New Answers for Psoriasis

Besides pain, discomfort and embarrassment, psoriasis researchers are now linking the skin disease to heart disease, stroke and other serious conditions. But there’s new help and hope. Read on for the latest breakthroughs and treatments... Over the years, my red, flaking skin has shed all over bed sheets, treadmills and laptops. It can be itchy, unsightly and, frankly, embarrassing. I have psoriasis – a skin disease that causes scaly, sometimes bloody patches to appear anywhere on the body. If that’s all women with this condition had to deal with, life would be difficult enough. But new research has found that in addition to skin lesions, psoriasis patients face serious health risks, including high blood pressure, diabetes, heart disease and stroke. “Until recently, doctors thought psoriasis was strictly a skin disease,” says dermatologist Abby Van Voorhees, M.D., director of the psoriasis clinic at University of Pennsylvania’s hospital in Philadelphia. “But now we understand that it’s actually part of a bigger spectrum of [related] diseases.” But there’s good news too: A class of drugs called “biologics” can offer relief – and sometimes complete remission – for even the toughest cases. And because they target the offending cells themselves, they don’t cause the same side effects as older medications. “Patients are thrilled to wear shorts and a T-shirt for the first time in years," says Lakshi Aldredge, R.N., a nurse practitioner in dermatology at the Portland VA Medical Center in Oregon. "They feel like they finally have control of their lives again.” Out-of-Control Skin Cells Psoriasis typically strikes between ages 15 and 25, and lasts a lifetime. It’s the most common autoimmune disease, affecting up to 7.5 million Americans (more than 2% of the population). Experts say the disease may be caused by a combination of genetic, immune-related and environmental factors. In psoriasis patients, the immune system misfires, causing skin cells to multiply faster than normal, maturing in just three or four days, rather than the usual 28-30 days. Rather than sloughing off the body, the skin cells pile up, forming scaly plaques that may itch and burn. Making matters worse, blood vessels also can expand and multiply in the affected areas, triggering bleeding. Scratching may increase bleeding and raise risk of infection. Just living with psoriasis can be difficult – even devastating. Patients are often stared at, accused of bad grooming, and sometimes even turned away from restaurants and hair salons. “Many people don’t understand that psoriasis isn't contagious and has nothing to do with hygiene,” says Alexa Kimball, M.D., vice chair of the dermatology department at Massachusetts General Hospital in Boston. Psoriasis patients have a 39% greater risk of clinical depression, 31% increase in risk of anxiety, and 44% rise in risk of suicidal thoughts, according to a 2010 University of Pennsylvania study published in the Archives of Dermatology. Not surprisingly, many psoriasis develop poor body image, Aldredge says. “They can’t wear that little black dress,” she notes. In fact, they often wear long sleeves, even in summer, to cover up the scales. Serious Health Risks Besides cosmetic issues, psoriasis is related to a variety of health problems too. Researchers have suspected for decades that psoriasis patients have a higher risk of heart attack and weight-related conditions. But they thought it was due to unhealthy habits – like smoking and overeating – often triggered by the disease's emotional toll, Kimball says. There’s some truth to this. In a 2005 University of Utah study of in-state residents, 37% of psoriasis patients were smokers, compared to only 13% of residents without psoriasis. And 34% were obese, compared to 18% of the general population. But more recently, several studies have connected psoriasis itself with serious health conditions. A 2010 German study found that psoriasis patients were almost three times more likely to have metabolic syndrome – a cluster of symptoms including excess stomach fat, high blood pressure and elevated blood fats – that can increase the risk for coronary artery disease and type 2 diabetes. The study also found that more than 35% had high blood pressure. According to a 2010 Harvard Medical School study, patients with moderate to severe psoriasis are 12% more likely to have a stroke and, over 10 years, a 28% greater risk for developing heart disease. The type of inflammation that occurs in severe psoriasis is similar to that involved in heart attacks, says dermatologist Joel Gelfand, M.D., medical director of University of Pennsylvania’s clinical studies unit. New Treatments Bring Hope Until recently, psoriasis patients had limited treatment options. The most common are topical steroid ointments and creams that slow skin-cell growth and reduce itch. But for some patients with advanced psoriasis, that’s like “putting a Band-Aid on a broken arm,” Aldredge says. Another standard treatment is ultraviolet light therapy, where a patient stands naked in a “light box” (a chamber lined with UVB lamps) as light wavelengths penetrate the skin. This slows skin-cell growth, but its effectiveness is mixed. For tough cases, dermatologists traditionally relied on two medications – methotrexate and cyclosporine. Both are still frequently prescribed, and they’re effective for some patients. But they suppress the entire body’s immune system. Biologics have caused a huge shift in psoriasis treatment. “Now, for moderate to severe [psoriasis] patients, I have a lot of ways to make their lives better,” Kimball says. Like methotrexate and cyclosporine, these newer drugs suppress immune cells that trigger rapid-fire skin-cell growth. But biologics target the offending cells, leaving most of the body’s immune system intact. There are six biologics on the market, and finding the right one for each patient may require trial and error. While older drugs are taken orally, biologics are given by injection or intravenous (IV) infusion. Some can be injected at home, while others must be administered at a dermatologist’s office. Biologics’ immediate side effects are typically mild, such as flu-like symptoms. But their long-term effects are unknown and there are some concerns. One is a potential elevated risk of lymphoma. According to a 2009 research review co-headed by Gelfand, the current data hasn’t established an increased risk of lymphoma with long-term use of biologics, but hasn’t ruled it out either. Treatment for up to four years “appears to be very safe with respect to lymphoma risk,” Gelfand says. The High Cost of Treatment Despite the benefits of biologics, their steep price – $15,000-$27,000 a year, according to the National Psoriasis Foundation – makes it tough for many patients to get their treatment covered by insurance. Biologics are classified as “specialty drugs” that are expensive to develop and produce, adding to the high cost, according to the American Pharmacists Association. “We’re seeing long approval delays, which leaves patients in flare-ups without treatment options,” says Sheila Rittenberg, senior director of advocacy for the National Psoriasis Foundation. Some insurance companies require patients to fail on two other treatments before they’ll cover biologics, Rittenberg says. Other insurers require patients on biologics to pay a greater portion of the bill, she adds. And the timing – of diagnosis and treatment – plays a role in coverage. Before approving patients for a biologic, some insurers require them to have been diagnosed for one year, Rittenberg says. Plus, insurers often approve the drugs for only 12 months, even if patients need to take them for years to keep psoriasis at bay, she says. Fortunately, for some, a course of biologics may last a long time. That’s what happened to me – I took one of these drugs when my dermatologist was offered a free 12-week trial for his worst-cases. The three-month treatment worked so well that my skin plaques vanished for more than two years. My psoriasis came back, as it usually does, but in a much milder form. I’ve kept away the plaques with topical ointments and light therapy. Sometimes, I even forget I have psoriasis. But the new research linking my disease to heart attacks and metabolic syndrome has snapped me to attention. I know I need to be especially vigilant about controlling my blood pressure, triglyceride levels and weight. For me, that’s no sweat. I’ve always liked exercising at the gym. Now that I can now do it without shedding all over the spin bike makes my workouts that much more enjoyable. Suzanne Schlosberg is author of The Ultimate Workout Log (Houghton Mifflin Harcourt) and co-author of Fitness for Dummies (John Wiley & Sons). For more information and expert advice, visit our Psoriasis Health Center. Are You Skin-Care Savvy?