Tools and Resources

Ask the Expert

You've got questions? We've got answers—from the leading psoriasis and psoriatic arthritis experts around the United States.

Treatment  |  Psoriatic arthritis  |  Psoriasis on specific skin sites
Children and teenagers  |  Co-morbidities  |  Lifestyle  |  Triggers and causes

 

Treatment

Q: Can stress-related drugs be useful for the treatment of psoriasis?

A: Stress plays an important role as a trigger factor in psoriasis, but stress-related drugs are not widely used to treat psoriasis, and many of these compounds have significant side effects, including the development of drug dependence. If your psoriasis is quite itchy, then antihistamines such as Benadryl or Atarax may provide some relief. These medications also have a sedative effect. I recommend that you consult with a dermatologist to determine which is best in your particular case.

James T. Elder, M.D., Ph.D.,  Kirk D. Wuepper Professor of Molecular Genetic Dermatology, Department of Dermatology at the University of Michigan

Q: I have been on Enbrel for ten months and the shots have significantly improved my psoriasis. However, I am concerned about the potential side effects of the long term use of systemic biologics. So would you say the risks are rare or high?

A: Dr. Leonardi, who hosted our webcast Systemics Treatments for Psoriasis webcast, had this to say:

The risks of biologic therapy are less than we expect that they would occur in systemic treatments. They have to be balanced against the risk of not treating your moderate to severe disease as well. We think we are improving the outcome of arthritis as well as other comorbid disease issues in reducing heart disease and strokes. That data is going to come. The big issue with biologics is what you end up doing when you're faced with what I would call a serious infection. We don't necessarily see a lot of serious infections while on these drugs. But, we do have situations where patients get an infection and they don't do the right thing. So I'm always telling my patients "patient, if you develop a fever of 100 degrees, hold your dose of therapy if it is time to give yourself an injection and I want you to call your family doctor and get an appointment." We don't want you sitting at home with a fever for three or four days. That is the way you get in trouble.  We want you to be more proactive in that regard. Sometimes patients will develop a chronic cough. That might indicate other types of infections that can affect the lungs. You want to be aware of that and bring it up with your dermatologist and family physician. Overall, the risk and benefit ratio of drugs like Enbrel are overwhelmingly positive and I would not be concerned about being on the medicine for more than ten months. I would be more concerned if you’re thinking about starting and stopping these treatments because everything we know about this disease is that it is chronic and it’s going to be grinding on you for the long haul.

Dr. Craig Leonardi, Clinical Professor of Dermatology Saint Louis University, St. Louis, Missouri

Q: I am not overweight, am a regular exerciser and drink green smoothies and eat fruits and vegetables. I am wondering if I there are more drastic measures I could take, such as Gerson Therapy, Optimal health institute, or fasting?

A: Fasting clears psoriasis for many people, but prolonged fasting is not compatible with life! Take another look at your diet. Do you eat more than 1 or 2 servings of grain (bread, rice, oatmeal, cereal, pasta, baked goods) per day? Do you go without eating for more than 3 hours at a time? Are you eating fewer than 3 palm-sized servings of concentrated protein foods per day? You may be able to fine-tune your diet. Journal your diet and your flares of psoriasis; it might help you identify a trigger food. How about lifestyle? Could you be over-exercising? Do you get 7-8 hours of uninterrupted sleep nightly? Do you have a peaceful interval built into your daily routine?

Valori Treloar, M.D., Wellesley, Massachusetts

Q: I am an identical twin and yet my twin sister does not have psoriasis. We have the exact genetic make-up so how can this be?

A: Dr. Blauvelt, who hosted our webcast Psoriasis: Cutting-edge Advances for an Ancient Disease, said:

 Identical twins have identical genes. So, if psoriasis is genetic we would expect that if one has psoriasis, the other should have psoriasis. That’s not the whole story. We know the environment is very important in psoriasis, too. The genes are important but probably not 100% of the story. We do know of some studies of identical twins and psoriasis; in those studies the twin had psoriasis 70% of the time, not 100%. But, this is much higher that the normal number of 2-3%. So, that is actually support for a genetic link because of the high amount of similarity in identical twins.

Andrew Blauvelt, M.D., Psoriasis Research Director of OHSU's Center for Excellence for Psoriasis and Psoriatic Arthritis, Portland, Oregon.  

Q: Can you use acupuncture as a treatment for psoriasis?

A: Lakshi Aldredge, who presented our Treating with Topicals webcast, answered on air: I am a firm believer in alternative medicine. If it is cheap, legal, and it works, use it. Acupuncture and massage are two excellent methods of stress reduction, which helps your psoriasis. People who have stressful events have worse psoriasis. So, if acupuncture is effective for you, use it.

Lakshi Aldredge, MSN, ANP-C, Lead Nurse Practitioner at Portland VA Medical Center, Portland, Oregon

Q: How can I control my mild psoriasis in between flares?

A: Lakshi Aldredge, who presented our Treating with Topicals webcast, answered on air: When my patients have a flare, I prescribe a high potency steroid like clobetasol then a low potency steroid like tiamcinolone. When you are flaring, you should use the high potency clobetasol two times per day for a couple of weeks until the plaque thins down. In between flares, you should use your low potency steroid, such as triamcinolone, to keep it at bay. You want to use the least potent steroid that is effective on your psoriasis to avoid thinning and stretching of the skin.

Lakshi Aldredge, MSN, ANP-C, Lead Nurse Practitioner at Portland VA Medical Center, Portland, Oregon

Q: At home I was receiving light therapy three days a week. I can't fit much time into my college schedule. Can light therapy be effective once a week or less?

A: Light therapy—either ultraviolet light B (UVB) or PUVA (the light-sensitizing drug psoralen combined with ultraviolet light A)—requires treatment two to three times a week to improve active psoriasis. Once the skin is clear, PUVA treatments every one to four weeks can maintain improvement. However, with UVB, improvement is hard to achieve or maintain with fewer than two sessions a week. Because of your schedule, I suggest you speak to your dermatologist about possibly obtaining an at-home UVB phototherapy unit.

Q: I used topical steroids with great success for about a year but then they seemed to stop working. What happened?

A: The phenomenon of steroids losing efficacy is referred to as tachyphylaxis (a rapidly decreasing response to a drug). It is a common occurrence. One trick I use to minimize this is to use combination therapy with non-steroid agents such as vitamin D derivatives (i.e., Dovonex or Taclonex) or immunomodulators (i.e., Protopic or Elidel). Rotating therapy with other agents or light can also help minimize the effect.

Erin Boh, M.D., Ph.D., Chief and Professor of Dermatology, Tulane University Health Sciences Center, New Orleans, La

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Q: I recently started taking a medication that prohibits me from drinking alcohol, and I've noticed that my psoriasis has improved a great deal.  Is there a connection?

A: Alcohol appears to affect psoriasis in men more strongly than in women. Heavy drinking may actually lower treatment response, particularly in men. Men with psoriasis tend to drink more than men without psoriasis, there is a significantly higher incidence of psoriasis in alcoholics, and abstinence from alcohol can improve the severity of the disease. In addition, it should be noted that alcohol may have a dangerous side effects when combined with certain psoriasis medications, such as methotrexate, so it is very important that you inform your physician of your alcohol intake.

Neil J. Korman, M.D., Associate Professor of Dermatology, Case Western Reserve University, University Hospital of Cleveland, Cleveland, Ohio.

Q: After years of trying different treatments for my psoriasis, I am looking at alternative approaches.  What are reasonable expectations if I follow a regimen of meditation, light exercise such as yoga, and a diet that reduces my refined sugar intake?

A:  A healthy lifestyle including a healthy, well-balanced diet, no tobacco, minimal alcohol and stress management will have a positive effect on your life and your psoriasis. Whether or not this will be adequate for disease control is highly variable, but the positive effects will translate into numerous benefits over your lifetime.

Jennifer Cather, M.D., Director of Clinical Research, Texas Dermatology Research Institute, Dallas, Texas

Q: My doctor is recommending phototherapy for my psoriasis.  What is the difference between narrow-band and broad-band UVB, and is one more effective than the other?

A: There are two types of ultraviolet light B (UVB) treatment: broad band and narrow band. Broadband UVB is more commonly used in the United States; however, narrow band has been shown in several studies to be very effective at treating psoriasis and is becoming increasingly available.  The main difference is the range of UV wavelengths (usually 311-312nm for narrow band and 290-320nm for broad band). Both are administered in the doctor's office, where the patient stands in a light box lined with UVB lamps or an enclosure that contains the lamps. Smaller units are available to treat palms and soles, as well as for home use by prescription. Patients generally receive treatments two to three times per week. It takes an average of 30 treatments to reach maximum improvements of psoriasis lesions. UVB may be used alone or in combination with topical treatments or systemic medications. Although narrow band has been shown in several studies to be more effective than broad band, it does not have the 80-year safety record of broad band.

Alexa Boer Kimball, M.D., M.P.H., Director, Clinical Unit for Research Trials in Skin (CURTIS), Massachusetts General and Brigham and Womens Hospitals, Harvard Medical School, Boston, Mass.

Q: I am a 34-year-old woman who has been using clobetasol propionate cream for the past 10 years to treat my guttate psoriasis. I was recently diagnosed as a "glaucoma suspect" and am curious if perhaps there is an association between long-term clobetasol propionate cream use and glaucoma. If there is an association between the two, can you suggest any other medication(s) that I can discuss with my doctor to treat my psoriasis?

A: Prolonged use of topical steroids around the eyes can result in glaucoma as well as cataracts. Superpotent topical steroids should not be used around the eyes. Psoriasis patients with guttate psoriasis tend to have a very good response to increasing increments of ultraviolet B (UVB) light. In general, it is impractical to treat patients with moderate to severe psoriasis with topical steroids.

Jerry Bagel, M.D., Director, Psoriasis Treatment Center of Central New Jersey, East Windsor, N.J.

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Psoriatic Arthritis

Q: I have psoriasis and worry about developing psoriatic arthritis.  What symptoms should I look for to detect early arthritis?

A: Psoriatic arthritis is a type of inflammatory arthritis that affects up to 30 percent of patients with psoriasis.  In 70 percent of patients with psoriasis, the skin symptoms appear before the arthritis. Psoriatic arthritis can involve any joint in the body, including the spine, hips, knees, feet and hands. If you have persistent joint pain, swelling, stiffness or loss of motion which lasts more than six weeks, you should see your doctor for an evaluation. 

Elizabeth Ann Tindall, M.D., Rheumatology & Immunology, West Linn, Ore.

Q: I have psoriasis of the nails. I've heard that this is an indicator of psoriatic arthritis. Is that true?

A: Psoriasis can produce a variety or nail changes which include pitting, ridging, a buildup or material under the nails (hyperkeratosis) or a lifting of the nail itself (onycholysis).  Nail abnormalities are common (20 to 40 percent) in patients who only have psoriasis. However, 60 to 80 percent of psoriatic arthritis patients- especially those with arthritis involving the joints at ends of the fingers (distal interphalangeal joints or DIP)- will have nail abnormalities too.

Elizabeth Ann Tindall, M.D., Rheumatology & immunology, West Linn, Ore.

Q: I have severe psoriasis and have just been diagnosed with psoriatic arthritis. Are any medications currently prescribed or on the horizon to treat both diseases?

A: Yes, several of the medications used to treat psoriatic arthritis will also treat psoriasis. Methotrexate is given orally or by injection once a week for both conditions. It is given with folic acid supplements to minimize side effects. Laboratory tests need to be monitored by your doctor every four to eight weeks. Alcohol must be avoided while taking methotrexate.

The anti-TNF (anti-tumor necrosis factor) biologic medications include Enbrel, Remicade and Humira. These are approved by the U.S. Food and Drug Administration (FDA) for treating both psoriasis and psoriatic arthritis in patients who are not adequately controlled on methotrexate. These biologic therapies decrease the inflammation in the skin and joints, thereby preventing further damage in most patients.

Remember that these medications may suppress your body's ability to fight infections or heal normally, so it is very important to let your doctor know if you are scheduled for surgery or running a fever or feel sick before you take your next dose.

Elizabeth Ann Tindall, M.D., Rheumatology & Immunology, West Linn, Ore.

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Psoriasis on specific skin sites

Q: I have some specific questions about how to care for a 12- year-old girl with severe psoriasis. Her scalp is about 80 percent covered. What do you recommend for her treatment?

A: Topical corticosteroids seem to work very well for scalp psoriasis, if people can find the time to actually put them on. I typically recommend starting with fluocinonide or clobetasol in a vehicle conductive for use on the scalp (solution, shampoo or foam vehicles seem to be easiest to use in the scalp). People with scalp psoriasis should try applying the medication twice a day for one week. This is not easy, as it can be hard to find the time to do it and not miss any applications. Hopefully with such regular use patients will see the psoriasis improve quickly.  If it doesn’t start to improve within a week, other things can be added, including salicylic acid or tar shampoos.

Steve Feldman, M.D., Ph.D., Professor of Dermatology, Pathology and Public Health Sciences, Wake Forest University, Winston-Salem, N.C.

Q: Occasionally I have psoriasis flare-ups in the genital area.  Should I avoid being intimate with my spouse during these times?

A: Psoriasis involvement of the genital region can be uncomfortable and embarrassing for both men and women; it should not, however, preclude you from being intimate with your spouse. For men, psoriasis can affect both the penis and scrotum, resulting in chronic discomfort. To limit the irritation and discomfort during intercourse, it may be helpful for the man to wear a condom.  This will help serve as a barrier to prevent further trauma and irritation. Prior to intercourse, it is important to wash all medications from the genital area to avoid transfer of the medications to your partner. After intercourse, it is important to cleanse the area and reapply your medications as directed by your doctor. Psoriasis is not contagious. Therefore, you cannot get psoriasis from someone through physical contact.

Neil J. Korman, M.D., Associate Professor of Dermatology, Case Western Reserve University, University Hospital of Cleveland, Cleveland, Ohio.

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Children and Teenagers

Q: My ten-year old son has mild psoriasis. Are there dermatologists who specialize in working with children?

A:  Pediatric dermatologists have specialized training for the diagnosis and treatment of children with dermatologic disorders. Check with your doctor about being referred to a pediatric dermatologist.

Jennifer Cather, M.D., Director of Clinical Research, Texas Dermatology Research Institute, Dallas, Texas.

Q: I am a teenager with mild psoriasis, but I believe I have the symptoms of psoriatic arthritis.  Am I too young for arthritis?

A: Psoriatic arthritis usually occurs in patients between the ages of 30 to 50. However, psoriatic arthritis makes up about 10 to 15 percent of all chronic childhood arthritis cases. The arthritis precedes the skin symptoms in more than half of the children. Unlike adults, psoriatic arthritis affects girls two to three times more than boys. Studies show that children and adults with psoriatic arthritis may start out with only one or two joints involved, but over time, more than half progress to four or more joints (polyarthritis). Unlike adults, psoriatic arthritis in children may be associated with chronic eye inflammation called uveitis. This is a treatable, controllable condition. It is frequently associated with a blood test called ANA (anti-nuclear antibody).

Elizabeth Ann Tindall, M.D., Rheumatology & Immunology, West Linn, Ore.

Q: My young daughter was just diagnosed with psoriasis. How can I help her understand this chronic disease?

A: It is very important for a parent to be well-informed about the nature of psoriasis. To explain how each person is different, use examples such as eye or hair color, then tell her that psoriasis is another quality that makes her unique. Meeting other children with psoriasis might be helpful, as well as joining local support groups. Acknowledging your child's initial emotional discomfort might make her more open about her feelings later on.

Alla Gruman, M.D., University Park Dermatology, Sarasota, Fla.

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Co-morbidities

Q: I have heard that the colon affects psoriasis. What research has been done to prove any connection between colon conditions and psoriasis?

A: I know of no correlation between colonic health and pathology with psoriasis.

Jerry Bagel, M.D Director Psoriasis Treatment Center of Central New Jersey

Q: Is risk for skin infections higher in people with psoriasis than in people who don't have psoriasis?

A:Psoriasis is characterized by skin cells which have a turnover rate higher than non-psoriatic skin.  The bacterial flora associated with plaques of psoriasis is similar to those seen in non-involved skin.  So theoretically, there should be no difference in terms of risk of infection.  But studies have shown that skin affected by psoriasis may be more susceptible to certain triggers, such as an increase in itching or scratching, which might lead to a higher incidence of infections in those with psoriasis- especially if there is abrasion of the skin.

Michael H. Gold, M.D., Medical Director/Founder, Gold Skin Care Center, Nashville, Tenn.

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Lifestyle

Q: I love to swim but am concerned about chlorine making my psoriasis worse.  Is there anything I can do to prevent that?

A: Swimming is great, and chlorine is actually a great disinfectant.  You just have to make sure that you moisturize and/or apply medication as soon as you are done swimming.

Alexa Boer Kimball, M.D., M.P.H., Director, Clinical Unit for Research Trials in Skin (CURTIS), Massachusetts General and Brigham and Womens Hospitals, Harvard Medical School, Boston, Mass.

Q: How does my weight affect my psoriasis?

A: A study published last year in the annals of Internal Medicine showed that "increasing adiposity [fat] and weight gain are strong risk factors for psoriasis in women."  In another study, cyclosporine was found to be three times more effective in the study group that lost 5 to 10 percent of their body weight compared with those who did not lose weight.  All subjects had a body mass index (BMI) of 30 or greater (obese).  The effect of weight loss alone has not yet been studied.

Valori Treloar, M.D., CNS, Dermatologist, Integrative Dermatology, PC, Newton, Mass.

Q: Is it okay to get tattoos when you have psoriasis, and can the dye irritate and cause infection or flare?

A: In general, reactions to tattoos are uncommon. There are cases of infections or allergic reactions to the dyes. These reactions are not more common in patients with psoriasis. If you would happen to have an abnormal reaction to the tattoo, the psoriasis could flare in this area. If you would not have a reaction to the tattoo, there would be no problem at all. It is just difficult to predict how often these unusual reactions occur. However, tattoos may "Koebnerize," causeing plaques at the site of the tattoo.

Robert E. Kalb, M.D., Buffalo Medical Group, Clinical Associate Professor of Dermatology, SUNY at Buffalo School of Medicine, Buffalo, N.Y.

Q: I am not overweight, am a regular exerciser and drink green smoothies and eat fruits and vegetables. I am wondering if I there are more drastic measures I could take, such as Gerson Therapy, Optimal health institute, or fasting?

A: Fasting clears psoriasis for many people, but prolonged fasting is not compatible with life! Take another look at your diet. Do you eat more than one or two servings of grain (bread, rice, oatmeal, cereal, pasta, baked goods) per day? Do you go without eating for more than three hours at a time? Are you eating fewer than three palm-sized servings of concentrated protein foods per day? You may be able to fine-tune your diet. Journal your diet and your flares of psoriasis; it might help you identify a trigger food. How about lifestyle? Could you be over-exercising? Do you get 7-8 hours of uninterrupted sleep nightly? Do you have a peaceful interval built into your daily routine?

Valori Treloar, M.D., CNS, Dermatologist, Integrative Dermatology, PC, Newton, Mass.

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Triggers and Causes

Q: My psoriasis tends to get worse during the fall and winter.  Why is this, and how can I take care of my skin during the cooler months?

A: You are not alone. Many patients get worse in cooler months, in part due to the lower humidity, which in turn dries out the skin. Psoriasis can occur in these dry areas.  Good skin care involves using mild soaps and emollients or moisturizers. Apply these agents to damp or wet skin. Additionally, psoriasis is a disease that responds very well to sunlight. Some patients remain clear in summer due in part to sunlight and tend to worsen in winter months. Dermatologists can use phototherapy or ultraviolet B (UVB) or ultraviolet A (UVA) to treat psoriasis.

Erin Boh M.D., Ph.D., Chief and Professor of Dermatology, Tulane University Health Sciences Center, New Orleans, La.

Q: Is there anything I can do to reduce my chances of having a psoriasis flare?

A: To reduce the risk of having a psoriasis flare, you need to reduce the triggers associated with psoriatic flares. These include skin injury; infections such as strep throat; and certain medicines such as lithium, beta-blockers, antimalarials, and some nonsteroidal anti-inflammatory drugs (NSAIDs). Emotional stress may be a trigger for some individuals. While most patients find benefit with sunlight, a small percentage will actually flare when their psoriasis is exposed to the sun.

Michael H. Gold, M.D., Medical Director/Founder, Gold Skin Care Center, Nashville, Tenn.

Q: Do food allergies play a role in psoriasis?

A: This is an area of controversy. Even the definition of "allergy" versus "sensitivity" raises questions. In the case of gluten sensitivity, I think the answer is, "yes, for some people." Other foods have not been studied.  Most dermatologists advise that you avoid foods that seem to worsen your psoriasis, but we do not base this advice on any scientific studies.

Valori Treloar, M.D., CNS, Dermatologist, Integrative Dermatology, PC, Newton, Mass.

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