Psoriasis: Routes to Relief-- Mark Lebwohl, MD-- 12/02/03
By Mark Lebwohl
Psoriasis has no cure, affects people of all ages, and torments many sufferers with both physical and emotional pain. So what's the good news? New treatments and research into the causes of psoriasis may mean a faster route to relief. We talked about it with dermatologist Mark Lebwohl, MD.
The opinions expressed herein are the guest's 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.
Member question: How do I care for my skin during cold weather? I always have challenges during this time of year preventing outbreaks?
Lebwohl: Many patients note that psoriasis flares in the winter, and so they know they have to increase their compliance with treatment regimens. If your psoriasis responds to topical therapies you have to be more conscientious about applying them in the winter.
Many patients who clear with sunlight or require phototherapy will notice their phototherapy requirement goes up in the wintertime. For example, patients who are able to stay clear in the summer with sun exposure may have to go in for phototherapy treatments in the winter.
Member question: I have both psoriasis and mild acne. Are there any skincare products and makeup that you can recommend that won't aggravate either condition? Now, most products for acne dry my skin out even more, while dry skin products bother my acne.
Lebwohl: There are a number of products that are very good for both conditions, specifically retinoids, such as tazarotene, is approved for both psoriasis and acne and is effective for both. It's available in both gels and creams. There are oral retinoids, such as acitretin, which are very beneficial for psoriasis and might help acne a bit, but oral tazarotene will be available soon and is good for both acne and psoriasis.
In addition, there are a number of over-the-counter products that benefit both psoriasis and acne, specifically products containing salicylic acid are used to treat both psoriasis as well as acne.
Member question: Is it okay to scratch my psoriasis when it itches?
Lebwohl: It's best to use a variety of agents to calm the itch rather that scratch the itch, because scratching can lead to a phenomenon known as the Koebner reaction:when you traumatize the skin or scratch the skin you might actually cause psoriasis to become worse in that area.
There are over-the-counter agents that contain menthol, including a variety of itch creams that are very helpful for itching. Topical steroids, which are available over-the-counter and in stronger prescription forms, also help relieve itching.
Member question: How dangerous is it to continually use steroid creams to control outbreaks on my neck?
Lebwohl: Steroids are very effective but if you use them chronically there are a number of side effects that result. Cutaneous atrophy, or thinning of the skin, and formation of small, dilated blood vessels can occur with long-term steroid use.
In addition, patients get used to topical steroids and they stop working. For that reason we try to switch patients from topical steroids to nonsteroids such as calcipotriene, tazarotene, or new topical immunomodulators such as tacrolimus ointment or pimecrolimus cream.
Member question: I was told that consumer soap products irritate psoriasis. What over-the-counter soap products would you recommend?
Lebwohl: Soap products that are helpful psoriasis fall into a number of categories. First of all there are very gentle soaps or soap substitutes such as Cetaphil or soaps that contain moisturizers, such as Dove soap. There are soaps that contain medications including soaps with tar or soaps with salicylic acid.
Member question: Where can I get information about clinical trials?
Lebwohl: The National Psoriasis Foundation is a good source of information for trials. In addition, there are a number of university websites that contain that information. I am embarrassed to say that even though in my department we do tens of psoriasis studies every year, I don't believe our web site keeps it up to date. Anyone can feel free to call 212-241-3288 and ask about our psoriasis studies.
The phone number for the National Psoriasis Foundation is 1-800-723-9166. The web site is www.psoriasis.org.
Member question: How can I tell whether or not a rash really is psoriasis? How is it diagnosed?
Lebwohl: It is usually an easy clinical diagnosis that a dermatologist would be able to make by examining you. It does not usually require a skin biopsy, although rarely we have to perform a skin biopsy to make the skin diagnosis. There are no blood tests for psoriasis. We simply rely on the appearance of skin lesions and the distribution of skin lesions to help us make the diagnosis.
Member question: Is psoriasis more common in one area of the body than any other?
Lebwohl: The most common sites are on the elbows, knees and scalp, but it can also involve the genital area, the crack between the buttocks, and in severe cases can involve 100% of the body surface area.
Member question: I'm using Luxiq for psoriasis on my head; it is doing nothing for the condition. Is there something better?
Lebwohl: Luxiq is a foam that is not messy for the hair. The same foam is available in a stronger form known as Olux. There are also a number of other nonsteroid medications that can be used to treat the scalp, such as tazarotene gel or calcipotriene solution. If all that doesn't work, injections into the scalp can be helpful.
Lebwohl: Occasionally psoriasis of the skin requires higher doses of medications like methotrexate to achieve clearing. There are a number of new medications that are in development for both psoriasis and psoriatic arthritis. One of those medications is etanercept, which is approved for psoriatic arthritis, and unlike methotrexate, which only relieves the pain of psoriatic arthritis; etanercept halts progression of joint damage in addition to relieving pain. It is also substantially safer than methotrexate, but unfortunately is much more expensive.
Member question: Do you have any ideas on how to keep a child from itching, when they are too young to understand?
Member question: What shampoos and soaps do you recommend using for my child that has psoriasis?
Lebwohl: If you're referring to scratching of the scalp when kids go to sleep it's helpful to put cotton gloves on their hands. Also, many of the shampoos and topical medications used for scalp psoriasis effectively relieve the itch of psoriasis.
Member question: Are there any alternative treatments?
Lebwohl: I do not prescribe herbal remedies or unconventional therapies of that nature. There is a long list of treatments that have been well studied and approved for psoriasis. Those treatments don't come under the list of treatment alternatives. When we run out of approved psoriasis treatments that aren't working there are a number of unconventional therapies that are effective, such as Azulfidine, hydroxyurea, azathioprine, mycophenolate mofetil, and 6-thioguanine.
Member question: I had a severe case of psoriasis on my legs that has now disappeared, thanks to a combination of medication, diet, and exercise. I now have skin spots (scarring) where the psoriasis once plagued me. Will this ever disappear or is this just a sign that the psoriasis will come back to this area?
Lebwohl: First of all, if you achieve marked flattening of psoriasis to the point where there is just residual discoloration, continuing the treatment that resulted in improvement will often gradually result in evening out of the color. That is particularly true of ultraviolet light treatments where psoriasis can clear leaving residual discoloration. If you continue the light treatments, however, the color gradually evens out.
Member question: How does stress impact psoriasis?
Lebwohl: There are some patients for whom stress is a major contributor to psoriasis, and there are others where it plays very little role. A number of attempts to look at stress in psoriasis have shown an association, and in fact a group of investigators at a psoriasis treatment center in Massachusetts tried to use calming tapes that patients listened to while receiving ultraviolet light treatments. The patients that used the tapes cleared more quickly than patients who didn't.
Member question: My understanding of some material that I have read is that psoriasis is now considered an autoimmune disease. Some of the new medications are geared toward suppressing the immune system. My psoriasis is present only on the soles of my feet and palms of my hands. During the initial breakout there were pustules present, however I no longer have those and the palms of my hands are basically in remission.
Would it be beneficial for me to try the new drugs or are they reserved for more severe cases? If that would be an option, what would be the risks? My concern is that I do not get a lot of relief from ointments on my feet etc. and there is a very strong family history of cancer so I am concerned about the immune suppression.
Lebwohl: The impact that psoriasis has on an individual plays a big role in determining what treatments are appropriate. If psoriasis on your palms and soles is having a major, negative impact on your quality of life, it may be worthwhile trying strong treatments.
One of the treatments that do not negatively impact the immune system is acitretin. That treatment is quite effective for palm and sole psoriasis and is often used in conjunction with other topical remedies.
In addition, some of the newer biologic treatments that have been introduced, such as etanercept, alefacept, infliximab, and efalizumab, have only minor effects on the immune system compared to older drugs such as methotrxate or cyclosporine.
Member question: Does psoriasis ever leave a particular area of the body?
Lebwohl: The answer is that it certainly can, although it does not, characteristically. It would be unusual for psoriasis to disappear from one part of the body never to come back, but that certainly has occurred to some patients.
Member question: Is there such a thing as nail psoriasis? Are the treatments and medications the same?
Lebwohl: When patients have psoriasis only in their nails, topical therapies are of limited benefit. The only treatments that work for isolated nail psoriasis are injections of steroids in and around the nails. Because that procedure is painful, most patients choose not to have it.
When psoriasis is more extensive on the rest of the body, systemic treatments that help generalize psoriasis will also benefit nail psoriasis.
Member question: Are there any new drug therapies on the horizon? Seems like I've tried everything and nothing really seems to work well for me.
Lebwohl: If you're a candidate for systemic medications, there are a number of new medications in development for psoriasis. Just recently, in this past year, two drugs were approved. One of them is called efalizumab. The other is alefacept. In addition, etanercept and infliximab are being developed for psoriasis as a newer drug known as adalimunab. There are also several other drugs in development for psoriasis, which you'll be hearing about in the coming years.
Member question: Is there a special diet that has proved helpful in the treatment of psoriasis?
Lebwohl: Until now, every attempt to find a diet that either makes psoriasis worse or better has failed. So there is no psoriasis diet.
Member question: How does the doctor determine if one is a candidate for a systemic medication treatment?
Lebwohl: If psoriasis involves a large percentage of body surface, 10% or more, or is having a negative impact on the patient's quality of life, systemic medication would be justifiable, even if the percentage of body affected is small. For example psoriasis of the palms and soles can affect only a few percent of the body's area but can have a profound effect on a patient's quality of life, such as when buttoning a shirt, and the person may be reluctant to shake other people's hands, or patients with psoriasis of the soles may have difficulty walking.
Member question: A few years ago there was a product on the market called "Skin Cap." This is to date the most amazing product I have ever used to treat my psoriasis. Do you have any idea why it was taken off the market and if there is another product similar to it currently available in the U.S. or Canada?
Lebwohl: Skin Cap was sold over-the-counter and was said not to contain topical steroids. In fact, it illegally contained very powerful steroids and patients developed side effects as a result.
There are several preparations that contain the same steroid ingredient that was in Skin Cap: clobetasol is available in creams, ointments and solutions and Olux, the foam preparation we discussed earlier, contains clobetasol.
Moderator: We are almost out of time. Do you have any final comments for us, Dr. Lebwohl?
Lebwohl: There are many areas we didn't touch on. I think the National Psoriasis Foundation is a wonderful resource. They have a wealth of online resources, brochures, newsletters, and other materials that patients with psoriasis will benefit from. Their telephone number is 800-723-9166, and again the web site is psoriasis.org
Member question: Thanks to Mark Lebwohl, MD, for sharing his psoriasis expertise with us.
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