Michelle: My name is Michelle Zimmerman and I have been a psoriasis patient for 36 years. I was diagnosed when I was five and I have been a volunteer now for many years with the National Psoriasis Foundation through supporting local community events, and work with the advocacy department, and I will be your moderator for today's discussion about psoriasis and other related health conditions, and what are some key screenings that can be done regularly to help prevent or catch some of these other related health diseases. Joining me is board certified dermatologist, researcher, published author and national speaker Dr. Chesahna Kindred. Dr. Kindred founded Kindred Hair and Skin Center in Maryland, where she treats people with hair and skin disorders of all ages and ethnicities. In addition to being the founder and president of Onyx Medical Society, Dr. Kindred is Chair of the National Medical Association Dermatology section, a member of the Women's Dermatologic Society, the American Society of Dermatologic Surgery, Fellow of the American Academy of Dermatology, and a member of the Medical Board of the National Psoriasis Foundation. Dr. Kindred is a true believer in empowering oneself, both on the skin as well as inside the body.

In the past I have been the moderator of the National Psoriasis Foundation’s More Than Skin Deep series, which clearly reflects how psoriasis and psoriatic disease impacts us on more than just the skin. What diseases or comorbidities are people who have psoriasis like myself at risk of developing and why is the risk so much higher?

Dr. Kindred: Hi Michelle, thank you for having me. So as a dermatologist, I treat a lot of patients with psoriasis. And one of the first things I try to make sure that the patients understand that psoriasis is not just a skin disease. It's really inflammation throughout the entire body. In other words, it's a systemic, inflammatory disease. It's chronic meaning it's long lasting. This is something where the body is creating the inflammation or it's pro-inflammatory. And when you have diseases like that, systemic, chronic, pro-inflammatory diseases, it doesn't just affect one organ, right? The skin is just one of multiple organs that in effect, it also could affect the joints leading to psoriatic arthritis. The eyes leading to uveitis, the heart causing cardiovascular diseases like high blood pressure and others, metabolic diseases, the GI tract such as irritable bowel disease and so on and so forth. So it really is a multi-system disease that just most commonly shows up in the skin.

Michelle: Yes, I have been dealing with psoriasis for 36 years now, so definitely something that we are with for the long haul. As many of us with psoriasis know we are at a greater risk of developing psoriatic arthritis. I believe it's about a 30% chance, or one in three people with psoriasis will develop psoriatic arthritis. So what is kind of the latest on why there's this connection and what can be done to minimize the risk? I know, it's something I worry about. And then are there recommended screening tools to help us diagnose or catch it early?

Dr. Kindred: So firstly, we don't fully understand the connection. We know it does indeed have to do with the inflammation. So there's inflammation of the skin. Skin is made up of a certain cell that are shared with other organs. We think that might have something to do with it but the screening tool is very simple. Not as complicated as the research going into all the different connections and how they develop. So one way to minimize the risk is really early recognition. That's why it's so important for patients with psoriasis to know that it can affect other organs and as far as a screening tool, PEST. Basically, Psoriasis Epidemiology Screening Tool or PEST is a series of just five really simple questions that ask about swollen joints, fingers and toes. Asks whether or not a doctor's ever diagnosed you with arthritis. A simple question about maybe some nail abnormalities, and if there's any pain in the heels. So a very, very simple screening tool. PEST is something that's easily searchable on psoriasis.org.

Michelle: Yes, I know I get those questions every year when I go in for my yearly check, skin check and medicine check and they ask any stiffness, anything with the nails so.

Dr. Kindred: Yes.

Michelle:  Hopefully it sounds like they're taking good care of me. So if people with psoriatic arthritis are also at risk of developing uveitis, which causes inflammation of the eye such as redness, pain, blurred vision, do you recommend yearly screenings with an ophthalmologist for patients with psoriatic arthritis? And how important is it to catch it early also?

Dr. Kindred: So I’ll answer the last question first. Early detection is key. Early detection for the eyes, for the joints in general. So psoriasis patients know that it's a skin disease and know that they should see a dermatologist, and psoriatic arthritis patients know that's the joint and they should see a rheumatologist.

But psoriasis patients and psoriatic arthritis patients both should also see ophthalmologist, right.
It's really important. Don't forget to see the ophthalmologist for the eyes. Uveitis or inflammation of the eyes that you just mentioned affects about 0.1% of people in the US, but for patients with psoriasis, this is more like 7%. So it's worth it. Just make that screening appointment with the eye doctor and get screened for uveitis.

Michelle: Great. We also know, all these things are related to our psoriasis and everything, but cardiovascular disease is something else that patients with psoriasis or psoriatic arthritis have to worry about. A lot of findings have come out in recent years about the connection between cardiovascular disease and psoriatic disease severity. This is due to research conducted by Dr. Nehal Mehta from the section of Inflammation and Cardiometabolic Disease at the NIH National Heart, Lung and Blood Institute and Dr. Joel Gelfand at the University of Pennsylvania. We featured on our podcast episodes 56 and 221 - if anybody wants to check those out. Given that research, can you elaborate a little bit on the alignment between psoriatic disease severity with the development of cardiovascular disease?

Dr. Kindred: Yes, thanks to the research done by Dr. Mehta, Dr. Gelfand and others, heart disease we found out is actually very important for psoriasis and this is something that we learned during my career. So very early as a medical student, we were taught it was a skin disease and by the time I was a resident, we were taught that there's a high cardiovascular risk factor for patients with psoriasis and it has to do with the inflammation, the systemic inflammation involved in psoriasis. And so there's been a ton of  research. So if we look at heart attacks and the general population, usually the patients are in their 60’s and 70’s. But patients with moderate to severe psoriasis, we see heart disease, refractory high blood pressure and others decades earlier or it's more severe. So I insist that all of my psoriasis patients and psoriatic arthritis patients as well, I insist they all have a primary care doctor because it's very easy for them to just see me if they feel otherwise healthy. But you can't feel high blood pressure. Actually, if you feel hypertension, you're too late, right? So if they have a primary.

Michelle: Right.

Dr. Kindred: care doctor monitoring the cardiovascular health, then I know they're covered and I know that the primary care doctor is following the latest JnC version for hypertension and stroke risk factors and hyperlipidemia, etc.  And I can't see the heart and dermatology is a visual science. I think this data about the cardiovascular risk factors that psoriasis poses really humbled dermatologists in that it's not just skin right? We thought the depression was because psoriasis patients were depressed about their psoriasis, right? We were looking at everything through the lens of skin. Now we know to look at psoriasis through the lens of inflammation and that inflammation certainly can affect the heart right and between the heart, brain and lungs, we really can't function without those three. And it's not just “oh a few people get it”. Like almost up to half of patients with psoriasis at risk for heart disease. That's something that every dermatologist pays very close attention to and we appreciate the previous podcast that the NPF covered on this subject.

Michelle: Yeah, I appreciate what you said about like even in your career like things we've learned and things we've understood. As I said earlier, I've had psoriasis for 36 years since I was 5 and there used to be nothing. There was you had some topicals to try and keep the psoriasis under control a little bit, but it's just so encouraging to me to see all the research and everything we're learning about psoriasis and then all the treatments that are able to be developed. So it's just so encouraging for somebody who's been on this path with psoriasis for many years.

Dr. Kindred: I'm glad you mentioned that. Because of all this amazing research, new treatments, etc, I never looked down upon a physician's treatment regimen from 10, 15, 20 or in your case 36 years ago. Because the obvious thing is they had to work with what existed right or what we knew existed. And so this research about the cardiovascular disease is within the last 10-15 years. So there's anyone out there who thinks that the dermatologist is only gonna give them a cream for their psoriasis, I want you to know that we’ve kind of stepped up our game, if you will, and we look at this as a whole systemic disease, not just a rash that deserves a cream.

Michelle: Yes. Yeah. Yeah. Because when I was a kid, it was like here's some creams and the sun and salt water's about all we know to tell you. So I spent so much time in the sun and now I'm in there every year getting my skin checks and everything.

Dr. Kindred: Yes, yes, yes, yes.

Michelle: But you know, it did work at the time. So yeah, you can only work with what you have.

Dr. Kindred: Right.

Michelle: And you had mentioned your primary care doctor and high blood pressure and everything. We know that metabolic syndrome is a strong predictor for the development of cardiovascular disease. Is there anything like around diabetes and other things that may be more to elaborate on and the association with psoriasis?

Dr. Kindred: Yes. So usually I work with a primary care doctor who already gets screening labs. There is indeed a higher risk of diabetes in patients with psoriasis. So early on we just knew there was a link. We didn't know what the link was. So for annual exams with the primary care doctor, they're usually screening for diabetes and just for the audience to know according to the American Diabetes Association, you want your fasting blood glucose, that is, you don't eat anything for about 8 hours. Get your blood drawn. Check your blood sugars and we want that to be preferably less than 100. If it’s between 100 and 125 that's prediabetes. 126 and above you're looking at diabetes. So I'm sure, the audience and you, you've had these labs done, you can look at your record results and just see where you fall. The reason for mentioning that is that if someone has psoriasis that involves 10% of your body will be like one of your entire legs covered from top to bottom in psoriasis, right. It's a lot, but it doesn't take too much if you have severe psoriasis to meet that criteria. So if you have 10% body surface area, (as we call it in dermatology) covered in psoriasis without anything else to be mindful of, you're more than likely going to develop diabetes and that's really important because diabetes outside of the psoriasis is linked to heart disease and high blood pressure, and a whole host of other illnesses. Let alone that psoriasis can make you prone to weight gain right? And weight gain, being overweight can make you prone to cardiovascular disease. Did I already mention that the heart is important, right? So just from the psoriasis, that is the weight gain.

Michelle: Right. (laughs)

Dr. Kindred: The psoriasis is the weight, diabetes etc., it's all connected. So if we look at the study and those who have psoriasis, diabetes is such a real thing. So I think we're having our list of doctors, now rheumatologists for the joints, dermatologists for the skin, ophthalmologist for the eyes, right. And then your primary care doctor, which I probably should have started with that honestly to screen you for diabetes and other metabolic syndrome.

Michelle: Yeah, I know I get injections every two weeks. I like to joke that it's my husband gives them to me because I just can't bring myself to do it. So I joke that it's good for our marriage and he gets to stab me every couple of weeks. But so I'm in there having my blood work done because of the medication that I'm on, seeing my primary care doctor every year and having that blood work done. So hugely important. And I know my derm says he has a hard time sometimes getting his patients to go do their blood work. So I would encourage everybody, they can't help you.

Dr. Kindred: Absolutely.

Michelle: They can't take care of you if they don't know what's going on.

Dr. Kindred: Right. I can't see your high cholesterol. And again if you feel it, that's too late.

Michelle: Right. So we talked a lot about different diseases and things associated with psoriasis and psoriatic disease. This next one we're going to talk about unfortunately I have now developed --inflammatory bowel disease, or IBD is also associated with psoriasis. I developed ulcerative colitis about 11 years ago and the gastroenterologist knew what was wrong within like 10 minutes. And this was after having been sick for a couple of months. So yes, you need the whole team of doctors like you said cause my primary care was doing her best, but I needed that specialist. So it's important to see that team of people you outlined. So why do you believe this risk occurs and what should other people be looking at?  I went through this guessing game of trying to figure out what was wrong with me. So what can we do to help other people not go through that guessing game?

Dr. Kindred: So that's really important the story that you were just sharing. So you developed symptoms, you had them for a couple of months and then you saw your primary doctor. You saw your primary doctor right away?

Michelle: I saw my primary care doctor right away and she assumed that it was some kind of infection I had gotten or something.

Dr. Kindred: Yeah.

Michelle: and then figured out after a couple of medications that wasn't working and sent me for a colonoscopy.

Dr. Kindred: then from the colonoscopy. Well, you went to GI. Did you have the colonoscopy

Michelle: They sent me straight for a colonoscopy because she didn't want me to have to wait to go see a doctor.

Dr. Kindred: Ah, yeah, yes.

Michelle: And then have to wait to be scheduled again for the colonoscopy and everything.

Dr. Kindred: So that’s really something that's unfair about some of these diseases that are associated with psoriasis. So you develop psoriasis, the dermatologist, I just look at and I see it. Usually within the first 30 seconds I know the diagnosis and the rest of the appointment is talking about what it is, what treatment options are available, side effects, what if we do nothing, blah blah blah.  But for the things that psoriasis are connected to, it's not so easy. So you, right, are amongst a bunch of other patients that  doctor saw that had a stomachache, or nausea, or vomiting, diarrhea, or whatever. And probably for that three months you were the only one with irritable bowel disease or ulcerative colitis. So sometimes your doctor has to try one thing and then try another before teasing it out. And since inflammation is your body's only weapon, right? It's the only way your body fights infections, and parasites, and cancer cells, is the reason why we can't cure some of these things. If it's an infection, we can cure that. So sometimes your doctor goes straight towards trying to cure a possible infection, and unfortunately IBD mimics an infection to a T. You might even thought you had a infection. Maybe say a fever so the connection is this inflammation that's also involved in infections. Inflammation is also involved with irritable bowel disease, Crohn's, ulcerative colitis, and psoriasis. What some of the data is showing is it has something to do with the community of germs in the gut, right? The community of germs in your stomach, small intestine, etc and that's called the gut microbiome. And if I were to collect all of your cells, there will be more bacterial cells than human cells, and that's how important the bacteria on and in our body are. And really, in our body is really mostly the gut and the skin by far. So what we found is not just as simple as there are good germs and bad germs in the gut. And with psoriasis there's a lack of diversity of germs in your gut, and it's something about that. This should be a nice, healthy variety of bacteria in this environment, in your gut. And it has something to do with leading to irritable bowel disease, which includes ulcerative colitis and Crohns. So that's the connection. And yes, patients with IBD and psoriasis, both GI doctors and derms like myself, lean towards TNF-alpha inhibitors. Is that the medication you were referring to?

Michelle: So I get a Humira injection every two weeks.

Dr. Kindred: Uh an anti TNF-alpha.

Michelle: And so luckily that treats both the psoriasis and the ulcerative colitis.

Dr. Kindred: Uh-huh. Yeah. It does as well.

Michelle: And then I take mesalamine every day for the ulcerative colitis.

Michelle: So we talked a little bit previously about the mental health impact of psoriasis and I for years just thought it was associated because psoriasis impacts your physical appearance. And I am the exception and not the rule having gotten psoriasis so young I don't remember not having it. But I know many people get it may be like in their 20’s or 30’s and everything. So to all of a sudden have your appearance affected that can have some social impacts. But you were alluding to earlier about how we, it might actually be more a part of the disease and what's going on in our body. So how do we help address those mental health issues?

Dr. Kindred: So it's a two way street. As physicians we need to ask, right and I can admit sometimes when the psoriasis is severe what's on our mind is the heart disease, the GI issues, the joint disease and so forth and we'll get a little bit focused on that. So one part is we have to ask and the other side of the coin is the patient needs to share it with us. Either volunteer it or just be honest when we do ask. Sometimes you come in and you’re chipper and you’re cheerful. On a list of questions to ask your mental health will go to the bottom, particularly if we see limping when you walk down a hallway, right. Then we're thinking arthritis. And as dermatologists, we screen for it but then we expect your primary care doctor who's well versed in mental health, or even the psychiatrist to then pick it up from there. Because I read the latest medical literature on dermatology, sometimes rheumatology and internal medicine, but not as well with psychiatry. So that's where that team approach, uh, I think we just added somebody to our list of doctors, which is psychiatrist, but sometimes it just a therapist or a really strong social network. So what I found is now that the goal is for patients to be completely clear of their skin disease, a strong social network tends to be very beneficial – in a good marriage, family support, healthy friendships, etc. seem to be perfect for my typical psoriasis patients. However, what's unfair is the more severe the disease, which tells me the greater the amount of inflammation, I do think that alone can contribute to some anxiety and depression, and we no longer think that it's just because the patient is embarrassed about their psoriasis or sad about their psoriasis. I have a patient, when she came in, she had psoriasis on her face, which is the indicator of it being severe or refractory, her hands, her arms, and her knees. And the BSA, the body surface area wasn't that great, meaning it didn't cover most of her body. It didn't even cover 10% of her body, and she worked from home, and she didn't have to be on zoom calls and people didn't have to see her for her work. So she wasn't in the public eye or visible where people could see her psoriasis. When I first started treating her and she still had depression, without a family history of depression. So I have anecdotal cases and some of the research. So it is something about that inflammation with psoriasis that can make someone more prone to anxiety and depression. And then the social pressures absolutely don't help if they're negative.

Michelle: Right. I think the great thing too, we've talked about how far all the research and everything has come. But I would also give a plug for how far the National Psoriasis Foundation has come, and all these community events that they have. I know we have one coming up here in Ohio in October, that I am participating in and everything. So there is more community now of psoriasis patients, family members, so people are looking for connection more and everything. I think the NPF has done a great job of trying to build that community.

Dr. Kindred: That's so important because sometimes patients feel alone if they don't know anyone with psoriasis. So feel like in a journey by their selves.

Michelle: Yes.

Dr. Kindred: So I highly, highly agree with you. I really wanna put an exclamation point next to National Psoriasis Foundation and their events.

Michelle: Yes. So one of the most dreaded words probably ever - cancer. I honestly don't know how much of a cancer risk there is associated with psoriasis and psoriatic disease. So given how far we've come with treatments and everything, like how great is the risk or association with psoriasis and cancer?

Dr. Kindred: Yes, so psoriasis in general can increase the risk of cancers, particularly if the inflammation is allowed to just wreck havoc on the body. There’s an increased risk of lymphomas and esophageal cancers, and others. However, so long as you are completing your age appropriate cancer screenings, have a primary care doctor that you see regularly, as in, at least annually. Those are things that could be caught early and again, early detection is key. Now there are treatments that think some patients are a little bit fearful of, they’re medications called TNF-alpha inhibitors. And Michelle, I think you just mentioned that you're on one, right?

Michelle: Yep.

Dr. Kindred: OK, so TNF-alpha inhibitors have been found to have a slight bump, a little blip on the screen of skin cancer. Well, who's the expert in skin cancer? It's your fellow dermatologist. So we're scanning your skin and we know how to look for it. Again even with skin cancer, typically in about a minute, if we're looking at a lesion, we can tell if it's a skin cancer, even tell if it's suspicious. And what's awesome about dermatology is 9 times out of 10, maybe more, we cure cancer. It's so awesome. You walk in the door with the cancer. We cut it out. You walk out and you're cured. If somebody had an exception to the rule somewhere, probably, but skin cancer is what we do. It's our bread and butter.  I personally have more patients not on a TNF-alpha inhibitor with skin cancers then I do with psoriasis patients with TNF- alpha inhibitors.  My skin cancer patients tend to be the person used a tanning bed in their teens and 20’s. PSA don't do that right. Patients who would bathe at high noon on the roof with iodine and baby oil on an aluminum tin foil blanket, right? So the sun exposure and particularly a sunburn during childhood has a much, much, much, much greater risk of skin cancer than, definitely in my practice, then my patients with psoriasis on a TNF-alpha inhibitor. And given all of the problems that psoriasis can create, if we weigh the risks and benefits, TNF-alpha’s are really doing you justice and service. Just make sure you have a skin cancer screening annually the same way as you should have other cancer screenings. And I hope that any one out there who is considering letting their psoriatic arthritis wreck havoc on their body.

Michelle: Yeah, like I believe I shared earlier, I'm in there every year getting my skin check because I definitely was a tanner but in doing the baby oil and stuff, so I'm in there getting those checks every year and then I get colonoscopies every two years due to the ulcerative colitis and get all my other regular screenings. So just encourage anybody to look for resources on when you should be having those cancer screenings because as you said, early detection is everything and your chances of survival skyrocket the earlier any disease that especially cancer is caught. What actions would you recommend for somebody with just psoriasis at this point? Or for me, who's already developed ulcerative colitis and is kind of worried about these other things, to help avoid or reduce our risks?

Dr. Kindred: That's awesome. So what we're talking about is controlling the controllables and there's certain things that I just can't fix. I can't write a prescription for it. I can't give you a cream for it and it's things like a healthy diet, right. Enough fiber intake. Taking a multivitamin.  Also, not smoking. As a resident my intern year, the worst deaths I ever saw were related to smoking. My worst psoriasis cases are in smokers. The worst kind of vascular disease are in smokers. Exercise 150 minutes a week, right? It could be 30 minutes Monday through Friday or however you wanna dice it is important. Stress management, now certainly wish I had a cream for stress management, but I don't. As soon as they come out with one, I will hook you all up and then right.

Michelle: We all need that, yes.

Dr. Kindred: Right, don't we and treat your psoriasis. Treat your psoriatic arthritis. Do those screenings that we talked about throughout the podcast, and those are the controllables, and it'll make a world of difference for reducing risks and just improving your overall health.

Michelle: And yeah for myself  I try and eat healthy. I'm sure I could eat healthier. I'm very big into yoga. I do a lot of yoga which I'm hoping will help with the psoriatic arthritis, help with my stress. So I know these things are going to happen. I know it's all associated, but at least for me, I could feel like I tried. I tried to do all the things I was supposed to do and if things go wrong then they go wrong and luckily I have a great team of doctors we've kind of listed off throughout the podcast that I rely on.

Dr. Kindred: Yeah.

Michelle: Well thank you so much for the great discussion and the link between psoriasis and psoriatic arthritis and all these other things. Are there any final comments that you'd like to share with the listeners?

Dr. Kindred: Yes, if you aren't already, please visit the National Psoriasis Foundation's website, psoriasis.org. A plethora of evidence based information, a community there that's willing to help and advocate for you, and Michelle thank you so much for having me on the podcast.

Michelle: Of course. Thank you. I've learned some stuff today.

Dr. Kindred: Awesome.

Michelle: Thank you again, Dr. Kindred for your time today and for sharing such interesting information about what can be done to reduce the health risks associated with health conditions we discussed. For our listeners, you can learn more about health screenings you need to reduce your risk for related health conditions by contacting our Patient Navigation Center to request a free kit by emailing education at psoriasis.org. And finally, thank you to our sponsors for providing support on behalf of this episode, AbbVie, Amgen, Bristol Myers Squibb, Johnson and Johnson, Novartis, and UCB.