Psoriasis: What to Know Head to Toe

Shiva: My name is Shiva Mozaffarian and I’m here to talk about what you need to know about managing psoriasis from head to toe with board-certified Family Nurse Practitioner Jayme Heim from West Michigan Dermatology Associates in Grandville, MI. Jayme specializes in treating people of all ages with psoriasis, psoriatic arthritis, eczema, and other skin-related diseases. She’s an Associate Adjunct Professor for Michigan State University and Grand Valley State University where she provides education to upcoming nurse practitioners and physician assistants. Jayme is also a professional member of the National Psoriasis Foundation, the National Eczema Association, the American Academy of Nurse Practitioners along with other organizations. Let’s hear what tips Jayme can provide in today’s episode around managing psoriasis head to toe.

Welcome Jayme and thank you so much for being on Psound Bytes™ today! Let’s literally start at the top with scalp psoriasis. We know 45 – 56% of people living with psoriasis have scalp psoriasis which can cause a lot of itching. What are some of your favorite products to use for treating scalp psoriasis?

Jayme: My favorite products for treating scalp psoriasis actually is to help treat the itch. When I talk about over-the-counter scalp psoriasis products, I actually like to use Head and Shoulders Clinical. That is one of the products I recommend quite a few times. The tar shampoos lots of times they do work, however, people have a hard time with the smell and so I like Head and Shoulders Clinical. It helps with the itch. As far as other products, I also use Derma Smooth FS oil sometimes and I also use steroid preparations.

Shiva: I love these recommendations, Jayme. So for scalp psoriasis, we know that it can be difficult to treat especially when trying to remove scale from skin. Sometimes it can be so frustrating for people that they say they just want to shave their hair off! What are your recommendations for removing scale from the hair?

Jayme: Ohh I'll tell you they do. They really wanna shave that hair off, but the problem is that when the scale is really thick, lots of times, they're also losing hair. I find that in the office especially with the thick plaques, patients are going ahead and they're trying to get that plaque out and their hair is just coming out in clumps and they come in, they're so distressed and they have so much broken hair. I recently had a 15-year-old that came in with her father and the first thing he said to me is you're touching her head. I said yes, she has scalp psoriasis. I need to do a full exam and he said no, you don't understand nobody will touch her head. The last dermatologist used a pencil to move her hair and then told her she needed to shave her head. So we need to get that plaque and the scale off there, but we need to do it gently because otherwise it does remove clumps of hair along with it and that is really horrible. So lots of times for my patients that have thick scalp psoriasis I do order Derma Smooth FS oil. There's a special way that I instruct them how to use this product. It's not an easy product to use because it truly is an oil with a topical steroid in it. The other thing is that with this particular preparation, you have to wear a shower cap or cover the hair. So what I have them do is I have them go ahead and moisten the scalp. They go ahead and put the oil on. The oil has to stand for at least four to six hours and then they have to cover the scalp with a shower cap. It's the combination, the synergistic effect of the water along with the medication, and the warmth that is kept within the shower cap that helps to loosen and lift those scales from the scalp. Afterwards, when they go ahead and rinse it out I have them do that in the shower and I have them put on usually a little Dawn along with their shampoo. Mix it together because it's an emulsifier, it breaks up oil. Go ahead and scrunch it through the hair and that and then rinse it out. Once they rinse it out I have them put a cream rinse in and then take a comb, which is usually a thicker tooth comb and then run the comb through their scalp. At that time, the plaques will gently raise off from the scalp without removing clumps of hair.

Shiva: That’s so important to know. Thank you for that tip Jayme! So how do you treat psoriasis that has extended onto the forehead or in the ears? We hear that from a lot of people with scalp psoriasis.

Jayme: Yes, and it is a very common area. In fact, lots of times when I do my assessment, I do it from head to toe and I always look at the ears and individuals will always say to me, why are you looking at my ears and I'll say because the ears are a very common area, especially with scalp psoriasis. The ears are very hard to treat because lots of times it's in the canals. So I usually use clobetasol solution because the solution goes in and it dries quickly. I've had individuals that have come to me that have fungal infections in their ears because of putting ointment or cream within the canals of the ears. And so clobetasol solution dries very quickly and you do not have that problem with the canal and the tympanic membrane being there and causing a fungal infection. If it's around the outside of the ears or the oracles of the ears, you can easily use a cream or an ointment, or you can use the clobetasol solution. You may even use a little bit of Derma Smooth FS Oil. The forehead is a very distressing area for individuals to have their forehead with plaque psoriasis and so lots of times with the forehead you need to treat with a low potency topical steroid or medication that is not a topical steroid. So, if we treat with a low potency we decrease the risk of atrophy and glaucoma around the eyes. Now we have two medications that are FDA approved that are not topical steroids. One of the medications is an aryl hydrocarbon and the other medication is a PDE4 inhibitor. These are medications for patients that are 12 years and older. It's once a day application and it actually is not sticky and it's not greasy and are a nice alternative to a steroid medication.

Shiva: So you mentioned a couple of low-potency treatments. We know treatment options for the face are more limited. What treatments do you feel work the best for psoriasis on the face and what daily regime do you recommend?

Jayme: Well, there really isn't a certain daily regime. If the psoriasis is clear, then I don't want them to use a topical steroid on their face and I don't want them to continue another medication. I always call my medications the tools in the toolbox. In other words, if something doesn't work, you go ahead and fix it. So you take the tool out of the toolbox. With facial psoriasis, we are very limited in the medication that we have to treat facial psoriasis due to the fact that the skin on the face is thinner skin. Also, the eyes are located on the face and so with topical steroids, we really have to be very careful with that. So the medications that are used with topical steroids have to be very low potency. Unfortunately, some individuals have very thick psoriasis located on their face and that does not work very well. There are also the two non-steroidal FDA-approved medications that I had mentioned previously. And they’re once-a-day applications and those are also alternatives to treating on the face. Some people will treat with medications such as tacrolimus but that is not FDA approved for psoriasis and also tazarotene which actually is very burning towards the face. So I would prefer to use a very low-potency topical steroid or use one of the newer FDA-approved medications for psoriasis on the face.

Shiva: And Jayme, I want to talk to you a little bit about cosmetics. Do you recommend use of cosmetics to help hide or tone down the redness caused by the plaques? Could this interact with topicals used for the face or the body?

Jayme: Well, it really doesn't interact with the topicals used for the body, and it actually can be very helpful. Some people just feel that I do not want to use any cosmetic on my face or on the area of the body and other people they would rather use a cosmetic product. The products themselves, sometimes they can cause a little bit of clumping, especially if you have a plaque that is thicker, it will actually look very clumpy on the plaque. So it's hard to find a cosmetic product that really blends well onto a plaque, but it definitely diminishes the redness of the plaque itself. So if they want to use something that is a cosmetic product to go out there and look between using something that is a liquid compared to something that is a brush-on or a powder application and see which feels most comfortable and most natural for them. But there really is not any kind of drug-to-drug interaction regarding the medication being placed on the body and the cosmetic product.

Shiva: I also wanted to ask you about shaving. What tips can you offer to help avoid potential cuts and risk for the Koebner phenomenon?

Jayme: Ah, the Koebner phenomenon is such a true phenomenon. And that's because of the fact that those cuts actually trigger the body to go ahead and replace those cells quicker to heal the body quicker. And it can trigger psoriasis plaquing. So it is very difficult with shaving because for individuals we want to go ahead and shave and keep up our physical appearance. I always tell my patients to use a razor that is at least a triple-bladed razor and I do like the Venus-style razors because they really have that protection. The other thing is that to use a gel instead of using a cream, because there's just seems to be more of a protective gliding effect with the gel itself. And then I also have them moisturize the skin afterwards. If there is a small cut on the area, I actually have them use a little 2.5% percent hydrocortisone on the area to heal it quickly so it doesn't develop the Koebner phenomena.

Shiva: And do you think electric shavers may be better than regular razors?

Jayme: Yes, I do. I really do, especially for men in bearded areas because there's less risk of having a cut on the facial area and developing the Koebner phenomenon.

Shiva: So Jayme, we previously discussed the face as being a sensitive area to treat. Another area that’s sensitive to treat is the genital area. Do you have any tips for treating genital psoriasis?

Jayme: The genital area for individuals is a very uncomfortable area. It's not only uncomfortable, but there's lots of times itching that takes place within that area and it's embarrassing. It's really socially stigmatizing for a lot of individuals and it is and it's a very uncomfortable area to have psoriasis. It's hard to treat that area because we have the same problem with that area that we do with facial area. In other words, you have an area where the skin is not as thick, it's thinner skin. It's an area where we have a limited amount of products that we're able to prescribe to take care of the psoriasis in this area. For a topical steroid, it has to be a low-potency medication. We could also use the FDA-approved medications for psoriasis, such as tapinarof which is the aryl hydrocarbon or we can use roflumilast which is also the PDE4 inhibitor. However, there is one FDA-approved biologic therapy and that is ixekizumab. That medication is FDA approved for genital psoriasis. Genital psoriasis is not, when we talk about the BSA as far as (body surface area), you do not have to have three or 10% body surface area to be considered moderate or severe. That area doesn't make up that large of a body surface area. However, the quality of life and the difficulty to treat that area with moderate to severe psoriasis, those individuals are definite candidates for ixekizumab which is FDA-approved biologic therapy for genital psoriasis.

Shiva: And earlier you mentioned moisturizing the skin. How important is a good moisturizer for care of the skin with psoriasis? And do you have any favorite products you tend to recommend?

Jayme: I do and I think that is extremely important because what happens is that when those plaques get so stiff, they get so itchy and at least with moisturizing it, those plaques, it brings individuals more comfort for moisturizing the plaques. The over-the-counter products I like to use, I like to use CeraVe psoriasis that has some salicylic acid in. It's in a wonderful base where it is very emollient. I also like to use the Eucerin products. I think it's extremely important to use a product that is really a therapeutic moisturizer. If you have a moisturizer that is mostly made up of water, that plaque is just gonna become dry. It's gonna crack and fissure again. It's going to be very uncomfortable and it's gonna itch. So I really like to use those products. Some people do like to use the Aveeno products. If they use an Aveeno product, I tell them to use the blue top product. The blue top product has more of the colloidal oat in it which helps to retain the moisture within that plaque. And so the plaque is just more flexible. It's more pliable. It's not pulling. It's not so uncomfortable and itchy.

Shiva: Thank you so much Jayme for providing such helpful information. For our listeners, stay with us for more tips and information about managing psoriasis from Jayme following this quick announcement about the Seal of Recognition program through the National Psoriasis Foundation.

Josh: The National Psoriasis Foundation’s Seal of Recognition highlights over-the-counter products that have been created or are intended to be non-irritating and safe. They are for people with psoriasis, psoriatic arthritis, and/or individuals living with severe sensitive skin or joint mobility limitations. Check out the list of products that have earned the Seal of Recognition at psoriasis.org/seal.

Shiva: Welcome back everyone. I hope you’ll take some time to check the list of products available through the Seal of Recognition Program. For now, let's turn back to Jayme. Jayme, are there other products that can help soothe the itch that comes with psoriasis plaques?

Jayme: Yes, there are. I really like to recommend for patients to use a mild soap. Soaps that have a shea butter base in them. Soaps that are just more softening and more sensitive for the skin itself and anything that you can do to help decrease the itch in the pliability of the plaque itself really helps to increase the comfort level. The other products I like to use too is I like to use the anti-itch products. CeraVe® has a wonderful line of anti-itch products and they're the red label products. Especially the moisturizer, a lot of individuals feel more comfort when using this product because it not only provides the moisturization, but it has the decrease in the itching within the plaques themselves. Also, I would like to say that I really like patients instead of using Epson salts which can be drying to the plaque to use a baking soda bath. Baking soda just seems to be more softening to the skin, and then once they get out of the bath to go ahead and moisturize.

Shiva: What a great tip! Thank you, Jayme! So given what we’ve spoken about so far are there any differences that occur for someone with skin of color?

Jayme: Absolutely. Individuals with darker pigmentation in their skin, what happens is that with topical corticosteroids, especially if you have more moderate or to high or medium to high topical steroids, there is so much vasoconstriction that takes place that there is often to those areas whitening of the skin especially on very sensitive skin areas. And other times with using medications there is hyperpigmentation. So it’s really a fine walk when you're prescribing those topical steroids to patients that have skin of color. I have not had that happen with our newer medications that are out, the PDE 4 inhibitor that I discussed previously, roflumilast, as well as the tapinarof which is that aryl hydrocarbon. Also for patients that are skin of color with scalp psoriasis their hair is a little bit thicker in consistency as well as the texture of their hair is more wiry consistently, you cannot use clobetasol solution. It dries out the scalp, it dries out the hair terribly and they will have breakage of their hair. Therefore using medications such as Derma Smooth FS oil really works much better for treating the plaque psoriasis on their scalp. In regards to a patient that has lighter skin color that may have a thinner hair or just less body and a straighter hair, they really cannot go ahead and use just on a regular basis to their scalp a Derma Smooth FS oil. It has to be rinsed out. They actually benefit from using a product that has an alcohol in its base, such as the clobetasol solution. Otherwise, their hair looks very oily and it’s clumped together and it just looks very unkept. So you really have to not only think about the general skin itself and whether it's going to be causing hyperpigmentation or hypopigmentation, as well as the scalp because the scalp is different for individuals that have darker skin color compared to lighter skin color.

Shiva: So Jayme we started this episode talking about scalp psoriasis. We know that scalp psoriasis may be an indicator for those who develop psoriatic arthritis, a disease that affects the joints and entheses. What’s the percentage of people with scalp psoriasis who develop psoriatic arthritis and is it possible to delay or prevent the development of psoriatic arthritis?

Jayme: The percentage of people who develop psoriatic arthritis are usually about 30%. However, I have seen that number I think in practice really is a little bit larger than 30%, especially if they have scalp and nail psoriasis in combination. Patients don't realize that. And a lot of providers do not realize that. They just feel that if it's scalps psoriasis then it's very minimal, but it's not. It's a very high indicator of developing psoriatic arthritis. It's really important to go ahead and identify scalp psoriasis in its relationship to psoriatic arthritis because we know that with psoriatic arthritis, if we do not treat the psoriatic arthritis and identify it in its early stages that it can lead to disability.

Shiva: We also know nail psoriasis can also be a sign of psoriatic arthritis. What are some of the symptoms to look for and how is nail psoriasis treated?

Jayme: We have to be really cognizant that nail psoriasis is associated with a high incidence of psoriatic arthritis. When you look at the nails, we have the fingernails, and below the nails are the nail matrix. What is below that nail matrix is the first joint in our finger, and so you're having that overproduction of those cells on not only the fingernail itself as it's growing out, but it can absolutely affect that top joint, therefore, leading to the psoriatic arthritis. That's where that close relationship comes in. The symptoms that we want to look for is we want to look at the nail itself. Patients, do they have any pitting in their nails? Do they have any white or little white oil spots or do they have any striate or do they have lifting of the nail itself? Lots of times patients they've been treated for fungal infections when really there's not a fungus at all under the nail, but that's the extra debris of the psoriasis that is pushing the nail upward. And so I always do a fungal culture to therefore rule out the fungus and rule in the nail psoriasis. It is very important to identify that because it needs to be treated. You cannot treat nail psoriasis with a topical medication. Nail psoriasis needs to be treated with a systemic medication. The matrix of the nail is located beneath the nail therefore it is located further into the body, it needs to have a systemic treatment. It's very important that people really recognize nail psoriasis because especially it causes that arthritis that we see with psoriatic arthritis within the fingers themselves.

Shiva: So, Jayme, psoriatic arthritis is often associated with severe psoriasis. Are there other diseases that are associated with psoriatic disease and what’s the best way to reduce the risk for such diseases?

Jayme: So many times, individuals that I see in the office, they do not recognize that this is just not a skin-deep disease. This is a disease that is immune-mediated. There is a lot of inflammation that takes place within the body itself. It's not about what we see on the outside. It's what we know is happening in the inside because of the fact that this is an inflammatory disease. And so, because it is an inflammatory disease, patients with psoriasis, no matter what type of psoriasis they have, they have an increased risk of cardiovascular disease. They have an increased risk of stroke, diabetes, liver disease, especially non-alcoholic fatty liver disease. In patients with psoriasis, because the burden of this disease, have a higher increased risk of depression. So we need to be cognizant of that. The only medication that is going to be protective for stroke, cardiovascular disease, diabetes in the inflammation that is taking place within the body as well as the mental health of the individual that is dealing with moderate to severe psoriasis, is treatment with systemic medication such as biologic therapy.

Shiva: We know that palmoplantar psoriasis on the hands and feet can significantly impact a person’s quality of life. What recommendations can you offer our listeners to help treat palmoplantar psoriasis?

Jayme: Palmoplantar psoriasis is extremely painful. The reason why it increases that impact on the quality of life is because it's functioning, basic functioning. I've had individuals come in and they are wearing slippers because they cannot wear shoes on their feet because of the fact that their psoriasis is so thick, it feels like shards of glass are sticking up into the raw meat of their feet. Individuals will come in and they are literally holding their hands in front of them in a semi-curled-up position because of the fact that they can't fully extend their fingers because when they do the skin literally fissures wide open because of the thickness of the plaque that just encases the hands and doesn't allow for that flexibility or the pliability within the skin. It is very difficult to treat. No moisturizer is going to go ahead and moisturize the hands enough to go ahead and heal them. No topical steroid most of the time is able to also treat moderate to severe palmoplantar psoriasis. This is a condition really that needs to be treated most of the time with biologic therapy. Patients need to be able to function. They need to be able to have some comfort. It's extremely painful in the skin because of the plaquing on the hands and feet. Like I said, encases the hands and feet and doesn't allow for daily functions that we normally do. it's very difficult even to wrap your hands around a toothbrush to brush your teeth. So I would say that those patients, they really need to see a person that works in dermatology who is a provider that works with psoriasis so they will be able to help them adequately.

Shiva: That's actually heartbreaking to hear.

Jayme: It really is. And I've had patients come in and they have to have their partners or even their children help to pull their pants up or to just get them things or they're in wheelchairs because they can't walk on their feet. It is extremely painful. That is really, it's debilitating. It really is and it takes away from the quality of life.

Shiva: Yeah, and I'm so glad they're doing research in this area to continue to develop treatments that specifically address palmoplantar psoriasis.

Jayme: Absolutely. I agree with you a 100 percent.

Shiva: Jayme, I have to thank you so much for offering such helpful tips to manage psoriasis head to toe today. Do you have any final comments you would like to share with our listeners?

Jayme: I do. And you know it's been my absolute privilege to work with individuals and patients with psoriasis for almost 20 years now. I just had a 30-year-old lady yesterday who has been given a 45-gram tube of mometasone for the last 10 years over and over and she has 20% of her body covered. And when I started talking to her about her psoriasis and about treatment, there were just tears falling from her face. And it's because the journey was so hard to finally get to somebody who understood and was able to treat her. It shouldn't be like that. And I have to tell you, there is an old saying. Psoriasis is not just skin deep, and if anything that I would like to leave as a final thought is that this is not just a skin-deep disease. The inflammation that happens within the body, the comorbidities that come with it, we definitely know that by intervening and treating individuals appropriately that we are actually helping them live lives with a much better quality of life and a life that is not filled with other comorbidities. So I really appreciate the fact that you allowed me to join you today and I hope that everyone that has psoriasis finds somebody that really knows how to treat them appropriately and realize that this is just not a skin-deep disease.

Shiva: Thank you so much for those comments and for the message of hope that if you treat psoriatic disease appropriately you can live a long and healthy life.

Jayme: You're so welcome. Thank you for having me.

Shiva: Thank you Jayme for giving our listeners so many insights on the management of psoriatic disease. It’s been such a pleasure exploring what options are available to treat psoriasis from head to toe. For our listeners, if you would like to receive additional tips on skin care, contact our Patient Navigation Center to request the free Skin Care E-Kit by calling (800) 723-9166 or by emailing education@psoriasis.org. And finally, thank you to our sponsors who provided support on behalf of this program activity through unrestricted educational grants from Bristol Myers Squibb, Janssen, and UCB.

Psoriasis: What to Know Head to Toe

Psound Bytes™ Transcript: Episode 199

Release date: July 18, 2023

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