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Treating Psoriasis: No One-Size-Fits-All Answers

Dr. Sanjay Gupta
 

By Dr. Sanjay Gupta

(Everyday Health) – Cleveland Clinic dermatologist John Anthony, MD, discusses the unique challenges of diagnosing and treating the skin condition.

Psoriasis is a chronic autoimmune disease of the skin affecting more than 7.5 million Americans. Faulty signals from a person’s immune system accelerate the growth cycle of skin cells, which can result in dry, red patches on the skin and a silvery buildup of dead skin cells resembling scales.

While psoriasis is a relatively common skin disease, its physical and emotional impact on an individual is a very personal journey. “Psoriasis really affects people in various ways,” says dermatologist John Anthony, MD, of the Cleveland Clinic in Ohio. “Some patients are very tolerant of their condition. Others are extremely troubled, either symptomatically or from an appearance standpoint.”

Dr. Anthony recently sat down to talk about the challenges of diagnosing and treating psoriasis, and something he wishes more people with the disease knew.

The visible nature of psoriasis poses real quality-of-life issues for so many people.One study found that 83 percent of patients frequently feel the need to hide their condition. Has that been your experience treating people with the disease?

Yes, it can be socially isolating. I have some patients who have psoriasis of the hands and nails, and they quite obviously try to hide it. They’ll keep their arms crossed and their hands covered. I often hear people say, “I can’t wear shorts in the summer.” Even though the sunlight might benefit their psoriasis, they’re too worried that people will ask what’s wrong with their skin. Or if it’s psoriasis of the scalp, they might be self-conscious about skin flakes on their clothing. It’s like acne in that it has some of the same stigma associated with it.

It’s not very surprising then that psoriasis has been linked to an increased risk of anxiety and depression, is it?

I know that statistically and nationally, we see increased risks of depression associated with psoriasis. I find among my patients, it’s more common among people who have more severe psoriasis. I’m thinking of one gentleman in particular who had very severe psoriasis, and it really wore on him. His mood improved substantially as the psoriasis was better managed.

At the same time, what might seem rather mild to the doctor may be very severe to the patient. So you need to determine not just how severe the psoriasis is, but how severely it’s affecting the patient.

Is it common for psoriasis to go undiagnosed or for the condition to be mistaken for something else?

There are some very unusual presentations of psoriasis that can delay diagnosis. The patient may not have scales on their skin; or the disease affects other areas like the fingertips, the palms, and the soles of their feet. A person might think they have aneczema kind of rash. If the psoriasis is pustular, triggering pus-filled bumps, the patient might be treated for infections or folliculitis. There are certainly situations where people are misdiagnosed and receive treatments that aren’t very effective.

The National Psoriasis Foundation has surveyed psoriatic patients about treatment satisfaction, and data collected over several years suggests that more than half were not satisfied. How do a doctor and patient see eye to eye on treatment?

Whether it’s a first visit or over the course of several visits, I try to gauge the patient’s treatment satisfaction. I often tell people that they get to kind of drive this train. I want to get a sense of where they are in their treatment: How onerous is the regimen, and what is it doing for them? From a compliancy standpoint, I want to make sure that what we’re giving them is going to be doable.

With so many treatment options — from topicals and light therapy to systemic and biologic medications — how do you settle on the right approach at the right time?

It’s an ongoing conversation the doctor has to have with the patient. At what point, for instance, should you move to systemic therapy if they’re not getting satisfactory results from topical creams? Some patients are hesitant because of potential side effects, and they’re less willing to go to a systemic until they’ve had an opportunity to try other therapies. Certain treatments may be cost-prohibitive for the patient. So you have to weigh cost versus benefits and risks.

What do you wish more people with psoriasis knew?

Even though psoriasis is chronic, there are a lot of very good treatments out there. And we’ll continue to see new and improved ones. This is a really amazing time.

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