By David Rosemary, MD, as reported to Stephanie Watson
The treatment of psoriasis is very different from what it was 10 or 20 years ago.
We have many great treatment options that are extremely effective. So we are usually able to achieve most people’s goals.
When someone comes to me with a diagnosis of psoriasis for the first time, I am very interested to know what their goals are. It is important that you tell me what you want to achieve with your treatment and how quickly you want to achieve it. That way I can give them the right treatment.
So I ask questions like:
How Fast Do You Need Clear Skin? Do you have a big event coming up? Do you want to be ready for vacation? Whether they need to see a reaction in a month or aren’t interested in a quick fix helps us make treatment choices.
For example, if someone wants a very quick response, we can use a drug that suppresses the immune system or a biologic that works quickly. When we do this, 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 you want to free your legs so you can wear shorts in the summer? Want to get their scalp cleaned so they don’t have to deal with flakes? Do you want to get rid of the itch?
We also talk about her nails when they pose a problem. It’s helpful to know this in advance, as nails can take longer to clean than skin.
How is your treatment tolerance? Biologics are targeted treatments that have revolutionized the way we help people with moderate to severe psoriasis. The ones we use to reduce inflammation come as injections or IV fluids. So are they afraid of needles? If this is the case, it may be better for them to undergo a treatment that involves an injection every 3 months rather than once a week. We also have other alternatives such as oral medications, phototherapy and topicals.
Overall, the side effects of biologics aren’t too bad. Infection is slightly 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 are safer too. For example, newer biologics don’t increase your risk of cancer.
However, it is important to me to know a person’s concerns and medical history before I prescribe them any medication.
Are your joints affected? I ask all the people I treat if they have joint pain or stiffness. If this is the case, they could have psoriatic joint disease. That means I have to give them a plan that treats both skin and joints. I can work with a rheumatologist to treat her.
One of the biggest hurdles we face in getting people the right treatment is insurance. Some of these drugs can be quite expensive. Insurance companies may prefer that we start with a specific treatment. They want Treatment A first, when we want Treatment B. Most of the time this is based on cost.
For example, many pharmaceutical companies have programs in place for people who are insured through an employer plan to get them straight to the drugs they need. Apart from a small co-payment, they cover the entire cost of the drug. For people on low incomes, foundations can help them afford their medication.
Weight can be another stop to relief. Some people with psoriasis are overweight. Those who are more severe may have a more serious illness. Sometimes losing weight can help your treatment work better.
The more open you are about your illness and its effects, the more productive your visits to the doctor will be. Come to each appointment to voice your concerns. This includes talking about sensitive topics, such as how your psoriasis is affecting your genitals. It is important to know that these visits are confidential. You can’t get relief if you don’t tell your doctor about your problems.
If your illness gets worse, don’t wait until your follow-up appointment to tell your doctor. Tell them immediately. You might want to send in photos to show what you’re going through.
When people are experiencing side effects from their medication, such as coughing or shortness of breath, recent infections, or anything they are unsure about as related to their medication, I always prefer that they call and ask. We can either reassure them or take action to address the issue.
For example, if your skin gets worse just before the next injection, your doctor may need to increase the dose. If you are no longer responding to your medications or never reached your original goal, your doctor may add a topical medication or switch you to a different medication. Some of these medications can become less effective over time.
We cannot cure psoriasis, we can only control it. It’s like having high blood pressure or high cholesterol. You have to stay on your regime. If you stop your psoriasis medication, the disease will come back.
You do not want to start and stop your medicine as it will result in 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 taking a drug indefinitely, but these drugs are safe long-term.
Psoriasis medications are very effective. Some of them improve the disease by an average of 90% after 4 months and 95% after a year. Some can even make people completely lucid.
It’s great to be a doctor treating these people because I can have a huge impact on their quality of life.