage your psoriasis. But what are the keys to making this partnership work well? What questions should you ask? And what should you expect from your MD? On Sept. 15, 2004, we chatted with psoriasis expert Craig Leonardi, MD, about what you and your doctor can do together to manage your psoriasis.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MODERATOR:
Today we're talking about how best to work with your doctor to manage your psoriasis. What is your first suggestion for those who need help in communicating with their physician?

LEONARDI:
I think the most important thing is to get organized before the visit occurs. Get a list of your past treatments, what medicines you've used, what worked, and what definitely did not work.

There are practical issues as well the doctor needs to know about. If your psoriasis is severe and you live far away from an ultraviolet treatment center you need to let the doctor know. If you are unable to take time off to come to the office for treatment, or if you have a job where you can't take time off during the day you need to let your doctor know.

There are a wide variety of medical and practical issues that you need to discuss when the doctor selects therapy. If I select a therapy you cannot receive then I'm not really treating you.

MODERATOR:
Does it help to keep a log of flare-ups and the circumstances surrounding each?

LEONARDI:
To a limited extent. It's important to know if the psoriasis has been unstable in the past and maybe in a general way what kinds of things cause the flare. For me it's not important to know all the details at that point. I'll ask for them if I want to know.

MEMBER QUESTION:
You say to tell the doctor the meds you take. Does this include nonpsoriasis meds and vitamins?

LEONARDI:
It's important to be able to provide a list of all the medicines you're taking if the doctor needs it. If you have a hard time pronouncing the words, have a written list. You cannot go wrong if you always have a written list. It's not so important if I'm using a topical therapy. If you need a systemic drug, a pill, or a shot for treating your psoriasis, at that point some of the medicines you are using for other conditions might be important in selecting the best therapy for treating your psoriasis.

MEMBER QUESTION:
Is it important to go to a dermatologist? I like my PCP, but he may not know the latest about psoriasis.

LEONARDI:
There's only one class of doctors that have been trained to treat psoriasis, and those are dermatologists. While your PCP may know a little bit, I would not expect your doctor to know about how to safely manage moderate to severe psoriasis using systemic medications. Dermatologists are the doctors who are trained to treat this condition, and if you are seeing a dermatologist, and what you're being told doesn't make sense, it's OK to seek a second opinion.

"Itching is not a reliable indication of psoriasis. Many patients have severe itching and many do not."

MEMBER QUESTION:
What should I be asking in order to get diagnosed? What should the doctor be asking me?

LEONARDI:
It's usually very easy to diagnose psoriasis just by looking at the skin. Sometimes when the skin eruption shows up for the fist time it may not be clear exactly what type of process is occurring in the skin. At that point a dermatologist might do a skin biopsy or a few other simple tests to determine the source of the eruption. For patients who have had psoriasis for several months or longer the diagnosis is usually made by physical exam just by looking at them.

MEMBER QUESTION:
What about scalp psoriasis?

LEONARDI:
Scalp psoriasis can be very difficult to treat. Sometimes we can confuse it with bad forms of seborrheic dermatitis. A biopsy usually helps us distinguish those two. Treatment options can be varied. Usually they involve medicated shampoos, and medicines applied to the scalp directly. In some cases it's necessary to use systemic therapies to treat scalp psoriasis.

MEMBER QUESTION:
I wanted to know if all psoriasis itches. I have been told I do not have it because it doesn't itch. I have also been told by a few that this is not true. Itching comes about later. I have had this almost three years. It was only in one area, now, it's in several, and gets to be more and more, bigger and bigger, spreading down along the skin.

LEONARDI:
Itching is not a reliable indication of psoriasis. Many patients have severe itching and many do not. So it's one of the things we ask about, but it's not one of the things we would rely upon to make the diagnosis.

MEMBER QUESTION:
I am 36, and at this time I don't have medical insurance. My father has psoriasis bad; all over his body. I have it on my feet and elbow area. Is there anything I can do now, maybe to help it not get as bad as his later on?

LEONARDI:
The first thing is to start with a diagnosis. You could work with your dermatologist and possibly receive a prescription for a topical steroid. For example, kenalog can be obtained inexpensively.

The other thing I recommend sometimes for my patients is natural sunlight exposure, sort of a poor man's phototherapy. Some patients do quite well with increased sun exposure in the summer months. If you're in an area where it's possible to receive sunlight throughout the year, then that might be a more successful strategy.

Whether any therapy prevents progression of the disease to more severe forms is not understood at this time. We all have the idea if you treat the disease successfully and keep it under good control you might keep it under progression, but there are no studies to prove or disprove this concept.

MEMBER QUESTION:
What are the things you can do to control flare-ups and keep them from happening again? And does water play a big part in helping with skin care, because I'm dealing with a bad flare-up right now.

LEONARDI:
Many patients experience flares of psoriasis after infections, especially after strep throat infections. So if you think you are experiencing an infection you may want to seek medical care for that infection, especially if you have a history of getting a flare after having a throat infection. You may want to be more aggressive about treating that early.

As far as the role of water in making psoriasis better or worse, I'm just not aware of that being a problem.

MODERATOR:
When you are experiencing a flare-up, how important is it to see your dermatologist?

LEONARDI:
I think it's very important. Your doctor may want to shift you to a more aggressive form of therapy to control the flare and hopefully taper you back off as tolerated. I think it's very important for you to seek your dermatologist's opinion when your psoriasis is breaking through your current form of therapy. Get on the phone, call the office, and insist on talking to the doctor or the nurse.

"There have been no results that support the idea that diet plays a role in controlling psoriasis or making it worse."

MEMBER QUESTION:
Since forward-thinking doctors have gotten to know a little more about nutrition and prevention I have learned a lot about how our bodies work and what they need to ward off disease. What part do antioxidants play in the onset of psoriasis? And since the average American diet is so barren of these nutrients, if one were to get the recommended five to nine fresh raw fruits and vegetables, could it help, delay, or remise the condition? I have been taking a "Whole Food" nutrition product for nearly two years and my psoriasis barely ever troubles me. I had it only on my hands and feet at first, but it was so bad that I would get deep cracks in my feet just from walking that would bleed and hurt. My nails were pitted as well. Then I got some patches on knees and elbows. I barely remember that I have it now. Let me know what you think.

LEONARDI:
I'm always happy when someone gets better by any mechanism, but I'm not aware of any nutritional supplement or diet program that can control psoriasis or affect its course. Because the disease waxes and wanes spontaneously, it's easy to get the idea that changing your diet might have a benefit in your psoriasis. This has been studied to a limited extent and there have been no results that support the idea that diet plays a role in controlling psoriasis or making it worse. If we did a study with this particular nutritional supplement, I suspect we would find no affect on the population. If it works for you, and it's safe, then I'm happy for you.

MEMBER QUESTION:
But since psoriasis is an autoimmune disease, isn't it important to maintain the best possible general health?

LEONARDI:
Of course it's important to maintain general health, but we don't think that diet plays a significant role in the function of your immune system or in its effects on psoriasis.

MEMBER QUESTION:
How do you find a good dermatologist for psoriasis?

LEONARDI:
You can start by asking your primary care physician. You might ask other psoriasis sufferers in your town. You can always go to the National Psoriasis Foundation or the American Academy of Dermatology to find dermatologists who specialize in treating psoriasis. Lastly, the most direct way would be to call the dermatology offices and ask if the doctor treats psoriasis and if he offer the full range of psoriasis treatments, including ultraviolet light therapy. MEMBER QUESTION:
I have more problems with my psoriasis in the wintertime. Do you have any suggestions for preventive care before winter hits full force?

LEONARDI:
Other than to make sure you use moisturizers and emollients on the psoriasis plaques, because our living environments are much drier in the winter. The role of moisturizers becomes more important in the winter. Also some patients have less ultraviolet exposure, and for some of those their psoriasis will get worse. This is an opportunity to say hi to your dermatologist and to make an adjustment in your treatment accordingly.

MEMBER QUESTION:
Why isn't there a cure? Is there any company or organization that is working on one or coming close to finding one?

LEONARDI:
There isn't a cure because we don't know what the cause is. In the last 10 years we've made great strides in understanding the pathogenesis of the disease. We know it's a genetic, inherited inflammatory disorder. Several psoriasis susceptibility genes have been identified. In the last 18 months, three spectacular treatments have emerged from clinical trials based on our new understanding of the disease, but we still don't know the cause, so the cure eludes us. Stay tuned.

MEMBER QUESTION:
Could you please tell me what a psoriases flare-up is?

LEONARDI:
There's no specific definition. A psoriasis flare is when the patient says it's getting worse. During research trials we have some definitions we use to characterize recurrence of psoriasis, but in real life, a flare is when the patient says it's getting worse.

"In the last 18 months, three spectacular treatments have emerged from clinical trials based on our new understanding of the disease, but we still don't know the cause, so the cure eludes us."

MEMBER QUESTION:
What kind of success rate have you seen with Enbrel for plaque psoriasis?

LEONARDI:
Enbrel is one of the exciting new drugs that have recently been approved to treat psoriasis. It has a good effect on skin and an even better effect of psoriatic arthritis. I have close to 200 patients who are on Enbrel who have achieved substantial control of their disease and use occasional topical therapy in addition to their Enbrel. Overall, I'd say these patients are doing extremely well.

MEMBER QUESTION:
A more delicate question: What do you recommend for "inverse" psoriasis?

LEONARDI:
Inverse psoriasis is a type of psoriasis that shows up under the arms and in the groin areas. It can be quite debilitating and challenging to treat. Depending on the degree of involvement, I think the full range of treatment options should be made available to patients with inverse psoriasis, and I would include the systemic drugs, both the standard as well as the new biologic agents, as well.

MEMBER QUESTION:
Can you get psoriasis on your penis? My boyfriend has it fairly badly on his body, and now there is what looks to be it on his penis. I hope it isn't herpes, and it sort of looks like what's on the rest of him, so I'm just wondering.

LEONARDI:
Yes, psoriasis can show up in all the "inconvenient" locations. Again, we would approach this with a variety of topical medicines, and if those were unsuccessful, and in my opinion psoriasis in this location might be considered severe, it would be deserving of more aggressive therapies. A dermatology consult is always appropriate, if you suspect you have psoriasis in this location.MEMBER QUESTION:
I've been doing some research on biologics and it seems like you have to get shots all the time. Is there any option that would give me a break from the needles for a while but still work?

LEONARDI:
The new biologic therapies all involve injections of one form or another. Three of the drugs involve subcutaneous injections, the kind of shot a diabetic would give themselves several times a day. In the case of these biologics, the shots are much less frequent than that. One of the drugs is given as a series of injections in the doctor's office for 12 weeks. In some of the patients, a 12-week course of therapy will have a very long-lived effect on their psoriasis.

The last drug is given as an intravenous infusion. Once the patient is established on the drug, the infusions, which last two to three hours, might occur every two months. In summary, the medicines are given as injections with a wide variety of treatment schedules, both in the home and in the doctor's office.

MEMBER QUESTION:
How do you treat nail psoriasis? My nails are all affected and are UGLY!

LEONARDI:
That's a very difficult form of psoriasis to control. I personally never had much success putting medicines on the fingers or around the nails. If there are a few nails involved then sometimes steroids can be injected into the surrounding skin. While that sounds barbaric, it's actually not that painful and can have some terrific effects for patients with bad nail disease, meaning if all of the nails are affected and this is interfering with quality of life. For example, it causes an inability to handle or pick up small objects.

I have a patient who plays a violin in one of the local orchestras; this might represent a severe form of psoriasis and then the spectrum of systemic treatments would be made available to the patient. Bottom line is it depends on how it affects your life and how much it affects your life.

MEMBER QUESTION:
Is it OK to wear acrylics?

LEONARDI:
As long as the acrylic nails are not causing further damage, then I guess it's OK. But it can camouflage the issue, so one of the things you should do when you go to see your dermatologist is to remove your acrylic nails so we can see how bad it is. As silly as it sounds, I have patients come into the office who profess to have bad nails, but we can't see them.

MEMBER QUESTION:
I'm having one of the worst outbreaks I've had yet. I'm immunodeficient, so I can't take a lot of the new drugs. All I use is a topical cream. Any suggestions?

LEONARDI:
This is exactly why you should be seeing a dermatologist. The nature of your immunodeficiency should be understood, and if it is significant it will certainly affect the types of therapies that are appropriate.

"Patients with psoriasis are more affected emotionally by their disease than are patients who have internal cancerous malignancies."

MEMBER QUESTION:
I have a 49-year-old sister who has been suffering from severe psoriasis on her legs for about two years now. She has seen doctors and tried all sorts of medication, but nothing has worked. It's really depressing for her. She has such beautiful legs, but has not and will not wear skirts, shorts, or even capris. She lives in Dallas and wearing pants with its humidity isn't exactly easy. What can she do?

LEONARDI:
There are many new medications that have been recently approved, and she should see a dermatologist to discuss appropriate therapies for her psoriasis. Without knowing more, all I can say is the new treatments are offering many patients therapeutic options they never had before.

MODERATOR:
Can we address the emotional issues that sometimes come with psoriasis?

LEONARDI:
There's a terrific psychosocial impact on patients who have it. Studies have shown patients with psoriasis are more affected emotionally by their disease than are patients who have internal cancerous malignancies. The impact of this disease is significant and sometimes devastating. Dermatologists know this better than any other doctor.

You can join the National Psoriasis Foundation. That's always a good place to seek others with your disease. You can always seek out others in your community with psoriasis, as well. There may be local support groups your dermatologist may know about.

MODERATOR:
We are almost out of time, Dr. Leonardi. Before we wrap things up for today, do you have any final words for us?

LEONARDI:
Again, it's a great time for psoriasis sufferers. We're seeing a huge class of highly effective and novel therapies emerging from clinical research. The drugs appear to be far more convenient and safe than the current treatment options, and psoriasis sufferers should be asking their dermatologists about the new treatments and whether they are appropriate for them. Again, the important thing is to find a good dermatologist and work with him or her to manage your disease.

MODERATOR:
Our thanks to Craig Leonardi, MD, for joining us. If you are in the St. Louis area, please call Dr. Leonardi at Central Dermatology.

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