Psoriasis is a chronic condition for which there isn’t a cure. It can, however, be effectively managed. Dr. Laura Wagner, a dermatologist in Chesterfield, explains that psoriasis is an autoimmune disease caused by a disregulation of the immune system. A characteristic inflammation of the skin causes skin cells to turn over twice as fast as normal, creating scaly patches.
On the scalp, it looks like really bad dandruff. Only one-fourth of patients have widespread skin involvement; most have it on the scalp, elbows and knees. It gets worse in the winter, around areas of trauma, and with stress. “Infection really revs up the immune system, including psoriasis,” she says. “The classic trigger is strep throat, and the typical age of onset is between 15 and 25, although people can be born with it. It’s a genetic disorder; 2.5 percent of the population carries the gene.”
Wagner says treatment depends in part on the patient’s perception of the disease. “Some people are OK taking a while to clear fairly extensive involvement, while others are upset with one little spot,” she explains. “One-third of psoriasis patients have arthritis with the skin condition. When we put them on biologics, joint stiffness and pain go away.” The biologics she refers to are a relatively new class of medication that treats autoimmune diseases by targeting specific parts of the immune system.
“Some target a specific protein and block its receptors,” Wagner explains. “By blocking the overactive part of the immune system, we can turn off the psoriasis, but only as long as the patient keeps taking it.” Most biologics are self-administered by the patient as subcutaneous injections twice or four times a month. Some are infusions given in the office by I.V. every two to three months. “Biologics were first used for rheumatoid arthritis, and doctors noticed that when patients were treated by them, their psoriasis also cleared up. We now know that much of what we thought was rheumatoid is actually psoriatic arthritis.”
Dr. Milan Anadkat, a dermatologist with Washington University School of Medicine, says that while we know psoriasis is autoimmune, we don’t know the actual target. “We know it’s genetically driven, but not in a typical autosomal dominant or recessive kind of way,” he says. “It just seems to run in families. We don’t know why people have it or any way to prevent it. Is it a skin disease or a joint disease? Newer research also seems to indicate an increased cardiovascular risk, especially in severe psoriasis, because of the generalized inflammation.”
About three years ago, the Journal of the American Medical Association (JAMA) published a study done in the UK showing that people with severe psoriasis had an increased risk of heart attack, Anadkat says. “We’re currently doing a clinical study of overweight people with psoriasis, to determine whether losing weight can help their psoriasis, while decreasing heart risk factors,” he adds. “We got the idea from case reports showing that after massive weight loss from bariatric surgery, psoriasis cleared up.” People interested in participating should call 362-1000.
Anadkat is very encouraged by what he sees with the biologics. “Eight to 10 years ago, we started injecting biologics, like Embrel used for rheumatoid arthritis. Now we have even better ones,” he notes. “They are targeted treatments with fewer side effects. Some patients have done well on them for a decade. The theory with biologics is that if the target is specific enough, we can just block that and reduce other systemic side effects. However, all biologics depress the immune system, so infections are a worry, just as they are with anti-rejection drugs after organ transplant.” He usually first tries an older drug known to be safe long-term that may take a little longer to clear up the problem.
Dr. Michael Heffernan with Central Dermatology says he has the largest psoriasis practice in the Midwest. “We have 1,300 patients we manage with psoriasis, and several of our staff have it,” he says. “Probably half our new patients hadn’t seen a doctor about their condition in the last three years because they became frustrated with the treatment options available then.” Heffernan and Central Dermatology have participated in at least 50 clinical studies, and he says they can offer patients otherwise unavailable treatments. He urges patients to stay with psoriasis treatment because one-third of them will develop symptoms of psoriatic arthritis, and several treatments have been shown to stop deterioration of the joints.
“More new medications for the condition have come out in the last five years than in the 50 years before that,” he says. “Severe psoriasis has been associated with heart attack, stroke and even lymphoma; it should be treated. There are newer medications and light therapies available that are more effective, more tolerable, and have fewer side effects. Some newer medications are also safer for pregnancy and nursing, so younger women who want children can still be treated. We are much more successful at getting people safely clear and keeping them clear longer than ever before.”