Could Your Joint Pain Actually Be Psoriatic Arthritis?

Joint pain with psoriasis is easy to brush off until it starts affecting your daily life. We sit down with Mark Lebwohl to break down the early warning signs of psoriatic arthritis, from nail pitting and heel pain to swollen “sausage” fingers and morning stiffness. We also explain how doctors diagnose it, why it is often mistaken for osteoarthritis, and why catching it early matters.

We also unpack the rapidly changing treatment landscape, including biologics that protect joints and improve skin disease, plus the major role inflammation and obesity play in worsening symptoms. If you have psoriasis and unexplained aches or swelling, this episode gives you a clear roadmap for what to watch for and what questions to ask next.

Transcript

Cold Open Weight Loss Boosts Response

SPEAKER_01 0:00

64% more patients achieve that ACR 50, which is an astonishing number. So it turns out that, you know, weight loss does help. DIP, distal interphalangeal joint involvement, very typical of psoriatic arthritis, this uh far joint uh of the fingers and toes. And I once had a room full of psoriasis. There were 107 psoriasis patients in the room. It was a talk I was giving at a patient meeting for the national psoriasis vandiction, and I asked everyone to stand up.

SPEAKER_00 0:34

Welcome

Psoriatic Arthritis Risk And Early Action

SPEAKER_00 0:35

to Dermot Schmatter, Don't Swear About Skin Care, where host Dr. Shannon C. Schmutter, 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_03 0:52

Welcome to the Dermot Schmatter, Don't Swear About Skin Care podcast. On today's episode, we have Dr. Mark Lebois, board-certified dermatologist, professor and chairman emeritus of the Department of Dermatology at the Mount Sinai School of Medicine. And he is an expert and guru in all things psoriasis and somebody that I truly admire, like most of my peers. Welcome to the podcast. It's so great to have you here.

SPEAKER_01 1:15

Thanks for having me, Shannon.

SPEAKER_03 1:17

Of course. And today we're going to dive into something with psoriasis that maybe some of our listeners don't know much about. And our goal is really to educate people on psoriatic arthritis. So I was going to have you kick us off, which is talking about, you know, really what is psoriatic arthritis. And for our listeners out there that think, gosh, I have psoriasis, but nobody's talked to me about, you know, joint pain or arthritis, what's the likelihood that I might develop it?

SPEAKER_01 1:40

So if you have psoriasis, the chance of getting psoriatic arthritis is about 30%, almost one in three. It's a fairly high number there.

SPEAKER_03 1:51

And do you think, you know, for those patients that have psoriatic arthritis, do you mind like defining like what does that look like? What does that mean? And people might say, well, I have some joint pain or discomfort, but you know, is it really psoriatic arthritis? How does it typically present?

SPEAKER_01 2:04

So, you know, if you have psoriasis and you have joint pain, don't let your physician just treat your psoriasis. You have to say, I have joint pain, because the treatments are very different based on whether you have psoriatic arthritis, or even if we think you might get psoriatic arthritis, we are going to use different medications than if you just have skin disease. So really important to let your doctor know about those uh joint pains. And I will say there's a tremendous amount of data showing that if you treat psoriatic arthritis early, you'll do a lot better in the long run than if you treat it late. And there's a tremendous literally every study that looks at that question shows that information.

SPEAKER_03 2:48

So probably a lot of people out there might be ignoring some of those joint symptoms or attributing it maybe they're just getting older, right? Or, you know, it's just normal to have that. So in the context of psoriasis, your advice is definitely bring it up because it might be psoriatic arthritis or it could be another form of arthritis too that potentially to be addressed. Or I guess you could have the double whammy, right? You could have an overlap. You might have psoriatic arthritis and maybe osteoarthritis combined with it, which I know could be challenging to manage.

Kids, Overlap Arthritis, And Eye Risk

SPEAKER_03 3:16

Probably a lot of the adults out there with psoriasis are thinking, okay, you know, I've got an element of some joint discomfort, but what about children in psoriasis? Because I think people wonder, does this even happen to kids too? Or is it less likely, or does it present any differently? Or does it need to be on the radar of those parents out there whose children have psoriasis?

SPEAKER_01 3:33

Yeah, so so uh two points there, and I will address the children question right away. But some of our most complicated patients have psoriasis of the skin and probably a combination of osteoarthritis and psoriatic arthritis, which makes them a little bit more difficult to diagnose and also a little bit more difficult to manage. Um, but many of our patients have both. And um and so that was a good point that you made. Um, as far as kids, yes, uh kids can get psoriatic arthritis. Uh, I've seen children as young as the age of two with psoriatic arthritis. And um, as kids get older, the kind of signs and symptoms they get are very similar to what we find in adults. But in young kids, um, a couple of things are are noteworthy. Um, you know, in in um general, we say that psoriasis precedes arthritis or occurs at the same time, 85% of the time. In um in children, uh, so that means only 15% does the arthritis precede the psoriasis. 80% of kids with psoriatic arthritis will get skin disease. Um, and so the numbers are much higher there. The association is much stronger. Um, there are also some different associations. They're more likely to get uveitis, for example. So uh so we're, you know, we're uh we treat kids with psoriatic arthritis quite specially. Fortunately, more and more drugs are now approved to treat psoriasis in children. Uh and uh uh and uh and since many of those kids will develop psoriatic arthritis, we do have tools we can use that are very effective in those children.

SPEAKER_03 5:20

So now that we've kind of tackled, you know, just sort of what is it

Why Psoriasis Hits Joints

SPEAKER_03 5:24

a little bit? A lot of people might be wondering, like, what what is this connection, you know, between the immune system, our skin, our joints, you know, why does this actually happen going into maybe like the science of it or a little bit of the immune system for our audience to understand? And, you know, why are do we know why some people are looking at not to do it?

SPEAKER_01 5:44

Sorry about that. Uh the uh the answer is that um both psoriasis and psoriatic arthritis are what we call multifactorial, meaning you inherit a combination of genes from both parents, and combined with external factors, it gives you the disease. So, for example, you may have uh one parent with psoriasis, the chance of a kid getting psoriasis might be one out of six. Um, but you take that same child and you move them close to the equator, it'll be lower. You move them to northern latitude, it'll be higher. Um it's a combination with external factors. If both parents have psoriasis, the chance of a child getting is probably about one in two. So uh it's a combination of genes from both parents combined with external factors, the same for psoriatic arthritis. The chemicals that we associate with psoriasis are often the same as those associated with psoriatic arthritis. For example, TNF alpha, IL-17 are both chemicals that we see in both diseases. And blocking both of those chemicals are highly effective in improving psoriasis and in improving psoriatic arthritis.

SPEAKER_03 6:57

You mentioned some of those external factors. What kind of external factors do you kind of think of in regards to that as well?

SPEAKER_01 7:03

So I would say, you know, sunlight is a major factor. Obesity, it turns out, is quite a factor. And uh, you know, just uh few weeks ago there was a press release and a publication about an article in patients treated with ixocisumab and tozepatide, which is a weight loss drug, and the results were off the charts. There's a tool we use to measure the severity of psoriatic arthritis called the ACR-50. And when you combine the two drugs, the weight loss drug with the biologic for psoriasis, 64% more patients achieve that ACR-50, which is an astonishing number. Um, so it turns out that you know weight loss does help. Um and uh, you know, we'll talk about diet a little bit later when you ask me about myths and in psoriasis. But um, you know, I'm saying there's no particular food, it's being overweight. And we know actually that people who are obese, that that extra fat that they get secretes some of the chemicals I just mentioned, like IL-17 and TNF alpha. And that's why both psoriasis and psoriatic arthritis are made worse by being obese.

SPEAKER_03 8:21

Yeah, I think it's fascinating how we we think of you know our fat or adipose tissue as sort of being just quiet and stagnant. People have this misconception, but it's pretty active metabolically and feeling things in the body and learning so much more about it, you know, and its role for psoriasis is fascinating. Now a new target for treatment, which we'll talk a little bit more about. But I also want to touch upon, you know, people are sitting there thinking, you know, do I have psoriatic arthritis? You know, we talked about joint pain, but I wanted to go into more about how it may present, you know, maybe where there's certain areas of skin involvement for psoriasis, or obviously nails, or things that might put you at risk that we know clinically, or you know, how did these joints actually look, or what areas tend to be affected for somebody that might have psoriatic arthritis?

SPEAKER_01 9:04

So

Hallmark Symptoms And Joint Patterns

SPEAKER_01 9:05

there are multiple forms of psoriatic arthritis. Um the most common is called oligoarticular, oligo means a few joints. So you might have, you know, one or two or three joints affected. Um uh the posse articula is the other word that's used for that. Um then there's a symmetrical uh arthritis that is very similar to rheumatoid arthritis, often involves the fingers and toes. Uh, and uh, but the patients have a negative rheumatoid factor, unlike rheumatoid arthritis, and they have psoriasis, unlike rheumatoid arthritis. So um so it can be distinguished from rheumatoid arthritis, but those patients get deformities that are identical to what we see in rheumatoid arthritis. So there's some uh old characteristic deformities called ulnar deviation or fibular deviation where the fingers and toes turn outward. Um there's uh something called uh swan neck deformity, which I'm having trouble doing there, but you the distal, the far joint bends forward and is stuck that way. There's something called the boutonier's deformity, which looks something like this. Uh and um and and those are typically seen in rheumatoid arthritis. We see them in psoriatic arthritis as well. Um uh and and there are there are other manifestations too. This characteristic DIP, distal interphalangeal joint involvement, very typical of psoriatic arthritis, this uh far joint uh of the fingers and toes. We see something called Hebridinous nodes, which doesn't hurt as much, or little like knobs on the distal, the DIP joints. That's an osteoarthritis. So, you know, um it helps to be able to distinguish those. Um uh there's uh ankylosing spondylitis, which is basically psoriasis of the spine. Those patients also get sacroilitis, inflammation in the sacroiliac joint. Um there's um uh a number of uh a number of uh and then there's arthritis mutilands, the worst form, where literally the joints are completely destroyed. Uh and those patients, we fortunately hardly ever see that anymore because the treatments have gotten so much better, but literally the bones are eaten away, and those patients come in with completely deformed hands and feet. Um difficult to use their hands, difficult to walk. Uh so uh fortunately that's a form of arthritis we don't see very often anymore. So there are some pretty specific findings, and I uh you may have alluded to that. Pitting of the nails is very common in psoriatic arthritis. Other nail changes are common in psoriatic arthritis. Um there's a condition called anthesitis, it's tenderness and swelling of the tissues around the joint uh can be very painful, and that's very characteristic of um uh psoriatic arthritis. In fact, when I see an entire digit that's swollen, um uh, which is because of enthesitis, uh, I or that we call that dactylitis. Um uh I I always assume that that is psoriatic arthritis, even if the patient doesn't have psoriasis. Uh, and I can tell you my success rate with treating that with usually IL-17 blockers has been 100%. Uh I find that they work really well for this awful form of very painful form of arthritis, uh, and um it really reverts it completely in every patient I've treated with with dactylitis.

SPEAKER_03 12:34

You mentioned kind of a couple interesting things there. One where you just commented, you know, that somebody may not have skin involvement but could have psoriatic arthritis. Is that a common presentation, or do you feel skin involvement eventually comes with it, or is that something you don't see very often?

SPEAKER_01 12:49

So um there's certainly a small proportion of patients who, by the way, have responded to the typical psoriatic arthritis drugs who have not gone on to develop psoriasis. Now, maybe it's because we've kept them on the psoriatic arthritis drugs. But normally, usually within eight to ten years, the patient's gonna have psoriasis of the skin. And by the way, in patients with psoriasis of the skin, it's about eight to ten years before that 30% develop psoriatic arthritis.

SPEAKER_03 13:19

And so for the diagnosis part,

Diagnosis With CASPAR And PEST

SPEAKER_03 13:21

polyolopular, okay, I I think I could have some signs and symptoms. You know, my dermatologist might think I'm there, might make the diagnosis, maybe they go to rheumatology. How is that diagnosis actually made? Like there are particular X-rays, lab work, is a more of a process of exclusion or criteria based? How does that diagnosis actually happen?

SPEAKER_01 13:41

So in truth, it's often seeing a patient and how they present to you what their history is that helps you make your way to the diagnosis. Um sometimes when we're not sure, we use the drugs that are specific for psoriatic arthritis, and that tells us whether or not the disease is there. However, there are criteria that we use. Uh, and there's one called the Caspar criteria, uh, and it's a point system where you are given uh uh uh points for whether you have psoriasis and other features. So if you have psoriasis at the time of presentation, you get two points. If you have a history of psoriasis or a family history of psoriasis, you get one point. If you have abnormal nails, like nail pinning or onacolysis, you get um you get one point. If you have a negative rheumatoid factor, you get one point. If you have swelling of an entire digit, you get one point. And to me, again, I that is almost always psoriatic arthritis. Um and then if you have on X-ray evidence of new bone formation next to a joint, uh, that is also um worth one point. And and you know, the bottom line is if you get enough points, you have a diagnosis of of uh of psoriatic arthritis. There's a tool that's used in clinical trials more than anything else. I actually printed it up. And I I don't use this in the office, but we use it in clinical trials to see if patients have uh might have psoriatic arthritis. If you have three points out of this these five yes-no questions, it is presumed that you have psoriatic arthritis. And this is just a kind of um screening tool that helps you a little bit. It's not a hundred percent sensitive, not a hundred percent specific, but it's fairly sensitive and specific. Um, so have you ever had a swollen joint or joints? Has a doctor ever told you you have arthritis? Do you have finger or toenail holes or pits? Do you have pain in your heel? Another fairly specific finding for psoriatic arthritis. And have you had a finger or toe that was completely swollen and painful for no apparent reason? Again, that's dactylitis, and that is again a much more specific question. If that if you answer the last question correctly, there's a high likelihood, in my opinion, of psoriatic arthritis. That tool is called the pest questionnaire, and we do use it in clinical trials.

SPEAKER_03 16:07

And I mean, I have to say, too, it's a great questionnaire, even in everyday practice, pretty straightforward and easy to do, or even I think if patients start thinking about that, you know, to really help, you know, define what's going on, maybe, and you know, suggest if yes, they could potentially have psoriatic arthritis.

Treatments From NSAIDs To Biologics

SPEAKER_03 16:22

Because I think after people are diagnosed, we've talked upon this a little bit. You know, the real question is, well, gosh, like what are the treatment options? And I know we could spend a whole podcast and just going through each of them individually, but I was hoping to give like an overview of maybe traditionally what we look at, and of course, where we've come today.

SPEAKER_01 16:38

So there are many drugs that are approved for psoriatic arthritis, um, but there's some that are clearly better than others. So we do when patients have mild disease, use NSAIDs just like any other form of arthritis. So um and and and the same NSAIDs, like I use a lot of enterocotic neproxin. Um and there are others, other favorites that other uh rheumatologists and dermatologists have. Uh but the bottom line is with limited disease you can easily control it, usually with pretty uh non-aggressive um therapies. Um if that doesn't work, um then our next uh uh our next step would likely be uh an oral or a biologic therapies. I would say that many rheumatologists go right to methotrexate. The reason that I don't is it is much less effective than biologics and much more dangerous. The thing is it's easy to get, it's cheap. Uh, and that's why rheumatologists go to it, and their guidelines even used to call for it as being the first line of treatment. I hardly ever use it anymore. There's honestly a real death rate associated with methotrexate, and I just you know don't want to always constantly be worried about my patient mixing another drug with it or getting into trouble because of their liver or bone marrow. Um so um the the go-to drugs have been uh more recently uh either TNF blockers, um, the names of those are am I allowed to use brand names in this podcast? Yeah, so it's NBRL, Humera are very effective. SIMSI is very effective. Um there's something called Symphony, uh, which rheumatologists use more than dermatologists, but it's very effective, and I've prescribed it. Uh and Remicaid, which is an intravenous form, probably uh the one with more side effects, but also very good efficacy. Um those are used to be first line. Now, more often I first line go to an IL-17 blocker. The drugs that are approved are TALTS, Cosentix. Seleek is not approved in the US, but it is approved in Japan and highly effective. And uh Bimzelix is the most recent one uh and uh works a little bit differently than the other IL-17 blockers because it blocks IL-17A and F. So certainly in psoriasis, it shows greater efficacy and at least comparable efficacy in psoriatic arthritis. Um there is some evidence recently that uh an um an IL-23 blocker called Tremphia doesn't just treat psoriatic arthritis, but also prevents the X-ray progression of joint disease. The TNF blockers and the IL-17 blockers have been long known to do that. Now the evidence is that if you use Tremphia, your patient it may actually also slow down the development of joint changes on X-ray. Uh and so uh uh of the 23 blockers, that has emerged probably as the most commonly used one. Having said that, there is data that Skyrisi and uh Ilumia, uh which are other 23 blockers, also work for psoriatic arthritis.

unknown 19:50

Okay.

SPEAKER_01 19:50

Uh last we didn't talk about actually the two is uh TIC2 and OTESLA are approved for psoriatic arthritis, so it's Telara, um, but they don't work quite as well as the 17 and 23 block. I'm sorry, the 17 blockers and the TNF blockers.

SPEAKER_03 20:06

So with all those treatment options out there, you mentioned you might start with an IL17 blocker. When you is it based on kind of your look at the data because I'm sure there's patients out there like, gosh, like, well, which one are they gonna put me on? I know sometimes there's other reasons to choose that class or not, but I wanted to get your thoughts specifically on psoriatic arthritis. Is that a lien that you maybe have? Are there other factors that you take into account as well?

Choosing The Right Drug

SPEAKER_01 20:30

There's I have a um a talk that I give which drug for which patient, and I I once had a room full of psoriasis. There were 107 psoriasis patients in the room. It was a talk I was giving at a patient meeting for the National Psoriasis Foundation, and I asked everyone to stand up, and then I said, I'm gonna read a list of factors that affect your psoriasis and your psoriatic arthritis. I don't want you to do anything while I read the list, but listen, and if I mention a condition that affects you, at the end of my talk, my list reading that list, I want you to sit down. And it included things like uh history of cancer, do you have uh uh heart disease, risk factors for heart disease, diabetes, hypertension, um a history of heart attack, family history of heart disease, um, cigarette smoking, um uh multiple sclerosis, uh inflammatory bowel disease, a long list of conditions. At the end of that, I said, okay, if I said something you read, obesity is on the list too, by the way, I should mention. And if I said yeah, if I said something that affects you, sit down. Out of 107 people, 106 sat down. And I think the 107th couldn't hear. Um but uh but but it was quite eye-opening. Uh and this it was based on an article that I published in 2019. We're actually publishing that now that there are all these new drugs added, the next iteration of that I'm reviewing the final manuscripts now, are gonna be a CME article in JAD in the Journal of the American Academy of Dermatology in the next few months. Because there are many things to consider which tells you which drug is best. Another factor is, to be honest, access. If we're able to more easily get the drug because if you're insured, that will have some impact. Although in many states there's step therapy legislation. So if we think one drug is better than another, we're going to push for that drug. The other thing that I look at very early on is obesity. If a patient is overweight, there's a very high chance that they will be leaving my office with a prescription for a weight loss drug. And uh I have over a hundred patients now on uh trzepatide, uh, which we have a lot of experience with. And we've shown that the combination of trzepatide with um, you know, with uh uh exacidimab again, uh is good for psoriatic arthritis. Well, it's also good for psoriasis. Um again, I can only say what's in the press release because the article's not published yet. Well, it's almost published. But the bottom line is when we look at past the 100, which means 100% of psoriasis clearing, it was 40% more likely if you were on the weight loss drug plus tilts, bound, plus tilts, as opposed to TELTS alone.

SPEAKER_03 23:25

Fascinating. So that kind of leads to talk about the obesity connection, the improvement you've seen. What what about diet? Do you do you feel like diet and exercise as effective, or do you feel like that's something that's a part of the complete treatment regimen to recommend to your patients as well in addition to

Exercise, Weight Loss, Diet Reality

SPEAKER_03 23:40

the other therapies?

SPEAKER_01 23:41

Yeah. So first of all, exercise is very important. And by the way, one of the signs of this is morning stiffness. So if you sit idle for a long time and then you have difficulty getting up because your feet hurt, or you're holding onto a steering wheel for an hour and then you have difficulty using your fingers for, you know, uh for a time, moving them lubricates them. And so uh, and if that lasts for 30 minutes, you know, you have to walk around for 30 minutes before the pain in your feet goes away, that's psoriatic arthritis that needs to be treated. Uh and uh uh so I will say um uh among the signs that we spoke about earlier, morning stiffness is one I didn't mention and is a very important one. Um now uh uh it also happens in the morning when people wake up, suddenly their feet hurt. They can't whereas when they went to sleep, they were fine. It's a little bit different than osteoarthritis, where wear and tear using it makes it worse. Here, wear and tear makes it better. Um I shouldn't say wear and tear makes it better, but basically as you start using it, it feels better. Now, uh a diet, there is no specific food that makes psoriatic arthritis better, but weight loss dramatically does. And weight loss is very important, and that's why ZeppBound had those great results that you heard about.

SPEAKER_03 24:58

And then I I think too, people are probably wondering, you know, well, I don't know that I have psoriatic arthritis. And you talked about treatment, some of the treatments they might be on are also approved for psoriatic arthritis that they happen to be taking for their skin psoriasis. Is there evidence to suggest that if we start somebody on one of those medications that may prevent or delay the onset of getting psoriatic arthritis? Do we have any data behind that, or is it more conjecture or kind of you know just our guess that it might help with that?

SPEAKER_01 25:25

There's

Prevention Data, Myths, And Closing

SPEAKER_01 25:26

some data and um some registry information where a large number of patients are followed for a long period of time. Um, in terms of the the data, the data that has been published a lot comes from electronic medical records. I have to say, I believe the data, but it is extremely flawed. There's data showing that if you're on an IL-23 blocker, you're actually less likely to develop psoriatic arthritis than on an IL-17 blocker. And the reason for that, and the authors even acknowledge it, is something called protopathic bias. What that means in English is if a patient comes to me and they have a little bit of joint pain and I'm not sure, I'm gonna probably pick an IL-17 blocker. So when I turn around in five years, the chance of that patient going on to develop real psoriatic arthritis is increased because they probably had it when they started. Whereas if a patient has no joint pain, I might be more likely to use an IL-23 blocker. And so you look five years at those patients and they're fine. And so there's there are data that are published suggesting that IL-23 are better, but that's because of that bias. Um the the best data is when you follow a patient uh prospectively, meaning you don't make the you treat them, you see, do they develop psoriatic arthritis? And that data was just presented uh with Bimakishumab, Bimzelix. Um, and they showed that over a period of years, and I I I was presented at the uh AAD meeting that just passed, and I saw the presentation. I don't remember the data exactly, but if I'm not mistaken, over five years, a group of psoriatic arthritis of psoriasis patients um who were followed regularly, only 2% in five years progressed to psoriatic arthritis. That is much lower than what you would expect. Uh and so it's pretty, to me, pretty good evidence that IL-17 blockers do indeed prevent the development of uh psoriatic arthritis. And I do think both sets of drugs are good at that for the following reason. When I started training and we didn't have these drugs, and all we had was methotrexate, we would commonly see patients with these deformed hands that they couldn't use and their deformed feet that were difficult to walk on. We hardly ever see that anymore because the drugs we have today are so much better. And when a patient comes and psoriatic arthritis is really painful, those are the patients who are going to be treated with the right drugs. So we hardly ever see that anymore.

SPEAKER_03 28:04

Gosh, I mean it's it's amazing kind of like where we've come, you know, with treatments, but there's still a lot of myths out there, I think, with psoriatic arthritis. So I want to give you an opportunity in the last couple minutes to kind of bust some of those or any advice obviously you have for the derms out there listening on how we manage our patients better.

SPEAKER_01 28:20

Sure. Eat all the gluten you want, but lose weight. And I can't tell you how many how many patients come to me on gluten-free diets, and it's a waste of time. I mean, you either have celiac disease or you don't, and that's easy to prove. There are blood tests that suggest it, and there are gastroenterologists that have procedures where they definitively make the diagnosis. So, you know, uh, and you know, when people ask me about diets, they're such believers. I'll just say, well, if it makes you feel better, you know, have it. Uh, if it makes you feel worse, don't have it. Um, and I'm kind of loose that way, but in my mind, I'm thinking, you know what, the diet has nothing to do with it. Um, the weight loss, on the other hand, has a lot to do with it. And uh losing weight is really good for you. And exercising, don't stop exercising because of psoriatic arthritis. That is really bad for you.

SPEAKER_03 29:12

It's going back to the old things that we know that work no matter what. I always have to say it always circles back. That's just the way life is, I think. Well, thank you so much for coming on the podcast. It's been great to have you on the podcast today, Dr. Levont, sharing your expertise. I know you've probably educated a lot of people out there, you know, online providers by our listeners, because certain arthritis is something we need more recognition for and really highlighting it.

SPEAKER_01 29:34

Yep, agree. Thank you very much for having me, Shannon.

SPEAKER_03 29:37

Of course. And stay tuned for the next episode of Dermot Schummeter Don't Swear About Skin Care.

SPEAKER_00 29:43

Thanks for listening to Dermotch Mutter. For more about skincare, visit dermitchmutter.com. 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.