April 22, 2025 • 24 mins
Psoriasis is more than a skin condition—it's a signal of whole-body health. In this episode, Dr. Steve Feldman, leading psoriasis expert and dermatology professor at Wake Forest, unpacks the evolution of our understanding of this complex disease.
Once seen as purely skin-deep, psoriasis is now known to be a systemic inflammatory condition linked to joint pain, heart disease, and depression. But which of these risks truly matter? Dr. Feldman separates clinical facts from online fearmongering, offering clarity on what patients should really pay attention to.
He also walks us through the dramatic shift in treatment—from coal tar and immunosuppressants to game-changing biologics that can clear skin with just a few injections a year. Plus, surprising insights from his research on medication adherence reveal how patient behavior affects outcomes more than we think.
Whether you have psoriasis or just want to understand the broader health implications, this episode is your guide to smarter care and realistic risk assessment.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Dermot Trotter Don't Swear About Skin
Care where host Dr Shannon CTrotter, a board-certified
dermatologist, sits down withfellow dermatologists and
skincare experts to separatefact from fiction and simplify
skincare.
Let's get started.
Speaker 2 (00:19):
Welcome to the Dermot Trotter Don't Swear About
Skincare podcast.
On today's show I have Dr SteveFeldman, professor of
dermatology, pathology, socialsciences and health policy at
the Wake Forest School ofMedicine.
Dr Feldman ranks among the topexperts in the world on
psoriasis by expertscapecom, andhe also serves as the editor
(00:41):
for the Journal ofDermatological Treatment and the
Journal of Dermatology andDermatological Surgery and as
chief medical editor of theDermatologist Magazine.
Welcome to the podcast, steve.
It's great to have you heretoday.
Speaker 3 (00:54):
Oh my, it's my pleasure to be with you.
Thank you so much for invitingme.
Speaker 2 (00:59):
Well, I'm really excited to have your expertise
on today because I want to talka bit more about psoriasis.
A lot of people out therelistening know somebody who has
psoriasis, or maybe evenpersonally has it, but what they
may not really realize is thatpsoriasis is kind of that cliche
.
We say more than skin deep, soI was hoping to kind of have you
talk a little bit more aboutpsoriasis as more than just a
(01:21):
skin disease.
Speaker 3 (01:23):
Yeah, so I started seeing patients with psoriasis
30-something years ago and thesituation has evolved
considerably.
I think we used to spend a lotof time talking about how it
affects people psychosociallyand how to explain to friends
(01:44):
that it's not contagious people,how it will see in the stores
and children will point orlifeguards won't let you into
the pool.
Hey, now we have drugs to clearthe skin up, and so now,
instead of focusing so much onthe psychosocial aspects of the
disease, we're more focused onclearing people up and the
(02:08):
internal manifestations.
I think we always knew that itaffected the joints in like a
third of the patients.
I'm here at Wake Forest, the guywho did psoriasis before I got
here, the wonderful MichaelZanolli.
He did a survey of all thepatients he was seeing with
psoriasis and I think was one ofthe first people to document
(02:33):
that about a third of thepatients have psoriasis
affecting their joints, causingstiffness, pain, swelling.
The folks at the University ofPennsylvania back about 15 years
ago did this seminal study, areal landmark study, using data
from British primary caredoctors showing that psoriasis
(02:56):
is associated with a clear,distinct increased risk of heart
disease and related vascularblood vessel diseases, and that
opened the floodgates, peoplestarted looking for all kinds of
other associations and findingall kinds of things associated
with psoriasis.
Speaker 2 (03:13):
So kind of what you're saying, you know it's
just so, especially for ourlisteners, because when they had
come in, they have psoriasis.
You know, obviously, like youmentioned, focused on the skin
Traditionally.
That's where we've been.
Now we've got great medicinesthat basically clear up the skin
, but now we're looking atproblems that are associated
with psoriasis that patientsmight have, like heart disease
and joint arthritis, as we callit, or joint problems too.
(03:34):
Beyond those two, are thereother things that somebody with
psoriasis should maybe sort ofstop and say okay, maybe I'm at
risk for other things as well.
Speaker 3 (03:45):
Well, yes and no.
So we Americans are at a highrisk of having depression.
We have it really good here,but we still get depressed.
And there's an increased riskof depression in patients with
psoriasis.
Hopefully really good treatmentreduces that risk, but I'm not
sure we have strong data to tellus one way or the other.
(04:07):
And then there's all kinds ofother things.
I had one of my students make alist of all kinds of things that
had been associated withpsoriasis Kidney disease,
melanoma, aortic aneurysm, solike the big blood vessel that
(04:28):
leaves your heart just blowingout.
All of these were associatedwith increased risk and many
other conditions.
But I'm not saying that yourlisteners should be worried
about any of these.
I'm just saying there'sassociations, and some of these
associations are based onstudying millions of people,
(04:52):
claims, data on millions ofpeople, and they can find
statistically significantassociations which gosh the
people who do the study get allexcited about and write papers
and publish, you know, stuffthat gets into the lay
literature saying there's anincreased risk of X, y, z and
(05:12):
you know, may not be clinicallymeaningful.
One of the study that thatstudent of mine did he looked at
the thing that had the highestrisk there was a six fold
increased risk of having amelanoma.
Now that sounds bad, right, butit was a study done in Taiwan,
where melanoma is so rare thatit would have taken 20,000
(05:37):
people with psoriasis before youwould see one more melanoma.
So yeah, it's statisticallyassociated, but it's clinically
meaningless.
The heart disease one glass halfempty, half full Probably not a
bad idea.
To eat a healthy diet, you know.
Get regular exercise, get yourcholesterol checked, you know,
(06:00):
and take something forcholesterol if you need to.
But everybody should do that,whether they have psoriasis or
not.
That first study that the folksat University of Pennsylvania
did found that if you had badpsoriasis, you were at like a
three-fold increased risk ofhaving a heart attack.
(06:23):
That sounds bad.
Well, that was 20 to30-year-olds.
If you were between the ages of20 and 30 and you had bad
psoriasis, you were at athree-fold risk of having a
heart attack.
But what's the risk that a 20to 30-year-old without psoriasis
is going to have a heart attack?
Roughly, it's roughly zero.
It's really small.
20 to 30-year-olds don'tusually have a will because
(06:46):
they're worried about having aheart attack.
So you multiply that by threeand it's still pretty close to
zero.
It's like almost no increasedrisk at all.
There might have been like a20% increased risk if you were
like old, like me.
Okay, that's a much bigger riskthan the threefold risk in
young people.
Speaker 2 (07:08):
So if you had a psoriasis patient coming into
you and you know they'reGoogling because you know that's
what everyone's doing nowadaysand say, okay, I've got
psoriasis, so I'm worried thatwhat else could I be at risk for
?
And they get that laundry listof things to talk about.
You know like heart disease, oryou know metabolic syndrome, or
they carry more fat around thecenter, or they're resistant to
insulin, more likely to getdiabetes or high blood pressure,
(07:29):
high cholesterol.
And then they even read oh gosh, like you could have
associations with increased riskfor certain types of cancer,
which really kind of freakseveryone out.
Speaker 3 (07:37):
when they find that online, how do you practically
break that down to say to themthese are truly the things I'm
potentially worried about, thatyou could be at risk for and
that we might need to do alittle bit closer monitoring for
yeah, I'm in North Carolina.
You know I don't get a lot ofquestions like that.
I'm in New York City, you know,big city, chicago, los Angeles,
(07:59):
and things would be different,but in North Carolina I don't
know that.
I've had a patient yet come askme about the comorbidities of
psoriasis.
Typically what they ask aboutis when I give them a biologic
for their skin disease.
They may say to me is thererisk from this?
And I'm like probably we'rereducing your risk of heart
(08:23):
disease more with this thanyou're actually going to have
risk from the treatments.
If somebody did ask me that, Iwould say look, yeah, you know,
are you having any morningstiffness, any joint pain, any
back pain, signs of psoriaticarthritis?
That would be something worthlooking out for.
I generally look at people tosee if they're having signs of
(08:43):
depression.
I usually don't ask them aboutdepression, but if they're
sitting there like this, youknow, then I'm going to ask him
questions about depression.
The rest of it I don't pay muchattention to at all.
I think if they're clearlyoverweight, I will bring it up
with them.
They have psoriasis.
(09:04):
You know there's goodtreatments for obesity nowadays
and obesity is clearly linkedwith stuff.
I'm involved with anotherUniversity of Pennsylvania study
you may want to get them on theshow if you haven't already
talking about it where we'relooking at the patients who are
40 and up and seeing if they hadtheir lipids checked, had their
(09:28):
cholesterol checked, you know,had their blood pressure checked
, and we're checking thosethings and giving them advice
when needed.
I've got high cholesterol, allright, and I've looked at the
numbers.
If I take my statin thatthey've prescribed me and keep
(09:50):
my cholesterol down, it reduces.
It should reduce my risk ofhaving a heart attack over 10
years by 30%, which sounds likea lot, but what that means is my
baseline risk is 7%.
A 30% reduction takes me to 5%and I'm scratching my head, you
(10:16):
know.
Does this 2% difference make itworth taking the statin?
Well, the statin costs mealmost nothing.
It's easy to take a pill everyday.
Okay, fine, I'll do it for the2%.
I'm not really excited about it.
I don't think it's really goingto change anything.
I asked my preventivecardiologist, you know, should I
take the statin for this 2%difference?
He says if you're one of the 2%, it really matters a lot.
(10:38):
I'm like all right, fine, butit doesn't really cause any
significant side effect from it.
Or if it costs a lot, I'dprobably blow it off or
something.
But if psoriasis has as big aneffect as cholesterol and
treating the psoriasis reducedthe risk as much as taking a
(10:58):
statin does for cardiovasculardisease we don't know that it
does, but if it did for mostpeople it's probably going to
make a small change.
Now that's what I would tell apatient if they came to see me.
If I was giving a talk toinsurers about how important it
is to pay for the cost of thesehigh-cost biologics for the
treatment of psoriasis, I wouldtell them you know, patients
(11:21):
with bad psoriasis can be up toa three-fold increased risk of
having a heart attack.
Because I want them to pay forthe drugs that my patients need
for the skin.
Speaker 2 (11:33):
The math is important , though, when you bring that up
, but I understand it's moreprofound when you say it that
way, but when you look at thenumbers you're right like it's.
You know what's the true impactlike, does it make sense?
So if you were so, like some ofmy patients?
So I'm in central ohio area andI have had people come in they
google and ask them I think,gosh like, how do I break this
down?
It sounds like your advicewould be you know, really, look
(11:54):
at potentially thatcardiovascular disease risk and
the risk for arthritis.
Those are the top two that youkind of hone in on as being most
clinically significant.
Would that be a fair kind ofassessment?
Speaker 3 (12:03):
That, and I think the depression might be the most
common thing, because so manyAmericans are depressed anyway.
If you're at any increased risk, that risk is probably up there
with psoriatic arthritis interms of the percentage of
psoriasis patients who havedepression.
But then you can pretty clearlyrecognize that when you see it
(12:25):
up front.
So screen for that, screen forthe arthritis and the
cardiovascular thing.
The neat thing aboutdermatologists is we get to see
everybody, you know we get tosee dermatologists is we get to
see everybody, you know we getto see young people, we get to
see old people, we get to treatmen between the ages of 20 and
45 who may not be going to afamily doctor.
Women, they're probably allseeing somebody, but the guys,
(12:50):
they go decades without gettingtheir blood pressure checked,
without ever having their lipidschecked.
So this is an opportunity thatwe could do for all our patients
.
But since psoriasis patientsare at increased risk, they
should certainly get therecommended screening, which
probably is blood pressure andcholesterol checks.
Speaker 2 (13:15):
I think that's you know, that's you know.
I love the way you say thatbecause it really shows to, from
the standpoint ofdermatologists, how we can have
an impact on somebody else'shealth.
Because you know, like you said, men don't utilize healthcare.
You know resources like womendo and just be able to get them
through the door because theyjust happen to come to you.
Because psoriasis botherspeople, right, they see it on
their skin and so they'remotivated to come in.
(13:35):
But you know, to get that blooddraw, you know, to get their
cholesterol checked or get theirblood pressure checked, not not
real attractive.
It's why I went into dermatology, because when we cleared
somebody's psoriasis, you cansee the impact on it had on
their quality of life.
They got the patient that I hadgot off disability.
His depression improved.
He was dating by the time.
I had left that rotation that Ifollowed and worked with a
(13:57):
colleague throughout a year'stime.
I thought, man, I want to dothat.
You lower somebody's bloodpressure.
You know, by 10 points theycould care less, right?
So I think that's reallyimportant message to take home
for clinicians out there thatyou can get people to the family
doc for that.
But if you're talking about thebiologic medicines and you're
like, okay, yeah, I want to putyou on something like this.
It's going to definitely helpclear your skin, may help
(14:17):
improve the joints.
But you know, the patients arelike, I don't know, I'm kind of
worried about the risk.
Like, how risky do you feel?
Like in general, psoriasistreatment is.
Like how do you present that tothe patient?
Speaker 3 (14:29):
Yeah, I basically tell them, for a lot of these
things there's no risk at all.
Some of these powerful drugs,it's like we're in an age of
miracles.
When I started something yearsago, I had chemotherapy drugs
like methotrexate or somethingto turn off your immune system,
like cyclosporine for patientswith really bad disease, or I
could really stone age.
(14:49):
I could cover people with tarand give them ultraviolet light
treatments.
Now I got drugs you might takean injection every two or three
months and if they ask me whatthe side effects are, I I'm like
I don't think there are any I'mnot real, like nothing.
I mean, the studies show lowerrates of serious infection on
the drug than often in theplacebo group, maybe more common
(15:12):
infections, but I think thecommon infections occur for
absolutely fascinating reasons.
See, I think psoriasis is asocially disabling disease.
So if you're in the placebogroup, you just do what you
normally do, which is sit athome miserable with skin lesions
, flaking, cracking skin If youmove, joint pain, depression,
just sit there, watch a latenight television, smoking with
(15:35):
one hand, drinking a beer withlistening to the podcast.
Speaker 2 (15:37):
That's what they're doing television smoking with
one hand drinking a beer withlistening to the podcast.
Speaker 3 (15:40):
That's what they're doing.
Podcast, I love that.
But if you, you know, if you'rein the drug group and your
psoriasis clears up your jointpain, you're like I feel great.
I'm going to go visit mynephews and nieces who have
runny noses and diarrhea.
I mean you know, go to the bars,meet men, women.
I could go either way.
This week, you know I'm goingto go to the Y, maybe exercise
(16:01):
and be with people, Maybe I'lltake a shower there.
Maybe without flip-flops youcould be exposed to all kinds of
common infections.
You know, once you clear thatpsoriasis up the treatments the
very good ones might have a riskof a yeast infection, or maybe
one in 300 people that mightexacerbate their inflammatory
(16:23):
bowel disease or it caused somediarrhea, something some of them
may have a little bit of like.
One in 100 patients might getshingles, but you can treat that
ahead of time by having gettingvaccinated.
Um, it's just so many greatoptions now.
Speaker 2 (16:43):
I think with all the options too, it's interesting.
You know, on TV you seecommercials.
Or, I hate to say it, a lot ofmy patients, especially my
younger ones, they don't watchTV but through streaming, or if
they get forced through acommercial, you know, on their
Amazon Prime they might see anad for a psoriasis medicine.
And I think it's interesting tojust think about, like why do
we see so many of these goingaround?
What's your explanation for allthe advertising, especially the
(17:05):
way they've kind of gone out tothe patient to make them aware
of what's out there?
Speaker 3 (17:09):
Yeah, I think historically doctors didn't like
direct to consumer ads.
I love it.
I like my patients to beeducated you know, by
commercials and podcasts and Ithink the commercials provide
required by federal law toprovide a balance.
So you hear the supposed sideeffects, if anything that scares
people and I have to tell themI don't worry about those things
(17:32):
because they saw those in theplacebo group too.
Yeah, I think it's happeningbecause it has become legal.
It's because these are consumerproducts.
Patients are involved in thedecision-making of what to do.
It does, as you said, increaseawareness.
I think it's great that peoplewith psoriasis, especially bad
(17:54):
psoriasis, know we got gottreatments to clear you up
available to you and gosh, onething your listeners should know
.
One of the things that reallybothers me is when a patient
tells me I didn't come inbecause I didn't have insurance.
I knew I wouldn't be able toget the drug.
Hey, the easiest patients tothe treat are the ones who are
poor and are uninsured, becauseI can get almost any drug for
(18:17):
them free nowadays, you knowfrom all the companies and
there's so much competitionbetween these drugs that you
know they want patients to knowabout their drugs so that
they'll ask their doctor for it.
Speaker 2 (18:30):
So you see, all these medicines that have come on the
market, especially since back,as you mentioned, in the dark
ages, when we're using coal tarand things like that.
Where do you feel like thefuture then for psoriasis
treatment is headed, since we'vecome so far, our expectation of
getting the skin clear I meanwe used to think, yeah, if we
got it 75% clear, 90% clear.
Now expectation, you know, 1%or less or you know, getting up
(18:54):
to 100% clear is kind of the newbar or standard.
Where do you feel like thefuture is and how does your
research play a role in that?
Speaker 3 (19:02):
Yeah, okay.
Well, there's two kinds ofpsoriasis, I think A limited
kind with just a few spots.
That would get better withtopical, with creams and
ointments and things.
Maybe there's a more extensiveinvolvement where you can't
possibly put creams andointments on all these spots.
For the people with milddisease, which is the vast
majority of people withpsoriasis just a few spots on
(19:23):
the elbows and knees the biggestlimitation to the treatment is
that the patient isn't puttingit on.
And so I think and my researchis on, you know, trying to
encourage people to use theirmedicine better If they would
put that clobidazole on theirpsoriasis.
Man, that stuff is fabulouslyeffective and clear it up.
(19:44):
We did studies with, you know,computer chips in the caps of
the containers that record theday and time people and open and
close the containers.
In the studies, in theirtreatment diaries, they say, oh,
we put it on twice a day, butthe computer chips say that
you're not opening the bottles.
Speaker 2 (20:02):
Liar, liar is what the chip said.
Speaker 3 (20:05):
I don't know that people are lying, because I
think people think they're doingit more than they really are,
but they're not, you know.
Speaker 2 (20:12):
So I think with your study, the one to that show.
They do it more consistent whenit gets closer to the
appointment with dermatology ortheir dermatologist doctor.
I thought I remember readingthat at some point.
Speaker 3 (20:21):
Yeah, if you have ever heard the mother of an acne
patient say so frustrating, youalways catch in on a good day.
I don't know why.
I don't even know why.
Yeah, I think people flosstheir teeth right before they go
to the dentist.
Now I floss my teeth every day,but if I have a dental
appointment coming up, I startflossing twice a day.
(20:48):
When do people practice piano?
You know they do it like rightbefore each lesson.
Doctors are kind of like a pianoteacher who says here's a
prescription for some sheetmusic.
Take it to the sheet musicstore.
I have no idea what it's goingto cost.
I want you to fill thisprescription for the sheet music
.
I want you to practice everyday.
We're not going to have weeklylessons, just practice every day
.
Practicing may cause rashes,diarrhea, possibly a serious
infection, but I want you topractice every day.
(21:09):
I'll see you at the recital inthree or four months and if the
recital doesn't sound good,which it often doesn't, I'll
give you another musicalinstrument, two or three more
musical instruments to practiceat the same time.
You know what we're doing setspeople up for poor adherence to
the treatment, and so you knowif anybody's listening and their
(21:31):
doctor prescribes some Clobata.
I would encourage them trydoing it really well for two or
three days and then call me andlet me know how it works.
Worked, because I bet it'sgoing to.
You know you could see theeffect of Clobazol in just a few
days Now.
For the people who have reallyextensive disease, I think the
future is already here.
We got drugs that you know youonly take them every two or
(21:52):
three months.
One of my patients today on anevery two-month drug for their
psoriasis said you may not wantto hear this, but I hadn't been
taken.
I stopped in October and I'mstill clear, so I'm not taking
it.
I'm like I don't mind that.
You don't need the risk, Idon't know if there is any risk,
(22:14):
but you don't need the tension.
If there is any risk from thedrug, minimize it by taking the
least you need.
It's going to save money in thelong run, yeah.
And if, for some reason, itstops working because you're not
taking it regularly, we gotother choices.
We can catch on.
Speaker 2 (22:30):
Fantastic.
Well, thank you, this has beena great conversation, aaron.
I mean just kind of going overyou know really should people
worry about, and you knowthere's so much information on
their own treatment and risk andyou know underlying health
issues that can be associatedwith psoriasis.
So I think we really broke itdown nicely for our listeners to
kind of get a nice grasp onkind of the basics of that.
So thank you so much for comingon the podcast with us today,
(22:52):
steve.
I want to give you anopportunity, though.
If our listeners want to findyou, where's the best place for
them to track you down?
Maybe online or elsewhere?
Speaker 3 (23:01):
uh, it's been an absolute pleasure being on with
you.
Um, the best place to find mewould be a literature search of
the medical literature, becausethen you can see all the stuff.
You know my minions have beenpublishing, uh, for the last few
years.
But you know, I got a Facebookpage and a Twitter presence and
(23:25):
you can find me there too.
Speaker 2 (23:28):
Great.
Well, be sure to look up Steve.
He's, like he said, he has hadmultiple publications in this
space a true expert on psoriasis.
So thanks again for coming onthe podcast.
We really appreciate your timetoday and, for those of you out
there, stay tuned for the nextepisode of Dermot Trotter.
Don't Swear About Skincare.
Speaker 1 (23:50):
Thanks for listening to Dermot Trotter.
For more about skincare, visitDermotTrottercom.
Don't forget to subscribe,leave a review and share this
podcast with anyone who needs alittle skincare sanity.
Until next time, stay skinsmart.
Welcome to Dermot Trotter Don't Swear About Skin
Care where host Dr Shannon CTrotter, a board-certified
dermatologist, sits down withfellow dermatologists and
skincare experts to separatefact from fiction and simplify
skincare.
Let's get started.
Speaker 2 (00:19):
Welcome to the Dermot Trotter Don't Swear About
Skincare podcast.
On today's show I have Dr SteveFeldman, professor of
dermatology, pathology, socialsciences and health policy at
the Wake Forest School ofMedicine.
Dr Feldman ranks among the topexperts in the world on
psoriasis by expertscapecom, andhe also serves as the editor
(00:41):
for the Journal ofDermatological Treatment and the
Journal of Dermatology andDermatological Surgery and as
chief medical editor of theDermatologist Magazine.
Welcome to the podcast, steve.
It's great to have you heretoday.
Speaker 3 (00:54):
Oh my, it's my pleasure to be with you.
Thank you so much for invitingme.
Speaker 2 (00:59):
Well, I'm really excited to have your expertise
on today because I want to talka bit more about psoriasis.
A lot of people out therelistening know somebody who has
psoriasis, or maybe evenpersonally has it, but what they
may not really realize is thatpsoriasis is kind of that cliche
.
We say more than skin deep, soI was hoping to kind of have you
talk a little bit more aboutpsoriasis as more than just a
(01:21):
skin disease.
Speaker 3 (01:23):
Yeah, so I started seeing patients with psoriasis
30-something years ago and thesituation has evolved
considerably.
I think we used to spend a lotof time talking about how it
affects people psychosociallyand how to explain to friends
(01:44):
that it's not contagious people,how it will see in the stores
and children will point orlifeguards won't let you into
the pool.
Hey, now we have drugs to clearthe skin up, and so now,
instead of focusing so much onthe psychosocial aspects of the
disease, we're more focused onclearing people up and the
(02:08):
internal manifestations.
I think we always knew that itaffected the joints in like a
third of the patients.
I'm here at Wake Forest, the guywho did psoriasis before I got
here, the wonderful MichaelZanolli.
He did a survey of all thepatients he was seeing with
psoriasis and I think was one ofthe first people to document
(02:33):
that about a third of thepatients have psoriasis
affecting their joints, causingstiffness, pain, swelling.
The folks at the University ofPennsylvania back about 15 years
ago did this seminal study, areal landmark study, using data
from British primary caredoctors showing that psoriasis
(02:56):
is associated with a clear,distinct increased risk of heart
disease and related vascularblood vessel diseases, and that
opened the floodgates, peoplestarted looking for all kinds of
other associations and findingall kinds of things associated
with psoriasis.
Speaker 2 (03:13):
So kind of what you're saying, you know it's
just so, especially for ourlisteners, because when they had
come in, they have psoriasis.
You know, obviously, like youmentioned, focused on the skin
Traditionally.
That's where we've been.
Now we've got great medicinesthat basically clear up the skin
, but now we're looking atproblems that are associated
with psoriasis that patientsmight have, like heart disease
and joint arthritis, as we callit, or joint problems too.
(03:34):
Beyond those two, are thereother things that somebody with
psoriasis should maybe sort ofstop and say okay, maybe I'm at
risk for other things as well.
Speaker 3 (03:45):
Well, yes and no.
So we Americans are at a highrisk of having depression.
We have it really good here,but we still get depressed.
And there's an increased riskof depression in patients with
psoriasis.
Hopefully really good treatmentreduces that risk, but I'm not
sure we have strong data to tellus one way or the other.
(04:07):
And then there's all kinds ofother things.
I had one of my students make alist of all kinds of things that
had been associated withpsoriasis Kidney disease,
melanoma, aortic aneurysm, solike the big blood vessel that
(04:28):
leaves your heart just blowingout.
All of these were associatedwith increased risk and many
other conditions.
But I'm not saying that yourlisteners should be worried
about any of these.
I'm just saying there'sassociations, and some of these
associations are based onstudying millions of people,
(04:52):
claims, data on millions ofpeople, and they can find
statistically significantassociations which gosh the
people who do the study get allexcited about and write papers
and publish, you know, stuffthat gets into the lay
literature saying there's anincreased risk of X, y, z and
(05:12):
you know, may not be clinicallymeaningful.
One of the study that thatstudent of mine did he looked at
the thing that had the highestrisk there was a six fold
increased risk of having amelanoma.
Now that sounds bad, right, butit was a study done in Taiwan,
where melanoma is so rare thatit would have taken 20,000
(05:37):
people with psoriasis before youwould see one more melanoma.
So yeah, it's statisticallyassociated, but it's clinically
meaningless.
The heart disease one glass halfempty, half full Probably not a
bad idea.
To eat a healthy diet, you know.
Get regular exercise, get yourcholesterol checked, you know,
(06:00):
and take something forcholesterol if you need to.
But everybody should do that,whether they have psoriasis or
not.
That first study that the folksat University of Pennsylvania
did found that if you had badpsoriasis, you were at like a
three-fold increased risk ofhaving a heart attack.
(06:23):
That sounds bad.
Well, that was 20 to30-year-olds.
If you were between the ages of20 and 30 and you had bad
psoriasis, you were at athree-fold risk of having a
heart attack.
But what's the risk that a 20to 30-year-old without psoriasis
is going to have a heart attack?
Roughly, it's roughly zero.
It's really small.
20 to 30-year-olds don'tusually have a will because
(06:46):
they're worried about having aheart attack.
So you multiply that by threeand it's still pretty close to
zero.
It's like almost no increasedrisk at all.
There might have been like a20% increased risk if you were
like old, like me.
Okay, that's a much bigger riskthan the threefold risk in
young people.
Speaker 2 (07:08):
So if you had a psoriasis patient coming into
you and you know they'reGoogling because you know that's
what everyone's doing nowadaysand say, okay, I've got
psoriasis, so I'm worried thatwhat else could I be at risk for
?
And they get that laundry listof things to talk about.
You know like heart disease, oryou know metabolic syndrome, or
they carry more fat around thecenter, or they're resistant to
insulin, more likely to getdiabetes or high blood pressure,
(07:29):
high cholesterol.
And then they even read oh gosh, like you could have
associations with increased riskfor certain types of cancer,
which really kind of freakseveryone out.
Speaker 3 (07:37):
when they find that online, how do you practically
break that down to say to themthese are truly the things I'm
potentially worried about, thatyou could be at risk for and
that we might need to do alittle bit closer monitoring for
yeah, I'm in North Carolina.
You know I don't get a lot ofquestions like that.
I'm in New York City, you know,big city, chicago, los Angeles,
(07:59):
and things would be different,but in North Carolina I don't
know that.
I've had a patient yet come askme about the comorbidities of
psoriasis.
Typically what they ask aboutis when I give them a biologic
for their skin disease.
They may say to me is thererisk from this?
And I'm like probably we'rereducing your risk of heart
(08:23):
disease more with this thanyou're actually going to have
risk from the treatments.
If somebody did ask me that, Iwould say look, yeah, you know,
are you having any morningstiffness, any joint pain, any
back pain, signs of psoriaticarthritis?
That would be something worthlooking out for.
I generally look at people tosee if they're having signs of
(08:43):
depression.
I usually don't ask them aboutdepression, but if they're
sitting there like this, youknow, then I'm going to ask him
questions about depression.
The rest of it I don't pay muchattention to at all.
I think if they're clearlyoverweight, I will bring it up
with them.
They have psoriasis.
(09:04):
You know there's goodtreatments for obesity nowadays
and obesity is clearly linkedwith stuff.
I'm involved with anotherUniversity of Pennsylvania study
you may want to get them on theshow if you haven't already
talking about it where we'relooking at the patients who are
40 and up and seeing if they hadtheir lipids checked, had their
(09:28):
cholesterol checked, you know,had their blood pressure checked
, and we're checking thosethings and giving them advice
when needed.
I've got high cholesterol, allright, and I've looked at the
numbers.
If I take my statin thatthey've prescribed me and keep
(09:50):
my cholesterol down, it reduces.
It should reduce my risk ofhaving a heart attack over 10
years by 30%, which sounds likea lot, but what that means is my
baseline risk is 7%.
A 30% reduction takes me to 5%and I'm scratching my head, you
(10:16):
know.
Does this 2% difference make itworth taking the statin?
Well, the statin costs mealmost nothing.
It's easy to take a pill everyday.
Okay, fine, I'll do it for the2%.
I'm not really excited about it.
I don't think it's really goingto change anything.
I asked my preventivecardiologist, you know, should I
take the statin for this 2%difference?
He says if you're one of the 2%, it really matters a lot.
(10:38):
I'm like all right, fine, butit doesn't really cause any
significant side effect from it.
Or if it costs a lot, I'dprobably blow it off or
something.
But if psoriasis has as big aneffect as cholesterol and
treating the psoriasis reducedthe risk as much as taking a
(10:58):
statin does for cardiovasculardisease we don't know that it
does, but if it did for mostpeople it's probably going to
make a small change.
Now that's what I would tell apatient if they came to see me.
If I was giving a talk toinsurers about how important it
is to pay for the cost of thesehigh-cost biologics for the
treatment of psoriasis, I wouldtell them you know, patients
(11:21):
with bad psoriasis can be up toa three-fold increased risk of
having a heart attack.
Because I want them to pay forthe drugs that my patients need
for the skin.
Speaker 2 (11:33):
The math is important , though, when you bring that up
, but I understand it's moreprofound when you say it that
way, but when you look at thenumbers you're right like it's.
You know what's the true impactlike, does it make sense?
So if you were so, like some ofmy patients?
So I'm in central ohio area andI have had people come in they
google and ask them I think,gosh like, how do I break this
down?
It sounds like your advicewould be you know, really, look
(11:54):
at potentially thatcardiovascular disease risk and
the risk for arthritis.
Those are the top two that youkind of hone in on as being most
clinically significant.
Would that be a fair kind ofassessment?
Speaker 3 (12:03):
That, and I think the depression might be the most
common thing, because so manyAmericans are depressed anyway.
If you're at any increased risk, that risk is probably up there
with psoriatic arthritis interms of the percentage of
psoriasis patients who havedepression.
But then you can pretty clearlyrecognize that when you see it
(12:25):
up front.
So screen for that, screen forthe arthritis and the
cardiovascular thing.
The neat thing aboutdermatologists is we get to see
everybody, you know we get tosee dermatologists is we get to
see everybody, you know we getto see young people, we get to
see old people, we get to treatmen between the ages of 20 and
45 who may not be going to afamily doctor.
Women, they're probably allseeing somebody, but the guys,
(12:50):
they go decades without gettingtheir blood pressure checked,
without ever having their lipidschecked.
So this is an opportunity thatwe could do for all our patients
.
But since psoriasis patientsare at increased risk, they
should certainly get therecommended screening, which
probably is blood pressure andcholesterol checks.
Speaker 2 (13:15):
I think that's you know, that's you know.
I love the way you say thatbecause it really shows to, from
the standpoint ofdermatologists, how we can have
an impact on somebody else'shealth.
Because you know, like you said, men don't utilize healthcare.
You know resources like womendo and just be able to get them
through the door because theyjust happen to come to you.
Because psoriasis botherspeople, right, they see it on
their skin and so they'remotivated to come in.
(13:35):
But you know, to get that blooddraw, you know, to get their
cholesterol checked or get theirblood pressure checked, not not
real attractive.
It's why I went into dermatology, because when we cleared
somebody's psoriasis, you cansee the impact on it had on
their quality of life.
They got the patient that I hadgot off disability.
His depression improved.
He was dating by the time.
I had left that rotation that Ifollowed and worked with a
(13:57):
colleague throughout a year'stime.
I thought, man, I want to dothat.
You lower somebody's bloodpressure.
You know, by 10 points theycould care less, right?
So I think that's reallyimportant message to take home
for clinicians out there thatyou can get people to the family
doc for that.
But if you're talking about thebiologic medicines and you're
like, okay, yeah, I want to putyou on something like this.
It's going to definitely helpclear your skin, may help
(14:17):
improve the joints.
But you know, the patients arelike, I don't know, I'm kind of
worried about the risk.
Like, how risky do you feel?
Like in general, psoriasistreatment is.
Like how do you present that tothe patient?
Speaker 3 (14:29):
Yeah, I basically tell them, for a lot of these
things there's no risk at all.
Some of these powerful drugs,it's like we're in an age of
miracles.
When I started something yearsago, I had chemotherapy drugs
like methotrexate or somethingto turn off your immune system,
like cyclosporine for patientswith really bad disease, or I
could really stone age.
(14:49):
I could cover people with tarand give them ultraviolet light
treatments.
Now I got drugs you might takean injection every two or three
months and if they ask me whatthe side effects are, I I'm like
I don't think there are any I'mnot real, like nothing.
I mean, the studies show lowerrates of serious infection on
the drug than often in theplacebo group, maybe more common
(15:12):
infections, but I think thecommon infections occur for
absolutely fascinating reasons.
See, I think psoriasis is asocially disabling disease.
So if you're in the placebogroup, you just do what you
normally do, which is sit athome miserable with skin lesions
, flaking, cracking skin If youmove, joint pain, depression,
just sit there, watch a latenight television, smoking with
(15:35):
one hand, drinking a beer withlistening to the podcast.
Speaker 2 (15:37):
That's what they're doing television smoking with
one hand drinking a beer withlistening to the podcast.
Speaker 3 (15:40):
That's what they're doing.
Podcast, I love that.
But if you, you know, if you'rein the drug group and your
psoriasis clears up your jointpain, you're like I feel great.
I'm going to go visit mynephews and nieces who have
runny noses and diarrhea.
I mean you know, go to the bars,meet men, women.
I could go either way.
This week, you know I'm goingto go to the Y, maybe exercise
(16:01):
and be with people, Maybe I'lltake a shower there.
Maybe without flip-flops youcould be exposed to all kinds of
common infections.
You know, once you clear thatpsoriasis up the treatments the
very good ones might have a riskof a yeast infection, or maybe
one in 300 people that mightexacerbate their inflammatory
(16:23):
bowel disease or it caused somediarrhea, something some of them
may have a little bit of like.
One in 100 patients might getshingles, but you can treat that
ahead of time by having gettingvaccinated.
Um, it's just so many greatoptions now.
Speaker 2 (16:43):
I think with all the options too, it's interesting.
You know, on TV you seecommercials.
Or, I hate to say it, a lot ofmy patients, especially my
younger ones, they don't watchTV but through streaming, or if
they get forced through acommercial, you know, on their
Amazon Prime they might see anad for a psoriasis medicine.
And I think it's interesting tojust think about, like why do
we see so many of these goingaround?
What's your explanation for allthe advertising, especially the
(17:05):
way they've kind of gone out tothe patient to make them aware
of what's out there?
Speaker 3 (17:09):
Yeah, I think historically doctors didn't like
direct to consumer ads.
I love it.
I like my patients to beeducated you know, by
commercials and podcasts and Ithink the commercials provide
required by federal law toprovide a balance.
So you hear the supposed sideeffects, if anything that scares
people and I have to tell themI don't worry about those things
(17:32):
because they saw those in theplacebo group too.
Yeah, I think it's happeningbecause it has become legal.
It's because these are consumerproducts.
Patients are involved in thedecision-making of what to do.
It does, as you said, increaseawareness.
I think it's great that peoplewith psoriasis, especially bad
(17:54):
psoriasis, know we got gottreatments to clear you up
available to you and gosh, onething your listeners should know
.
One of the things that reallybothers me is when a patient
tells me I didn't come inbecause I didn't have insurance.
I knew I wouldn't be able toget the drug.
Hey, the easiest patients tothe treat are the ones who are
poor and are uninsured, becauseI can get almost any drug for
(18:17):
them free nowadays, you knowfrom all the companies and
there's so much competitionbetween these drugs that you
know they want patients to knowabout their drugs so that
they'll ask their doctor for it.
Speaker 2 (18:30):
So you see, all these medicines that have come on the
market, especially since back,as you mentioned, in the dark
ages, when we're using coal tarand things like that.
Where do you feel like thefuture then for psoriasis
treatment is headed, since we'vecome so far, our expectation of
getting the skin clear I meanwe used to think, yeah, if we
got it 75% clear, 90% clear.
Now expectation, you know, 1%or less or you know, getting up
(18:54):
to 100% clear is kind of the newbar or standard.
Where do you feel like thefuture is and how does your
research play a role in that?
Speaker 3 (19:02):
Yeah, okay.
Well, there's two kinds ofpsoriasis, I think A limited
kind with just a few spots.
That would get better withtopical, with creams and
ointments and things.
Maybe there's a more extensiveinvolvement where you can't
possibly put creams andointments on all these spots.
For the people with milddisease, which is the vast
majority of people withpsoriasis just a few spots on
(19:23):
the elbows and knees the biggestlimitation to the treatment is
that the patient isn't puttingit on.
And so I think and my researchis on, you know, trying to
encourage people to use theirmedicine better If they would
put that clobidazole on theirpsoriasis.
Man, that stuff is fabulouslyeffective and clear it up.
(19:44):
We did studies with, you know,computer chips in the caps of
the containers that record theday and time people and open and
close the containers.
In the studies, in theirtreatment diaries, they say, oh,
we put it on twice a day, butthe computer chips say that
you're not opening the bottles.
Speaker 2 (20:02):
Liar, liar is what the chip said.
Speaker 3 (20:05):
I don't know that people are lying, because I
think people think they're doingit more than they really are,
but they're not, you know.
Speaker 2 (20:12):
So I think with your study, the one to that show.
They do it more consistent whenit gets closer to the
appointment with dermatology ortheir dermatologist doctor.
I thought I remember readingthat at some point.
Speaker 3 (20:21):
Yeah, if you have ever heard the mother of an acne
patient say so frustrating, youalways catch in on a good day.
I don't know why.
I don't even know why.
Yeah, I think people flosstheir teeth right before they go
to the dentist.
Now I floss my teeth every day,but if I have a dental
appointment coming up, I startflossing twice a day.
(20:48):
When do people practice piano?
You know they do it like rightbefore each lesson.
Doctors are kind of like a pianoteacher who says here's a
prescription for some sheetmusic.
Take it to the sheet musicstore.
I have no idea what it's goingto cost.
I want you to fill thisprescription for the sheet music
.
I want you to practice everyday.
We're not going to have weeklylessons, just practice every day
.
Practicing may cause rashes,diarrhea, possibly a serious
infection, but I want you topractice every day.
(21:09):
I'll see you at the recital inthree or four months and if the
recital doesn't sound good,which it often doesn't, I'll
give you another musicalinstrument, two or three more
musical instruments to practiceat the same time.
You know what we're doing setspeople up for poor adherence to
the treatment, and so you knowif anybody's listening and their
(21:31):
doctor prescribes some Clobata.
I would encourage them trydoing it really well for two or
three days and then call me andlet me know how it works.
Worked, because I bet it'sgoing to.
You know you could see theeffect of Clobazol in just a few
days Now.
For the people who have reallyextensive disease, I think the
future is already here.
We got drugs that you know youonly take them every two or
(21:52):
three months.
One of my patients today on anevery two-month drug for their
psoriasis said you may not wantto hear this, but I hadn't been
taken.
I stopped in October and I'mstill clear, so I'm not taking
it.
I'm like I don't mind that.
You don't need the risk, Idon't know if there is any risk,
(22:14):
but you don't need the tension.
If there is any risk from thedrug, minimize it by taking the
least you need.
It's going to save money in thelong run, yeah.
And if, for some reason, itstops working because you're not
taking it regularly, we gotother choices.
We can catch on.
Speaker 2 (22:30):
Fantastic.
Well, thank you, this has beena great conversation, aaron.
I mean just kind of going overyou know really should people
worry about, and you knowthere's so much information on
their own treatment and risk andyou know underlying health
issues that can be associatedwith psoriasis.
So I think we really broke itdown nicely for our listeners to
kind of get a nice grasp onkind of the basics of that.
So thank you so much for comingon the podcast with us today,
(22:52):
steve.
I want to give you anopportunity, though.
If our listeners want to findyou, where's the best place for
them to track you down?
Maybe online or elsewhere?
Speaker 3 (23:01):
uh, it's been an absolute pleasure being on with
you.
Um, the best place to find mewould be a literature search of
the medical literature, becausethen you can see all the stuff.
You know my minions have beenpublishing, uh, for the last few
years.
But you know, I got a Facebookpage and a Twitter presence and
(23:25):
you can find me there too.
Speaker 2 (23:28):
Great.
Well, be sure to look up Steve.
He's, like he said, he has hadmultiple publications in this
space a true expert on psoriasis.
So thanks again for coming onthe podcast.
We really appreciate your timetoday and, for those of you out
there, stay tuned for the nextepisode of Dermot Trotter.
Don't Swear About Skincare.
Speaker 1 (23:50):
Thanks for listening to Dermot Trotter.
For more about skincare, visitDermotTrottercom.
Don't forget to subscribe,leave a review and share this
podcast with anyone who needs alittle skincare sanity.
Until next time, stay skinsmart.
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