How Treating Psoriatic Disease Has Changed

By Nilanjana Bose, MD, as told to Susan Bernstein

I am an adult rheumatologist, so I see patients who are 18 and above, with the whole gamut of rheumatologic conditions. Every patient I see is different. For patients with classic psoriatic disease, skin psoriasis symptoms often occur before their arthritis symptoms happen. These two conditions could even develop years apart for some people. But that’s not absolute. You can develop arthritis, or joint pain and swelling, first and then later develop psoriasis.

Patients typically first come to see us for their joint swelling. Usually, psoriatic arthritis causes a peripheral joint swelling. They’ll have swelling of your fingers and toes, which can look similar to rheumatoid arthritis (RA). We do an initial workup and examine their skin, too. If they have psoriasis, including nail pitting or psoriasis plaques, or if they have a family history of psoriasis or psoriatic arthritis, this may suggest that they may have psoriatic arthritis.

COVID: Hello, Telehealth

Once the pandemic hit last year, for the first couple of months, we had to go into retreat mode at our clinic. We really had to scramble to adapt. We moved quickly into using telehealth to treat our patients. We didn’t have some of the telehealth technology, but once we understood that there were resources out there, like telehealth portals and online platforms we could use, we started adopting them.

I think our patients also adapted to telehealth fairly quickly. There were some challenges with older folks. Some didn’t have internet access or found it harder to work out the logistics of telehealth. But for those patients, we were able to conduct regular telephone visits as well.

Telehealth came with its own challenges. We had to learn how to “examine” a patient over the internet. It’s not easy, and it’s not optimal for joint or skin conditions. But a telehealth visit is any day better than a patient missing their appointment altogether and not accessing medical care.

For follow-up visits, telehealth is easy and works well. You can check in with patients and see how they’re doing on their current medications. Some of my patients really prefer telehealth for the convenience. Again, it’s not optimal. We still encourage our psoriatic disease patients to come into the office. It can be tough to see everything using the camera.

Overall, telehealth has been a fun experience, but if a patient needs to be examined in person, I ask them to come in. We’re all still masked up, practicing social distancing, and taking every precaution. We are very committed to the whole aspect of infection control with our patients.

I’ve even seen new patients using telemedicine, especially during the worse phases of the COVID pandemic. If they were referred to me by another physician because they have psoriasis, I can do the initial consultation remotely, but I still try to have them come in. Just getting in and seeing a rheumatologist to begin your treatment is ultimately the most important step with psoriatic disease. You can establish a rapport with your doctor and get the information you need.

Biologics: Game Changer for Psoriatic Disease

Biologics have totally changed the way we manage this disease. Once you’re diagnosed with psoriatic arthritis, there are great treatment options out there. In the past, we had steroids, DMARDs (disease-modifying antirheumatic drugs), and TNF inhibitors, but now, we have IL-17 and IL-23 inhibitors, and JAK inhibitors, too.

Initially, we evaluate our new patients with lab tests and joint imaging and go over all of their symptoms. Some people will have milder psoriatic disease, and some will have more systemic symptoms. With younger patients, we may try to be more aggressive at controlling their disease, because they’re at greater risk for joint damage.

When we go over treatment options, it’s really a two-way, fluid discussion. I talk with my patients about all the risks and benefits of each treatment. If my patient is doing better after a few months, we talk about it and may re-assess the treatment plan.

It’s very rare to see people with psoriatic arthritis these days who develop chronic joint deformities. It may happen if someone was diagnosed a long time ago, before there were better treatment options, or if they were unable to access care before they came to us. The improvements are mainly due to advances in drug treatment, but also because people are more conscious of rheumatic diseases. They Google it. They just have more awareness of rheumatic conditions and that they need to see a rheumatologist.

We screen every patient. Some of them have a true inflammatory, psoriatic disease, while some do not. They may have osteoarthritis or fibromyalgia causing joint pain. Every patient deserves a thorough, complete examination. We want to diagnose these patients as early as possible to begin treatment to control their disease and prevent damage.

COVID and Other Infections: Take Extra Precautions

We were having this exact discussion with our patients before COVID, too. They are at higher risk for serious infections not just COVID, but also other types of pneumonia and other infections. We had already been encouraging these patients to wash their hands often, take commonsense precautions, avoid close contact with sick people, and to get all their vaccinations.

Once the COVID vaccines became available, I told them, “Please get vaccinated and keep wearing your mask.” People who are on a biologic to treat their psoriatic disease are by default more cautious. For new patients who were just starting their biologics, I advised them on how to take precautions to prevent infection. We told many of our psoriatic patients, “Stay home as much as you can right now, and avoid close contact with others.” Patients do listen to this advice because they trust us as their doctors.

Making Psoriatic Patients Feel Safer

Always have a backup plan with telehealth technology! Also, I have encouraged all of my patients to enroll in our online patient portal, so we can stay connected. They can send me messages, I can update their prescriptions, and we can share test result with them.

Technology is a beautiful thing. We need to use it to the fullest advantage in modern medical care. Technology can make it easier to stay in touch with patients with psoriatic disease, who need ongoing care. But some patients may not be used to telehealth, so they can experience some frustration at first. Be patient, take your time to learn to use these tools, and help your patients adapt. Don’t give up if something doesn’t work right at first.

Face-to-face interaction is still very important when you are working with patients with psoriatic arthritis. It can be difficult to form a new patient/doctor relationship without any in-person component.

After they’re diagnosed, some patients continue to see me virtually, and it seems like we are really able to get to know each other well. Telehealth is a safe, secure environment for patients. They’re in their home or office, or even in their car. Sometimes, when I’m talking with a psoriatic patient over telehealth, I see them taking notes. That’s good! Some people find that they’re less anxious when they’re in a telehealth appointment instead of being in their doctor’s office.

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How Science Has Transformed What We Know About Psoriatic Disease

By Alice B. Gottlieb, MD, PhD, dermatologist, as told to Kristen Fischer

Certain things, like your genes, can increase your risk for psoriatic arthritis. If you have a first-degree relative with psoriatic arthritis, you have 39 times the risk of developing it. 

Other risks for psoriatic arthritis include psoriasis on the scalp and nails. Inverse psoriasis, or intertriginous psoriasis, also raises your risk for psoriatic arthritis. (Inverse psoriasis occurs in folds of the body, such as in the armpits or groin area.)

A common misconception is that only people with moderate to severe psoriasis get psoriatic arthritis. You can get psoriatic arthritis even if you have mild psoriasis. Early detection is key. If you can manage psoriasis, you may be able to stop psoriatic arthritis from getting worse – maybe prevent it completely. 

Why Does Early Diagnosis of Psoriatic Disease Matter?

Family doctors – especially dermatologists – need to spot psoriasis so they can prevent disabilities caused by psoriatic arthritis. Once detected, we can do something about it.

That’s a paradigm shift from when I was a rheumatology fellow at the Hospital for Special Surgery. Back then, we had nothing that could keep the disease from getting worse. Doctors didn’t even control signs and symptoms that well.

Now there are several medications on the market to treat psoriatic arthritis . Some are tumor necrosis factor (TNF)-alpha inhibitors blockers, Interleukin inhibitors, and JAK inhibitors.

There’s also research that found people who took medication had less damage, compared to those who didn’t. That suggests that you may even prevent psoriatic arthritis.

How Can Dermatologists Detect Psoriatic Disease?

Dermatologists may not know how important their role is in detecting psoriatic arthritis. They don’t have to be experts in diagnosing it, but they must check for it. Then they can refer you to a rheumatologist. They need to ask you about joint pain. Many people don’t realize that aches and pains can be a disease. It has to be brought up.

Missing a diagnosis can be serious. Research tells us that a delay in diagnosis and treatments causes increased joint erosion, deformity, and arthritis mutilans (a form of psoriatic arthritis where bone degeneration shortens your fingers and toes).

In dermatology practices, people usually have signs of enthesitis before they have a psoriatic disease. Enthesitis is inflammation where tendons and ligaments insert into bone. It can cause joint pain, stiffness, and mobility problems. Some ultrasound evidence shows that enthesitis increases the risk of a future psoriatic arthritis diagnosis by five times.

How Is Psoriatic Disease Care Improving?

Doctors have simple, quick screening methods to spot psoriatic diseases. We need to get these in the hands of more general practice doctors and dermatologists – and they have to use them.

I’m working with a team to encourage more doctors to use these screening tools. Mount Sinai recently started a new program that integrates psoriatic disease screening tools with our electronic medical records (EMRs). 

Here’s how it works: People who come to us will respond to the five-question Psoriasis Epidemiology Screening Tool (PEST) while they’re in the waiting room. When they see their doctor, their PEST results will come up on the EMR. If they answer three or more questions positively, the EMR application alerts the doctor that the score shows possible psoriatic arthritis. It will give the doctor a prompt to refer the patient to a rheumatologist. It couldn’t be easier.

They’re also integrating the industry-standard Psoriatic Arthritis Impact of Disease (PsAID) Questionnaire into EMR. People with an existing psoriatic disease, or those who are PEST-positive, will have to respond to 12 questions. If they have a certain score, it will alert the doctor that the case is not controlled. It will then prompt the doctor to set up an appointment with a rheumatologist. The EMR will also suggest medications.

These screening tools are available in some other EMR systems, but my project is different because I will measure how well it works.

At the end of 18 months, I’ll see if the percentage of cases goes up. The system will be able to tell if people are managing their psoriatic diseases, and we will be able to assess how treatments work.

If all goes well, this will make it easy for doctors to give patients better care. It will help them to be more aware about diagnosing psoriatic diseases, and to know if people have their disease under control. 

The screening tools are available on the GRAPPA app, which is produced by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.

What’s New in Psoriatic Disease Medications?

There are some advances in medications to treat psoriatic arthritis. TNF blockers are the gold standard to treat psoriatic diseases. But they don’t work for everyone. 

Deucravacitinib is a newer FDA-approved drug for psoriasis – but not for psoriatic arthritis. There is some evidence that it can improve psoriatic arthritis. Clinical trials look good for bimekizumab, an oral medication that clears skin for 3 years, but it is not yet approved in the U.S.

In 2023, adalimumab (Humira) will be available in generic form. I don’t think the price will come down much.

I give preference to treatments that stop psoriatic arthritis from getting worse, even in patients that only have psoriasis. That’s because there’s some evidence that the drugs may prevent psoriatic arthritis. 

For now, the combination of working treatments – and getting more people diagnosed so we can prevent disabilities from psoriatic diseases – is a priority.

We have great treatments for psoriatic diseases, but many are expensive. Many people can’t afford them, even people with supplemental insurance. 

What’s Next for Psoriatic Arthritis and Psoriasis?

Overall, people need to know that psoriasis is much more than something that affects their skin. It can cause lasting damage and complications.

That’s why screening for psoriasis and psoriatic arthritis is so important, and why I’m dedicated to making sure everyone gets checked.

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