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MedEvidence! Truth Behind the Data
🎙Getting to the Root of Psoriasis Ep. 321
Dermatologist Dr. Kristen Stewart digs deep to get to the root of psoriasis, a skin condition that affects approximately 3% of Americans. She talks about the role of systemic inflammation and how excessive inflammation can impact multiple body systems beyond just the skin. Dr. Stewart reviews her experience treating psoriasis, differentiating it from eczema, and the improvements in modern treatments. Dr. Stewart explains that newer treatment options have revolutionized management approaches, shifting goals from simply reducing symptoms to achieving near-complete clearance and addressing the underlying inflammation.
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Music: Storyblocks - Corporate Inspired
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Dr. Kristen Stewart:Psoriasis is one of my favorite conditions to take care of, because almost always which you shouldn't always say you can get people a lot better and feeling a lot better, so it's very satisfying for everybody. But just to kind of get started, so which of the following areas can be affected by psoriasis? The face and neck, the scalp, elbows and knees, the palms, hands and soles of the feet, any takers, all of the above, all of the above. So that is absolutely it. So it really can happen anywhere. Those are the areas where it tends to like, and sometimes the distribution of psoriasis can help us tell where the rash is, the difference between psoriasis and eczema, and we'll talk about that a little bit too.
Dr. Kristen Stewart:Which of the following is not a common trigger for psoriasis? Flares, stress. Well, I think stress can flare just about anything Acne, eczema and psoriasis and I tell my patients all the time I wish I could come up with a lotion or potion that took away stress, but we haven't figured that out yet. But skin injury, cold weather, improved sleep, so actually. So the one that's not is the improved sleep. So skin injury, there's something called kebnerization and Dr Kebner was the one who realized this, so it's still named after him that psoriasis often comes up in areas of injury, so, for example, even like a scratch in the arm, then sometimes it'll come up it doesn't happen every time or a surgical site. I had a patient with psoriasis who then had a procedure to treat their skin cancer and the psoriasis came up along where, like at first, they thought the wound was infected, but it was just that the psoriasis came up along the wound. So sometimes a trigger or stress is skin injury and cold weather can make psoriasis flare. Hot weather can too, especially kind of in the groin or you feel itchier a lot with hot weather too.
Dr. Kristen Stewart:So what is psoriasis? We know it's a chronic disease. We know that we don't yet have a cure for it. It's where the cells of the skin build up quickly and that's what forms the plaques, and they usually causes red or brown discoloration. It's usually scaly or flaky and the plaques can be itchy. Some plaques in psoriasis aren't itchy and some are, and everybody's a little bit different to the degree of itch that they have. But that's what it is in general, things that it's not contagious and a lot of people worry about that and it's not contagious. Or when other people aren't familiar with psoriasis, they worry about how other people perceive them or worry that, like, if I shake your hand and you have psoriasis, am I going to get it? It is not at all contagious whatsoever. It can vary in severity. Some people have very mild psoriasis and affecting a few people places and it doesn't bother them. Some people are covered head to toe.
Dr. Kristen Stewart:We talk a lot about psoriasis and body surface area and I'll talk about that at the end like one of our goals or treatments, and our goal is to have it affect a low body surface area. So body surface area is the palm of your hand and you have like a certain area. So if I have a psoriasis plaque, this is 1% of my body surface area. If it's this big and if I have 10 of those, then it's affecting 10% of my body surface area. But it can vary in severity.
Dr. Kristen Stewart:It's immune mediated the inflammation of psoriasis caused by dysfunction of the immune system. What else do we know about that or how do we know how to describe that? We really don't. There's a lot that. We know a lot of triggers. We know a lot of cytokines. We know a lot of inflammation, but we have not figured it all totally out, but we know that it's the immune system that's almost kind of overreacting and causing this inflammation. Right now, as I mentioned, there is not a cure, but we have lots of treatments to manage it and really improve the quality of life. So it's kind of like high blood pressure While you take your high blood pressure medicine, your blood pressure is controlled, but if you stop taking it, it comes back again. Same thing with our psoriasis treatments While you take your psoriasis treatments it works, but we do expect it to come back afterwards.
Dr. Kristen Stewart:Psoriasis tends to affect both the skin and the nails, and there's some nail changes to it too. We treat those the same. But what's important, and when we talk about treatments, the inflammation of psoriasis also affects other parts of the body. We see it in the skin and the nails, but it can really affect the joints, which causes arthritis or psoriatic arthritis, which is very important to treat, and it can cause inflammation in the blood vessels. It can be related to cardiovascular disease. That's why we see more cardiovascular disease in people who have psoriasis. But the inflammation is not just in the skin and the nails, but internally in the body too.
Dr. Kristen Stewart:How common is it? Well, psoriasis affects men and women equally and it occurs both in children and adults. We certainly see it more in adults, but we still see it in kids too. I've seen psoriasis in kids as young as six months. It's much less common. Really, overall, the peak ages of onset are between 30 and 39 years or in between 50 and 69 years old. So it is something more of an adult onset. But lots of people do get it as a kid or in their 20s. That can happen too. But overall, about 3 out of 100 Americans or adults in the US have psoriasis and again, that severity degree may be very mild or may be very severe, but 3% overall. So it's really quite common.
Dr. Kristen Stewart:Why does it occur? And, like I said, we know it's an immune dysregulation, but the real wise, we don't totally understand all the parts of it. We believe that there's a big part that's by genetics, the immune system as well as the environment. Psoriasis plaques occur again because the immune system is overreacting and it speeds up that skin growth. Normally skin cells completely grow and shed off and the skin turns over about once a month, but in psoriasis that happens every three to four days. And the other thing is you get that complete growth but it doesn't shed off and that's why the skin thickens and that's why it's flaky.
Dr. Kristen Stewart:And who develops psoriasis we just talked about one of those key factors is genetics and maybe a family member having it. So 40% of people with psoriasis have a family member, but 60% don't, you know. So we know that there's a factor, but it's not the whole thing. And someone with a family member is more likely to have psoriasis, but it doesn't mean that they're going to. Either family member is more likely to have psoriasis, but it doesn't mean that they're going to either, and I think we don't. Again, it doesn't mean that if a mother or father has psoriasis, that their child will definitely. But we do see it a little bit more.
Dr. Kristen Stewart:We talked the other slide talked about genetics, the immune system and environment, and the environment like sometimes there's a triggering agent that may change the immune system and cause or trigger the onset of psoriasis, and we see this especially with strep infections. Someone who may have a family predisposition to psoriasis they have a family member with it, but they've never had it they get strep throat and they break out in a rash. Sometimes you just think it's part of that, but sometimes there's something about that strep infection that can trigger someone who is already predispositioned to have psoriasis, and then that's the start point or that's the age where it comes on for them. We also see that with HIV and some medications. We do see more psoriasis in people who smoke or are overweight or have high alcohol. It's not the trigger or it's not a total, it's an exacerbating factor. We see it more often, but it's not a direct, but it's a risk factor overall. And so what does it look like? So we just talked about psoriasis can happen anywhere on the body.
Dr. Kristen Stewart:It can be varied in severity, from mild to nearly all over. Those common locations are the scalp, elbows, knees and the groin. The plaques can be red or brown. They can be sometimes there's guttate psoriasis, in which little tiny... guttate is like Greek or Latin for dew drops, so they're little drops in their little, little tiny psoriasis plaques. And other times, and what we see most often, is large plaque psoriasis. Where the plaques are larger, some areas may feel thick and be raised and have that white, dry, flaking skin and sometimes, especially over areas of bend, that thickened skin will kind of fracture or break and it can bleed and that can be very painful too. Skin with active psoriasis can feel itchy or irritated, sometimes burny or stingy, and we mentioned that.
Dr. Kristen Stewart:It can also change nails. Sometimes to the nails we'll see like a what's called. We call it an oil stain and it's just a yellowing underneath the nail plate. Sometimes we'll see nail pits or little things. They're not specific to psoriasis because we do see them in other conditions. So I can't always look at nails and know it's psoriasis, but it's a clue. Another thing that's a clue in another location is like the crease of the buttocks is super common in psoriasis. So if I'm looking at someone and I'm trying to figure out if it's eczema or psoriasis, and I look there and it's more likely to be psoriasis. So sometimes those locations and those nails are clues to what's going on.
Dr. Kristen Stewart:So in diagnosing, a lot of times we're looking at the appearance of the skin and nails. There are times that I can walk into a room and I know it's psoriasis, just experience and seeing it and it's classic and I don't have any doubt. And there are other times I look and I'm like this could be lots of other things, because lots of other rashes are red, itchy or scaly. I'm looking at the locations for those and where they may be and the history of it, the family history and stuff like that, and I'll talk a little bit more at the end. The location and the locations tend to be classic, like, for example, eczema, commonly, and there's no absolutes. But eczema tends to be in the flexures where we flex at our arms, so the flexures of our arms and the flexures of the back of the leg, where psoriasis tends to be on the extensor surfaces, so it's on the back of the elbows and the fronts of the knees. And so again, there is overlapping features with other skin rashes, with the itching, and sometimes I can't tell. You know what it is and I'll do a biopsy. And sometimes, when I can't tell if it's eczema or psoriasis, sometimes the biopsy can tell, sometimes the biopsy can't tell either. Sometimes it comes back and it says this looks like eczema and psoriasis and I'm like that's what I thought. You know what I mean. And there's that overlap too. But there are times that the biopsy can push us in one direction or the other when they overlap. But there are definitely people who have straightforward eczema and there are definitely people who have straightforward psoriasis, but there's a small group in between that have overlapping features and that's just what they are. They have overlapping features and so we always want to try to put a label on it, and sometimes we need to, but they're just a little bit in between people or individuals.
Dr. Kristen Stewart:Why treat? We treat the skin because of the itch and the irritation. We treat the skin so that people feel confident, because sometimes it's really hard with psoriasis, especially in when areas that it shows and, like I said, people who aren't familiar with it it's you know. It's hard for them to shake hands or to do things or to wear certain things or put bathing suits on and that type of thing, just to be out there, because people who don't understand psoriasis aren't always kind and I think that can be really hard. I have some patients who tell me that I am finally better because I don't have to vacuum my bathroom floor every single day, just because sometimes there's just the shedding when the skin is very dry with psoriasis and it leaves that shed and that mark and having that help and just you know.
Dr. Kristen Stewart:We treat psoriasis so that people aren't staring at your plaques and you feel good and where you are, and so there's a whole range of where people are. Some people are very accepting of their psoriasis and it doesn't bother them at all and it's not itchy, and and other people it affects them a lot and also in their self-confidence, and so that's the one, one of the reasons we treat. The second reason we treat is just to go back to the other slide that it's not just about the skin, that inflammation is inside the body, to the amount that that inflammation is in the body also varies, and and it may be very, very mild or it could be more severe, but we know that the skin psoriasis is a sign of inflammation occurring in the body, and people with mild psoriasis, which is considered less than 3% which is, you know, if you put all the ear plaques together and all their psoriasis, it would equal three palms that they may have some inflammation in the body too. And even though there's no cure for psoriasis, systemic treatments meaning taking something by mouth or by injection, something affecting the whole body versus a topical can help improve the skin symptoms as well as lower the risk of the psoriatic, arthritis, heart disease, obesity, diabetes and depression that sometimes we see more in people with psoriasis. So currently our treatment options we have a lot.
Dr. Kristen Stewart:When I started in dermatology 15, 20 years ago, we had like topical steroids, light box and Enbrel or Humira. We had like two things. You know what I mean, and I remember the first time prescribing one of those because they were new and they seemed a little bit scary. But over the last 15 to 20 years it's so different. The other thing is my goal for treating patients when I first started was like so they weren't miserable, you know, and that they weren't itchy and I got it as better as I could. But like I didn't even dream of clearing anyone you know what I mean or really controlling it. I was just trying to control it as much as I could for them. But we have both steroidal and non-steroidal topicals. The non-steroid ones are also very new and it's exciting to have new things that work well.
Dr. Kristen Stewart:Phototherapy is light therapy and in general dermatologists, we all tell you to stay out of the sun, right. But we use the light box to treat things that are red and itchy and different things. So we use it for psoriasis, we use it for eczema. It is different than a tanning booth. It is very. It's a narrow spectrum so that you you're actually trying to get a little bit of immunosuppression to the skin to have to decrease the inflammatory response of the psoriasis, but we're trying to do it without giving the risk of skin cancer. So we protect other areas. And it's a special. The lights are special. A lot of times we talk about UV light in a spectrum so it was, you know, 200 to 400 nanometers and this is just 311 to 313. And that's why the phototherapy that we use in dermatology is safer than a regular tanning bed. But there are times, living in Florida, we have I'll have people say my psoriasis is fine all summer long. You know what I mean. Or when I'm out in my shorts, you know, and I'm not covered up because of getting a little bit of sun can help it, so you can use natural light too.
Dr. Kristen Stewart:The systemic treatments includes oral pills and the biologic agents, which are injectables, and those are really what has transformed and changed so that we can get people more clear and in a good spot, and those are the ones that also, if there is internal inflammation from the psoriasis, those are the only ones that are going to address that part. So recent research in psoriasis has led to all these new things which are revolutionizing it, like I said, where my goal of getting someone to better just to not be miserable, literally, and that's true, I mean I didn't think of it in that way until looking at it in retrospect, 20 years ago, and now we the treat to target is really kind of stringent, and this is what the American Academy of Dermatology is kind of putting out, like our goal should be that the psoriasis affects less than 1% body surface area and within three months of starting the treatment Does that always happen? No, you know what I mean. But when we're thinking about treatment or evaluating where are you with treatment?
Dr. Kristen Stewart:I think a lot of times it's a very personal decision. Like I'll try to tell patients I don't want to over-treat you, I don't want to under-treat you. You know where are you with your psoriasis and my psoriasis is controlled, but I spend two hours a day putting cream on my body. You know what I mean and you know and how much homework you have at home to do that and to maintain it, and you know, so I. It looks good, but is it too much work? Do we need to be doing something else?
Dr. Kristen Stewart:Or, um, somebody who, um, has it, uh, psoriasis, and not a lot a high body percentage area, but it's on their palms or it's in their groin and it itches like the location really matters to feet. The hands and feet, um, I think are hands, feet and groin are harder to treat and have more. Not that elbow psoriasis isn't impactful, but it can sometimes have more impact. But the impact of psoriasis is also very personal and I think that's something that you have to work with your doctor. Be like how much is this bothering you? These are our options. What do you want to do? And that there are lots of options. But that target to treat is setting a whole new bar for psoriasis that we didn't have years ago.
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