Derm-It Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-It Trotter! Don't Swear About Skincare.
Biologics, Myths, and Monitoring: The Evolution of Psoriasis Treatment
Psoriasis is more than a skin condition—it's a signal of whole-body health. In this episode, Dr. Steve Feldman, leading psoriasis expert and dermatology professor at Wake Forest, unpacks the evolution of our understanding of this complex disease.
Once seen as purely skin-deep, psoriasis is now known to be a systemic inflammatory condition linked to joint pain, heart disease, and depression. But which of these risks truly matter? Dr. Feldman separates clinical facts from online fearmongering, offering clarity on what patients should really pay attention to.
He also walks us through the dramatic shift in treatment—from coal tar and immunosuppressants to game-changing biologics that can clear skin with just a few injections a year. Plus, surprising insights from his research on medication adherence reveal how patient behavior affects outcomes more than we think.
Whether you have psoriasis or just want to understand the broader health implications, this episode is your guide to smarter care and realistic risk assessment.
Welcome to Dermot Trotter Don't Swear About Skin Care where host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
Speaker 2:Welcome to the Dermot Trotter Don't Swear About Skincare podcast. On today's show I have Dr Steve Feldman, professor of dermatology, pathology, social sciences and health policy at the Wake Forest School of Medicine. Dr Feldman ranks among the top experts in the world on psoriasis by expertscapecom, and he also serves as the editor for the Journal of Dermatological Treatment and the Journal of Dermatology and Dermatological Surgery and as chief medical editor of the Dermatologist Magazine. Welcome to the podcast, steve. It's great to have you here today.
Speaker 3:Oh my, it's my pleasure to be with you. Thank you so much for inviting me.
Speaker 2:Well, I'm really excited to have your expertise on today because I want to talk a bit more about psoriasis. A lot of people out there listening know somebody who has psoriasis, or maybe even personally has it, but what they may not really realize is that psoriasis is kind of that cliche. We say more than skin deep, so I was hoping to kind of have you talk a little bit more about psoriasis as more than just a skin disease.
Speaker 3:Yeah, so I started seeing patients with psoriasis 30-something years ago and the situation has evolved considerably. I think we used to spend a lot of time talking about how it affects people psychosocially and how to explain to friends that it's not contagious people, how it will see in the stores and children will point or lifeguards won't let you into the pool. Hey, now we have drugs to clear the skin up, and so now, instead of focusing so much on the psychosocial aspects of the disease, we're more focused on clearing people up and the internal manifestations. I think we always knew that it affected the joints in like a third of the patients.
Speaker 3:I'm here at Wake Forest, the guy who did psoriasis before I got here, the wonderful Michael Zanolli. He did a survey of all the patients he was seeing with psoriasis and I think was one of the first people to document that about a third of the patients have psoriasis affecting their joints, causing stiffness, pain, swelling. The folks at the University of Pennsylvania back about 15 years ago did this seminal study, a real landmark study, using data from British primary care doctors showing that psoriasis is associated with a clear, distinct increased risk of heart disease and related vascular blood vessel diseases, and that opened the floodgates, people started looking for all kinds of other associations and finding all kinds of things associated with psoriasis.
Speaker 2:So kind of what you're saying, you know it's just so, especially for our listeners, because when they had come in, they have psoriasis. You know, obviously, like you mentioned, focused on the skin Traditionally. That's where we've been. Now we've got great medicines that basically clear up the skin, but now we're looking at problems that are associated with psoriasis that patients might have, like heart disease and joint arthritis, as we call it, or joint problems too. Beyond those two, are there other things that somebody with psoriasis should maybe sort of stop and say okay, maybe I'm at risk for other things as well.
Speaker 3:Well, yes and no. So we Americans are at a high risk of having depression. We have it really good here, but we still get depressed. And there's an increased risk of depression in patients with psoriasis. Hopefully really good treatment reduces that risk, but I'm not sure we have strong data to tell us one way or the other. And then there's all kinds of other things.
Speaker 3:I had one of my students make a list of all kinds of things that had been associated with psoriasis Kidney disease, melanoma, aortic aneurysm, so like the big blood vessel that leaves your heart just blowing out. All of these were associated with increased risk and many other conditions. But I'm not saying that your listeners should be worried about any of these. I'm just saying there's associations, and some of these associations are based on studying millions of people, claims, data on millions of people, and they can find statistically significant associations which gosh the people who do the study get all excited about and write papers and publish, you know, stuff that gets into the lay literature saying there's an increased risk of X, y, z and you know, may not be clinically meaningful. One of the study that that student of mine did he looked at the thing that had the highest risk there was a six fold increased risk of having a melanoma. Now that sounds bad, right, but it was a study done in Taiwan, where melanoma is so rare that it would have taken 20,000 people with psoriasis before you would see one more melanoma. So yeah, it's statistically associated, but it's clinically meaningless.
Speaker 3:The heart disease one glass half empty, half full Probably not a bad idea. To eat a healthy diet, you know. Get regular exercise, get your cholesterol checked, you know, and take something for cholesterol if you need to. But everybody should do that, whether they have psoriasis or not. That first study that the folks at University of Pennsylvania did found that if you had bad psoriasis, you were at like a three-fold increased risk of having a heart attack.
Speaker 3:That sounds bad. Well, that was 20 to 30-year-olds. If you were between the ages of 20 and 30 and you had bad psoriasis, you were at a three-fold risk of having a heart attack. But what's the risk that a 20 to 30-year-old without psoriasis is going to have a heart attack? Roughly, it's roughly zero. It's really small. 20 to 30-year-olds don't usually have a will because they're worried about having a heart attack. So you multiply that by three and it's still pretty close to zero. It's like almost no increased risk at all. There might have been like a 20% increased risk if you were like old, like me. Okay, that's a much bigger risk than the threefold risk in young people.
Speaker 2:So if you had a psoriasis patient coming into you and you know they're Googling because you know that's what everyone's doing nowadays and say, okay, I've got psoriasis, so I'm worried that what else could I be at risk for? And they get that laundry list of things to talk about. You know like heart disease, or you know metabolic syndrome, or they carry more fat around the center, or they're resistant to insulin, more likely to get diabetes or high blood pressure, high cholesterol. And then they even read oh gosh, like you could have associations with increased risk for certain types of cancer, which really kind of freaks everyone out.
Speaker 3:when they find that online, how do you practically break that down to say to them these are truly the things I'm potentially worried about, that you could be at risk for and that we might need to do a little bit closer monitoring for yeah, I'm in North Carolina. You know I don't get a lot of questions like that. I'm in New York City, you know, big city, chicago, los Angeles, and things would be different, but in North Carolina I don't know that. I've had a patient yet come ask me about the comorbidities of psoriasis. Typically what they ask about is when I give them a biologic for their skin disease. They may say to me is there risk from this? And I'm like probably we're reducing your risk of heart disease more with this than you're actually going to have risk from the treatments. If somebody did ask me that, I would say look, yeah, you know, are you having any morning stiffness, any joint pain, any back pain, signs of psoriatic arthritis? That would be something worth looking out for. I generally look at people to see if they're having signs of depression. I usually don't ask them about depression, but if they're sitting there like this, you know, then I'm going to ask him questions about depression. The rest of it I don't pay much attention to at all. I think if they're clearly overweight, I will bring it up with them. They have psoriasis. You know there's good treatments for obesity nowadays and obesity is clearly linked with stuff.
Speaker 3:I'm involved with another University of Pennsylvania study you may want to get them on the show if you haven't already talking about it where we're looking at the patients who are 40 and up and seeing if they had their lipids checked, had their cholesterol checked, you know, had their blood pressure checked, and we're checking those things and giving them advice when needed. I've got high cholesterol, all right, and I've looked at the numbers. If I take my statin that they've prescribed me and keep my cholesterol down, it reduces. It should reduce my risk of having a heart attack over 10 years by 30%, which sounds like a lot, but what that means is my baseline risk is 7%. A 30% reduction takes me to 5% and I'm scratching my head, you know.
Speaker 3:Does this 2% difference make it worth taking the statin? Well, the statin costs me almost nothing. It's easy to take a pill every day. Okay, fine, I'll do it for the 2%. I'm not really excited about it. I don't think it's really going to change anything.
Speaker 3:I asked my preventive cardiologist, you know, should I take the statin for this 2% difference? He says if you're one of the 2%, it really matters a lot. I'm like all right, fine, but it doesn't really cause any significant side effect from it. Or if it costs a lot, I'd probably blow it off or something. But if psoriasis has as big an effect as cholesterol and treating the psoriasis reduced the risk as much as taking a statin does for cardiovascular disease we don't know that it does, but if it did for most people it's probably going to make a small change. Now that's what I would tell a patient if they came to see me. If I was giving a talk to insurers about how important it is to pay for the cost of these high-cost biologics for the treatment of psoriasis, I would tell them you know, patients with bad psoriasis can be up to a three-fold increased risk of having a heart attack. Because I want them to pay for the drugs that my patients need for the skin.
Speaker 2:The math is important, though, when you bring that up, but I understand it's more profound when you say it that way, but when you look at the numbers you're right like it's. You know what's the true impact like, does it make sense? So if you were so, like some of my patients? So I'm in central ohio area and I have had people come in they google and ask them I think, gosh like, how do I break this down? It sounds like your advice would be you know, really, look at potentially that cardiovascular disease risk and the risk for arthritis. Those are the top two that you kind of hone in on as being most clinically significant. Would that be a fair kind of assessment?
Speaker 3:That, and I think the depression might be the most common thing, because so many Americans are depressed anyway. If you're at any increased risk, that risk is probably up there with psoriatic arthritis in terms of the percentage of psoriasis patients who have depression. But then you can pretty clearly recognize that when you see it up front. So screen for that, screen for the arthritis and the cardiovascular thing. The neat thing about dermatologists is we get to see everybody, you know we get to see dermatologists is we get to see everybody, you know we get to see young people, we get to see old people, we get to treat men between the ages of 20 and 45 who may not be going to a family doctor. Women, they're probably all seeing somebody, but the guys, they go decades without getting their blood pressure checked, without ever having their lipids checked. So this is an opportunity that we could do for all our patients. But since psoriasis patients are at increased risk, they should certainly get the recommended screening, which probably is blood pressure and cholesterol checks.
Speaker 2:I think that's you know, that's you know. I love the way you say that because it really shows to, from the standpoint of dermatologists, how we can have an impact on somebody else's health. Because you know, like you said, men don't utilize healthcare. You know resources like women do and just be able to get them through the door because they just happen to come to you. Because psoriasis bothers people, right, they see it on their skin and so they're motivated to come in. But you know, to get that blood draw, you know, to get their cholesterol checked or get their blood pressure checked, not not real attractive.
Speaker 2:It's why I went into dermatology, because when we cleared somebody's psoriasis, you can see the impact on it had on their quality of life. They got the patient that I had got off disability. His depression improved. He was dating by the time. I had left that rotation that I followed and worked with a colleague throughout a year's time. I thought, man, I want to do that. You lower somebody's blood pressure. You know, by 10 points they could care less, right? So I think that's really important message to take home for clinicians out there that you can get people to the family doc for that. But if you're talking about the biologic medicines and you're like, okay, yeah, I want to put you on something like this. It's going to definitely help clear your skin, may help improve the joints. But you know, the patients are like, I don't know, I'm kind of worried about the risk. Like, how risky do you feel? Like in general, psoriasis treatment is. Like how do you present that to the patient?
Speaker 3:Yeah, I basically tell them, for a lot of these things there's no risk at all. Some of these powerful drugs, it's like we're in an age of miracles. When I started something years ago, I had chemotherapy drugs like methotrexate or something to turn off your immune system, like cyclosporine for patients with really bad disease, or I could really stone age. I could cover people with tar and give them ultraviolet light treatments. Now I got drugs you might take an injection every two or three months and if they ask me what the side effects are, I I'm like I don't think there are any I'm not real, like nothing.
Speaker 3:I mean, the studies show lower rates of serious infection on the drug than often in the placebo group, maybe more common infections, but I think the common infections occur for absolutely fascinating reasons. See, I think psoriasis is a socially disabling disease. So if you're in the placebo group, you just do what you normally do, which is sit at home miserable with skin lesions, flaking, cracking skin If you move, joint pain, depression, just sit there, watch a late night television, smoking with one hand, drinking a beer with listening to the podcast.
Speaker 2:That's what they're doing television smoking with one hand drinking a beer with listening to the podcast.
Speaker 3:That's what they're doing. Podcast, I love that. But if you, you know, if you're in the drug group and your psoriasis clears up your joint pain, you're like I feel great. I'm going to go visit my nephews and nieces who have runny noses and diarrhea.
Speaker 3:I mean you know, go to the bars, meet men, women. I could go either way. This week, you know I'm going to go to the Y, maybe exercise and be with people, Maybe I'll take a shower there. Maybe without flip-flops you could be exposed to all kinds of common infections. You know, once you clear that psoriasis up the treatments the very good ones might have a risk of a yeast infection, or maybe one in 300 people that might exacerbate their inflammatory bowel disease or it caused some diarrhea, something some of them may have a little bit of like.
Speaker 3:One in 100 patients might get shingles, but you can treat that ahead of time by having getting vaccinated. Um, it's just so many great options now.
Speaker 2:I think with all the options too, it's interesting. You know, on TV you see commercials. Or, I hate to say it, a lot of my patients, especially my younger ones, they don't watch TV but through streaming, or if they get forced through a commercial, you know, on their Amazon Prime they might see an ad for a psoriasis medicine. And I think it's interesting to just think about, like why do we see so many of these going around? What's your explanation for all the advertising, especially the way they've kind of gone out to the patient to make them aware of what's out there?
Speaker 3:Yeah, I think historically doctors didn't like direct to consumer ads. I love it.
Speaker 3:I like my patients to be educated you know, by commercials and podcasts and I think the commercials provide required by federal law to provide a balance. So you hear the supposed side effects, if anything that scares people and I have to tell them I don't worry about those things because they saw those in the placebo group too. Yeah, I think it's happening because it has become legal. It's because these are consumer products. Patients are involved in the decision-making of what to do. It does, as you said, increase awareness.
Speaker 3:I think it's great that people with psoriasis, especially bad psoriasis, know we got got treatments to clear you up available to you and gosh, one thing your listeners should know. One of the things that really bothers me is when a patient tells me I didn't come in because I didn't have insurance. I knew I wouldn't be able to get the drug. Hey, the easiest patients to the treat are the ones who are poor and are uninsured, because I can get almost any drug for them free nowadays, you know from all the companies and there's so much competition between these drugs that you know they want patients to know about their drugs so that they'll ask their doctor for it.
Speaker 2:So you see, all these medicines that have come on the market, especially since back, as you mentioned, in the dark ages, when we're using coal tar and things like that. Where do you feel like the future then for psoriasis treatment is headed, since we've come so far, our expectation of getting the skin clear I mean we used to think, yeah, if we got it 75% clear, 90% clear. Now expectation, you know, 1% or less or you know, getting up to 100% clear is kind of the new bar or standard. Where do you feel like the future is and how does your research play a role in that?
Speaker 3:Yeah, okay. Well, there's two kinds of psoriasis, I think A limited kind with just a few spots. That would get better with topical, with creams and ointments and things. Maybe there's a more extensive involvement where you can't possibly put creams and ointments on all these spots. For the people with mild disease, which is the vast majority of people with psoriasis just a few spots on the elbows and knees the biggest limitation to the treatment is that the patient isn't putting it on. And so I think and my research is on, you know, trying to encourage people to use their medicine better If they would put that clobidazole on their psoriasis. Man, that stuff is fabulously effective and clear it up. We did studies with, you know, computer chips in the caps of the containers that record the day and time people and open and close the containers. In the studies, in their treatment diaries, they say, oh, we put it on twice a day, but the computer chips say that you're not opening the bottles.
Speaker 2:Liar, liar is what the chip said.
Speaker 3:I don't know that people are lying, because I think people think they're doing it more than they really are, but they're not, you know.
Speaker 2:So I think with your study, the one to that show. They do it more consistent when it gets closer to the appointment with dermatology or their dermatologist doctor. I thought I remember reading that at some point.
Speaker 3:Yeah, if you have ever heard the mother of an acne patient say so frustrating, you always catch in on a good day. I don't know why. I don't even know why. Yeah, I think people floss their teeth right before they go to the dentist. Now I floss my teeth every day, but if I have a dental appointment coming up, I start flossing twice a day. When do people practice piano? You know they do it like right before each lesson.
Speaker 3:Doctors are kind of like a piano teacher who says here's a prescription for some sheet music. Take it to the sheet music store. I have no idea what it's going to cost. I want you to fill this prescription for the sheet music. I want you to practice every day. We're not going to have weekly lessons, just practice every day. Practicing may cause rashes, diarrhea, possibly a serious infection, but I want you to practice every day. I'll see you at the recital in three or four months and if the recital doesn't sound good, which it often doesn't, I'll give you another musical instrument, two or three more musical instruments to practice at the same time.
Speaker 3:You know what we're doing sets people up for poor adherence to the treatment, and so you know if anybody's listening and their doctor prescribes some Clobata. I would encourage them try doing it really well for two or three days and then call me and let me know how it works. Worked, because I bet it's going to. You know you could see the effect of Clobazol in just a few days Now. For the people who have really extensive disease, I think the future is already here. We got drugs that you know you only take them every two or three months. One of my patients today on an every two-month drug for their psoriasis said you may not want to hear this, but I hadn't been taken. I stopped in October and I'm still clear, so I'm not taking it. I'm like I don't mind that. You don't need the risk, I don't know if there is any risk, but you don't need the tension.
Speaker 3:If there is any risk from the drug, minimize it by taking the least you need. It's going to save money in the long run, yeah. And if, for some reason, it stops working because you're not taking it regularly, we got other choices. We can catch on.
Speaker 2:Fantastic. Well, thank you, this has been a great conversation, aaron. I mean just kind of going over you know really should people worry about, and you know there's so much information on their own treatment and risk and you know underlying health issues that can be associated with psoriasis. So I think we really broke it down nicely for our listeners to kind of get a nice grasp on kind of the basics of that. So thank you so much for coming on the podcast with us today, steve. I want to give you an opportunity, though. If our listeners want to find you, where's the best place for them to track you down? Maybe online or elsewhere?
Speaker 3:uh, it's been an absolute pleasure being on with you. Um, the best place to find me would be a literature search of the medical literature, because then you can see all the stuff. You know my minions have been publishing, uh, for the last few years. But you know, I got a Facebook page and a Twitter presence and you can find me there too.
Speaker 2:Great. Well, be sure to look up Steve. He's, like he said, he has had multiple publications in this space a true expert on psoriasis. So thanks again for coming on the podcast. We really appreciate your time today and, for those of you out there, stay tuned for the next episode of Dermot Trotter. Don't Swear About Skincare.
Speaker 1:Thanks for listening to Dermot Trotter. For more about skincare, visit DermotTrottercom. Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skincare sanity. Until next time, stay skin smart.
