Psoriasis Disease: How Treatment Has Changed

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December 19, 2022
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By Nilanjana Bose, MD, as told by Susan Bernstein

I’m an adult rheumatologist, so I see patients as young as 18 with the full range of rheumatologic conditions. Every patient I see is different. In patients with classic psoriasis disease, skin psoriasis symptoms often appear before their arthritis symptoms appear. These two conditions can even be years apart in some people. But that is not absolute. They may develop arthritis or joint pain and swelling first and later develop psoriasis.

Patients usually come to us first because of their joint swelling. Usually, psoriatic arthritis causes peripheral joint swelling. You will have swelling in your fingers and toes that may resemble rheumatoid arthritis (RA). We do an initial work-up and also examine their skin. If you have psoriasis, including nail pits or psoriatic plaques, or if you have a family history of psoriasis or psoriatic arthritis, this may indicate that you may have psoriatic arthritis.

COVID: Hello, telemedicine

When the pandemic hit last year, we had to go into retreat mode at our clinic for the first few months. We really had to adapt. We quickly transitioned to using telemedicine to treat our patients. We didn’t have some of the telemedicine technologies, but once we realized that there were resources out there like telemedicine portals and online platforms that we could use, we started adopting them.

I think our patients got used to telemedicine pretty quickly too. There were some challenges with older people. Some did not have internet access or found it more difficult to work out the logistics of telemedicine. But for these patients we were also able to carry out regular telephone visits.

Telemedicine brought its own challenges. We had to learn how to “examine” a patient over the Internet. It’s not easy, and it’s not optimal for joint or skin conditions. But a telemedicine visit is any day better than a patient who misses their appointment in the first place and has no access to medical care.

For follow-up visits, telemedicine is easy and works well. You can check in with patients and see how they are doing on their current medications. Some of my patients prefer telemedicine for convenience. Again, it’s not optimal. We still encourage our psoriasis patients to come to the practice. It can be difficult to see everything on camera.

Overall, telemedicine was a fun experience, but if a patient needs to be seen in person, I ask them to come in. We are all still masked, practicing social distancing and taking every precaution. We are very committed to the whole aspect of infection control in our patients.

I’ve even seen new patients using telemedicine, especially during the worse phases of the COVID pandemic. If they have been referred to me by another doctor because they have psoriasis, I can do the initial consultation remotely, but I still try to let them come. Simply coming in and seeing a rheumatologist to start your treatment is ultimately the most important step in psoriasis disease. You can build a relationship with your doctor and get the information you need.

Biologics: Game Changers for Psoriasis Disease

Biologics have completely changed the way we deal with this disease. Once you’ve been diagnosed with psoriatic arthritis, there are great treatment options. In the past we had steroids, DMARDs (disease modifying anti-inflammatory drugs) and TNF inhibitors, but now we also have IL-17 and IL-23 inhibitors and JAK inhibitors.

First, we screen our new patients with lab tests and joint scans, and go through all of their symptoms. Some people will have milder psoriasis disease, and some will have more systemic symptoms. With younger patients, we may try to control their disease more aggressively because they are at greater risk of joint damage.

As we go through treatment options, it’s really a two-way, fluid discussion. I talk to my patients about all the risks and benefits of each treatment. If my patient is better after a few months, we can talk about it and re-evaluate the treatment plan.

It is very rare nowadays for people with psoriatic arthritis to develop chronic joint deformities. It can happen that someone was diagnosed a long time ago, before better treatment options were available, or because they did not have access to medical care before they came to us. The improvements are mainly due to advances in drug treatment, but also to greater awareness of rheumatic diseases. You google it. They just have more awareness of rheumatic diseases and that they need to see a rheumatologist.

We screen every patient. Some of them have true inflammatory psoriasis disease, some don’t. You may have osteoarthritis or fibromyalgia, which causes joint pain. Every patient deserves a thorough, complete examination. We want to diagnose these patients as early as possible to start treatment to control their disease and prevent harm.

COVID and other infections: Take extra precautions

We had exactly this discussion with our patients before COVID. You are at higher risk of serious infections not only COVID but also other types of pneumonia and other infections. We had already encouraged these patients to wash their hands often, take sensible precautions, avoid close contact with sick people, and get all their vaccinations.

When the COVID vaccines became available, I told them, “Please get vaccinated and keep wearing your mask.” People who take a biologic to treat their psoriasis are more cautious by default. I have advised new patients who have just started taking biologics to take precautions to prevent infection. We have told many of our psoriasis patients, “Stay at home as much as possible now and avoid close contact with others.” Patients listen to this advice because they trust us as their doctors.

Psoriasis patients feel safer

Always have a backup plan with telemedicine technology! I have also encouraged all my patients to sign up for our online patient portal so we can stay connected. They can message me, I can update their recipes, and we can share test results with them.

Technology is a beautiful thing. We have to use it optimally in modern medical care. Technology can make it easier to stay in touch with patients with psoriasis who need ongoing care. However, some patients may not be used to telemedicine, so they may be a bit frustrated at first. Be patient, take the time to learn how to use these tools, and help your patients adapt. Don’t give up if something doesn’t work at first.

Personal interaction is still very important when working with patients with psoriatic arthritis. It can be difficult to form a new patient/doctor relationship without a personal component.

Some patients continue to see me virtually after diagnosis and it seems like we can get to know each other really well. Telemedicine is a safe environment for patients. They are at home or in the office or even in their car. Sometimes when I talk to a psoriasis patient about telemedicine, I see them taking notes. It’s good! Some people find that they are less anxious when they have a telemedicine appointment than when they are in the doctor’s office.

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Psoriasis Disease: How Treatment Has Changed
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