August 6, 2025 • 17 mins
Dermatologist Dr. Kristen Stewart digs deep to get to the root of psoriasis, a skin condition that affects approximately 3% of Americans. She talks about the role of systemic inflammation and how excessive inflammation can impact multiple body systems beyond just the skin. Dr. Stewart reviews her experience treating psoriasis, differentiating it from eczema, and the improvements in modern treatments. Dr. Stewart explains that newer treatment options have revolutionized management approaches, shifting goals from simply reducing symptoms to achieving near-complete clearance and addressing the underlying inflammation.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcement (00:00):
Welcome to the MedEvidence podcast.
This episode is a rebroadcastfrom a live MedEvidence
presentation.
Dr. Kristen Stewart (00:06):
Psoriasis is one of my favorite conditions
to take care of, because almostalways which you shouldn't
always say you can get people alot better and feeling a lot
better, so it's very satisfyingfor everybody.
But just to kind of get started, so which of the following
areas can be affected bypsoriasis?
The face and neck, the scalp,elbows and knees, the palms,
(00:27):
hands and soles of the feet, anytakers, all of the above, all
of the above.
So that is absolutely it.
So it really can happenanywhere.
Those are the areas where ittends to like, and sometimes the
distribution of psoriasis canhelp us tell where the rash is,
the difference between psoriasisand eczema, and we'll talk
(00:47):
about that a little bit too.
Which of the following is not acommon trigger for psoriasis?
Flares, stress.
Well, I think stress can flarejust about anything Acne, eczema
and psoriasis and I tell mypatients all the time I wish I
could come up with a lotion orpotion that took away stress,
(01:15):
but we haven't figured that outyet.
But skin injury, cold weather,improved sleep, so actually.
So the one that's not is theimproved sleep.
So skin injury, there'ssomething called kebnerization
and Dr Kebner was the one whorealized this, so it's still
named after him that psoriasisoften comes up in areas of
injury, so, for example, evenlike a scratch in the arm, then
sometimes it'll come up itdoesn't happen every time or a
surgical site.
I had a patient with psoriasiswho then had a procedure to
(01:37):
treat their skin cancer and thepsoriasis came up along where,
like at first, they thought thewound was infected, but it was
just that the psoriasis came upalong the wound.
So sometimes a trigger orstress is skin injury and cold
weather can make psoriasis flare.
Hot weather can too, especiallykind of in the groin or you
feel itchier a lot with hotweather too.
(01:58):
So what is psoriasis?
We know it's a chronic disease.
We know that we don't yet havea cure for it.
It's where the cells of theskin build up quickly and that's
what forms the plaques, andthey usually causes red or brown
discoloration.
It's usually scaly or flaky andthe plaques can be itchy.
Some plaques in psoriasisaren't itchy and some are, and
(02:21):
everybody's a little bitdifferent to the degree of itch
that they have.
But that's what it is ingeneral, things that it's not
contagious and a lot of peopleworry about that and it's not
contagious.
Or when other people aren'tfamiliar with psoriasis, they
worry about how other peopleperceive them or worry that,
like, if I shake your hand andyou have psoriasis, am I going
to get it?
It is not at all contagiouswhatsoever.
(02:43):
It can vary in severity.
Some people have very mildpsoriasis and affecting a few
people places and it doesn'tbother them.
Some people are covered head totoe.
We talk a lot about psoriasisand body surface area and I'll
talk about that at the end likeone of our goals or treatments,
and our goal is to have itaffect a low body surface area.
So body surface area is thepalm of your hand and you have
(03:07):
like a certain area.
So if I have a psoriasis plaque, this is 1% of my body surface
area.
If it's this big and if I have10 of those, then it's affecting
10% of my body surface area.
But it can vary in severity.
It's immune mediated theinflammation of psoriasis caused
by dysfunction of the immunesystem.
What else do we know about thator how do we know how to
describe that?
We really don't.
(03:28):
There's a lot that.
We know a lot of triggers.
We know a lot of cytokines.
We know a lot of inflammation,but we have not figured it all
totally out, but we know thatit's the immune system that's
almost kind of overreacting andcausing this inflammation.
Right now, as I mentioned,there is not a cure, but we have
lots of treatments to manage itand really improve the quality
of life.
So it's kind of like high bloodpressure While you take your
(03:51):
high blood pressure medicine,your blood pressure is
controlled, but if you stoptaking it, it comes back again.
Same thing with our psoriasistreatments While you take your
psoriasis treatments it works,but we do expect it to come back
afterwards.
Psoriasis tends to affect boththe skin and the nails, and
there's some nail changes to ittoo.
We treat those the same.
(04:11):
But what's important, and whenwe talk about treatments, the
inflammation of psoriasis alsoaffects other parts of the body.
We see it in the skin and thenails, but it can really affect
the joints, which causesarthritis or psoriatic arthritis
, which is very important totreat, and it can cause
inflammation in the bloodvessels.
It can be related tocardiovascular disease.
(04:32):
That's why we see morecardiovascular disease in people
who have psoriasis.
But the inflammation is notjust in the skin and the nails,
but internally in the body too.
How common is it?
Well, psoriasis affects men andwomen equally and it occurs
(04:54):
both in children and adults.
We certainly see it more inadults, but we still see it in
kids too.
I've seen psoriasis in kids asyoung as six months.
It's much less common.
Really, overall, the peak agesof onset are between 30 and 39
years or in between 50 and 69years old.
So it is something more of anadult onset.
But lots of people do get it asa kid or in their 20s.
That can happen too.
(05:14):
But overall, about 3 out of 100Americans or adults in the US
have psoriasis and again, thatseverity degree may be very mild
or may be very severe, but 3%overall.
So it's really quite common.
Why does it occur?
And, like I said, we know it'san immune dysregulation, but the
real wise, we don't totallyunderstand all the parts of it.
(05:38):
We believe that there's a bigpart that's by genetics, the
immune system as well as theenvironment.
Psoriasis plaques occur againbecause the immune system is
overreacting and it speeds upthat skin growth.
Normally skin cells completelygrow and shed off and the skin
turns over about once a month,but in psoriasis that happens
(06:01):
every three to four days.
And the other thing is you getthat complete growth but it
doesn't shed off and that's whythe skin thickens and that's why
it's flaky.
And who develops psoriasis wejust talked about one of those
key factors is genetics andmaybe a family member having it.
So 40% of people with psoriasishave a family member, but 60%
(06:25):
don't, you know.
So we know that there's afactor, but it's not the whole
thing.
And someone with a familymember is more likely to have
psoriasis, but it doesn't meanthat they're going to.
Either family member is morelikely to have psoriasis, but it
doesn't mean that they're goingto either, and I think we don't
.
Again, it doesn't mean that ifa mother or father has psoriasis
, that their child willdefinitely.
But we do see it a little bitmore.
(06:46):
We talked the other slide talkedabout genetics, the immune
system and environment, and theenvironment like sometimes
there's a triggering agent thatmay change the immune system and
cause or trigger the onset ofpsoriasis, and we see this
especially with strep infections.
Someone who may have a familypredisposition to psoriasis they
(07:08):
have a family member with it,but they've never had it they
get strep throat and they breakout in a rash.
Sometimes you just think it'spart of that, but sometimes
there's something about thatstrep infection that can trigger
someone who is alreadypredispositioned to have
psoriasis, and then that's thestart point or that's the age
where it comes on for them.
We also see that with HIV andsome medications.
(07:29):
We do see more psoriasis inpeople who smoke or are
overweight or have high alcohol.
It's not the trigger or it'snot a total, it's an
exacerbating factor.
We see it more often, but it'snot a direct, but it's a risk
factor overall.
And so what does it look like?
(07:50):
So we just talked aboutpsoriasis can happen anywhere on
the body.
It can be varied in severity,from mild to nearly all over.
Those common locations are thescalp, elbows, knees and the
groin.
The plaques can be red or brown.
They can be sometimes there'sguttate psoriasis, in which
little tiny.
.
.
guttate is like Greek or Latinfor dew drops, so they're little
(08:12):
drops in their little, littletiny psoriasis plaques.
And other times, and what wesee most often, is large plaque
psoriasis.
Where the plaques are larger,some areas may feel thick and be
raised and have that white, dry, flaking skin and sometimes,
especially over areas of bend,that thickened skin will kind of
fracture or break and it canbleed and that can be very
painful too.
Skin with active psoriasis canfeel itchy or irritated,
(08:35):
sometimes burny or stingy, andwe mentioned that.
It can also change nails.
Sometimes to the nails we'llsee like a what's called.
We call it an oil stain andit's just a yellowing underneath
the nail plate.
Sometimes we'll see nail pitsor little things.
They're not specific topsoriasis because we do see them
in other conditions.
So I can't always look at nailsand know it's psoriasis, but
(09:00):
it's a clue.
Another thing that's a clue inanother location is like the
crease of the buttocks is supercommon in psoriasis.
So if I'm looking at someoneand I'm trying to figure out if
it's eczema or psoriasis, and Ilook there and it's more likely
to be psoriasis.
So sometimes those locationsand those nails are clues to
what's going on.
So in diagnosing, a lot of timeswe're looking at the appearance
of the skin and nails.
There are times that I can walkinto a room and I know it's
(09:21):
psoriasis, just experience andseeing it and it's classic and I
don't have any doubt.
And there are other times Ilook and I'm like this could be
lots of other things, becauselots of other rashes are red,
itchy or scaly.
I'm looking at the locationsfor those and where they may be
and the history of it, thefamily history and stuff like
(09:42):
that, and I'll talk a little bitmore at the end.
The location and the locationstend to be classic, like, for
example, eczema, commonly, andthere's no absolutes.
But eczema tends to be in theflexures where we flex at our
arms, so the flexures of ourarms and the flexures of the
back of the leg, where psoriasistends to be on the extensor
surfaces, so it's on the back ofthe elbows and the fronts of
(10:02):
the knees.
And so again, there isoverlapping features with other
skin rashes, with the itching,and sometimes I can't tell.
You know what it is and I'll doa biopsy.
And sometimes, when I can'ttell if it's eczema or psoriasis
, sometimes the biopsy can tell,sometimes the biopsy can't tell
(10:23):
either.
Sometimes it comes back and itsays this looks like eczema and
psoriasis and I'm like that'swhat I thought.
You know what I mean.
And there's that overlap too.
But there are times that thebiopsy can push us in one
direction or the other when theyoverlap.
But there are definitely peoplewho have straightforward eczema
and there are definitely peoplewho have straightforward
psoriasis, but there's a smallgroup in between that have
(10:45):
overlapping features and that'sjust what they are.
They have overlapping featuresand so we always want to try to
put a label on it, and sometimeswe need to, but they're just a
little bit in between people orindividuals.
Why treat?
We treat the skin because ofthe itch and the irritation.
We treat the skin so thatpeople feel confident, because
sometimes it's really hard withpsoriasis, especially in when
(11:07):
areas that it shows and, like Isaid, people who aren't familiar
with it it's you know.
It's hard for them to shakehands or to do things or to wear
certain things or put bathingsuits on and that type of thing,
just to be out there, becausepeople who don't understand
psoriasis aren't always kind andI think that can be really hard
.
I have some patients who tellme that I am finally better
(11:30):
because I don't have to vacuummy bathroom floor every single
day, just because sometimesthere's just the shedding when
the skin is very dry withpsoriasis and it leaves that
shed and that mark and havingthat help and just you know.
We treat psoriasis so thatpeople aren't staring at your
plaques and you feel good andwhere you are, and so there's a
whole range of where people are.
Some people are very acceptingof their psoriasis and it
(11:52):
doesn't bother them at all andit's not itchy, and and other
people it affects them a lot andalso in their self-confidence,
and so that's the one, one ofthe reasons we treat.
The second reason we treat isjust to go back to the other
slide that it's not just aboutthe skin, that inflammation is
inside the body, to the amountthat that inflammation is in the
(12:13):
body also varies, and and itmay be very, very mild or it
could be more severe, but weknow that the skin psoriasis is
a sign of inflammation occurringin the body, and people with
mild psoriasis, which isconsidered less than 3% which is
, you know, if you put all theear plaques together and all
their psoriasis, it would equalthree palms that they may have
(12:35):
some inflammation in the bodytoo.
And even though there's no curefor psoriasis, systemic
treatments meaning takingsomething by mouth or by
injection, something affectingthe whole body versus a topical
can help improve the skinsymptoms as well as lower the
risk of the psoriatic, arthritis, heart disease, obesity,
diabetes and depression thatsometimes we see more in people
(12:58):
with psoriasis.
So currently our treatmentoptions we have a lot.
When I started in dermatology 15, 20 years ago, we had like
topical steroids, light box andEnbrel or Humira.
We had like two things.
You know what I mean, and Iremember the first time
prescribing one of those becausethey were new and they seemed a
(13:18):
little bit scary.
But over the last 15 to 20years it's so different.
The other thing is my goal fortreating patients when I first
started was like so they weren'tmiserable, you know, and that
they weren't itchy and I got itas better as I could.
But like I didn't even dream ofclearing anyone you know what I
mean or really controlling it.
I was just trying to control itas much as I could for them.
(13:41):
But we have both steroidal andnon-steroidal topicals.
The non-steroid ones are alsovery new and it's exciting to
have new things that work well.
Phototherapy is light therapyand in general dermatologists,
we all tell you to stay out ofthe sun, right.
But we use the light box totreat things that are red and
itchy and different things.
So we use it for psoriasis, weuse it for eczema.
(14:03):
It is different than a tanningbooth.
It is very.
It's a narrow spectrum so thatyou you're actually trying to
get a little bit ofimmunosuppression to the skin to
have to decrease theinflammatory response of the
psoriasis, but we're trying todo it without giving the risk of
skin cancer.
So we protect other areas.
(14:25):
And it's a special.
The lights are special.
A lot of times we talk about UVlight in a spectrum so it was,
you know, 200 to 400 nanometersand this is just 311 to 313.
And that's why the phototherapythat we use in dermatology is
safer than a regular tanning bed.
But there are times, living inFlorida, we have I'll have
(14:49):
people say my psoriasis is fineall summer long.
You know what I mean.
Or when I'm out in my shorts,you know, and I'm not covered up
because of getting a little bitof sun can help it, so you can
use natural light too.
The systemic treatments includesoral pills and the biologic
agents, which are injectables,and those are really what has
transformed and changed so thatwe can get people more clear and
(15:10):
in a good spot, and those arethe ones that also, if there is
internal inflammation from thepsoriasis, those are the only
ones that are going to addressthat part.
So recent research in psoriasishas led to all these new things
which are revolutionizing it,like I said, where my goal of
getting someone to better justto not be miserable, literally,
(15:30):
and that's true, I mean I didn'tthink of it in that way until
looking at it in retrospect, 20years ago, and now we the treat
to target is really kind ofstringent, and this is what the
American Academy of Dermatologyis kind of putting out, like our
goal should be that thepsoriasis affects less than 1%
body surface area and withinthree months of starting the
(15:55):
treatment Does that alwayshappen?
No, you know what I mean.
But when we're thinking abouttreatment or evaluating where
are you with treatment?
I think a lot of times it's avery personal decision.
Like I'll try to tell patientsI don't want to over-treat you,
I don't want to under-treat you.
You know where are you withyour psoriasis and my psoriasis
is controlled, but I spend twohours a day putting cream on my
(16:16):
body.
You know what I mean and youknow and how much homework you
have at home to do that and tomaintain it, and you know, so I.
It looks good, but is it toomuch work?
Do we need to be doingsomething else?
Or, um, somebody who, um, has it, uh, psoriasis, and not a lot a
high body percentage area, butit's on their palms or it's in
their groin and it itches likethe location really matters to
(16:38):
feet.
The hands and feet, um, I thinkare hands, feet and groin are
harder to treat and have more.
Not that elbow psoriasis isn'timpactful, but it can sometimes
have more impact.
But the impact of psoriasis isalso very personal and I think
that's something that you haveto work with your doctor.
Be like how much is thisbothering you?
These are our options.
What do you want to do?
(16:58):
And that there are lots ofoptions.
But that target to treat issetting a whole new bar for
psoriasis that we didn't haveyears ago.
Announcement (17:08):
Thanks for joining the MedEvidence podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Welcome to the MedEvidence podcast.
This episode is a rebroadcastfrom a live MedEvidence
presentation.
Dr. Kristen Stewart (00:06):
Psoriasis is one of my favorite conditions
to take care of, because almostalways which you shouldn't
always say you can get people alot better and feeling a lot
better, so it's very satisfyingfor everybody.
But just to kind of get started, so which of the following
areas can be affected bypsoriasis?
The face and neck, the scalp,elbows and knees, the palms,
(00:27):
hands and soles of the feet, anytakers, all of the above, all
of the above.
So that is absolutely it.
So it really can happenanywhere.
Those are the areas where ittends to like, and sometimes the
distribution of psoriasis canhelp us tell where the rash is,
the difference between psoriasisand eczema, and we'll talk
(00:47):
about that a little bit too.
Which of the following is not acommon trigger for psoriasis?
Flares, stress.
Well, I think stress can flarejust about anything Acne, eczema
and psoriasis and I tell mypatients all the time I wish I
could come up with a lotion orpotion that took away stress,
(01:15):
but we haven't figured that outyet.
But skin injury, cold weather,improved sleep, so actually.
So the one that's not is theimproved sleep.
So skin injury, there'ssomething called kebnerization
and Dr Kebner was the one whorealized this, so it's still
named after him that psoriasisoften comes up in areas of
injury, so, for example, evenlike a scratch in the arm, then
sometimes it'll come up itdoesn't happen every time or a
surgical site.
I had a patient with psoriasiswho then had a procedure to
(01:37):
treat their skin cancer and thepsoriasis came up along where,
like at first, they thought thewound was infected, but it was
just that the psoriasis came upalong the wound.
So sometimes a trigger orstress is skin injury and cold
weather can make psoriasis flare.
Hot weather can too, especiallykind of in the groin or you
feel itchier a lot with hotweather too.
(01:58):
So what is psoriasis?
We know it's a chronic disease.
We know that we don't yet havea cure for it.
It's where the cells of theskin build up quickly and that's
what forms the plaques, andthey usually causes red or brown
discoloration.
It's usually scaly or flaky andthe plaques can be itchy.
Some plaques in psoriasisaren't itchy and some are, and
(02:21):
everybody's a little bitdifferent to the degree of itch
that they have.
But that's what it is ingeneral, things that it's not
contagious and a lot of peopleworry about that and it's not
contagious.
Or when other people aren'tfamiliar with psoriasis, they
worry about how other peopleperceive them or worry that,
like, if I shake your hand andyou have psoriasis, am I going
to get it?
It is not at all contagiouswhatsoever.
(02:43):
It can vary in severity.
Some people have very mildpsoriasis and affecting a few
people places and it doesn'tbother them.
Some people are covered head totoe.
We talk a lot about psoriasisand body surface area and I'll
talk about that at the end likeone of our goals or treatments,
and our goal is to have itaffect a low body surface area.
So body surface area is thepalm of your hand and you have
(03:07):
like a certain area.
So if I have a psoriasis plaque, this is 1% of my body surface
area.
If it's this big and if I have10 of those, then it's affecting
10% of my body surface area.
But it can vary in severity.
It's immune mediated theinflammation of psoriasis caused
by dysfunction of the immunesystem.
What else do we know about thator how do we know how to
describe that?
We really don't.
(03:28):
There's a lot that.
We know a lot of triggers.
We know a lot of cytokines.
We know a lot of inflammation,but we have not figured it all
totally out, but we know thatit's the immune system that's
almost kind of overreacting andcausing this inflammation.
Right now, as I mentioned,there is not a cure, but we have
lots of treatments to manage itand really improve the quality
of life.
So it's kind of like high bloodpressure While you take your
(03:51):
high blood pressure medicine,your blood pressure is
controlled, but if you stoptaking it, it comes back again.
Same thing with our psoriasistreatments While you take your
psoriasis treatments it works,but we do expect it to come back
afterwards.
Psoriasis tends to affect boththe skin and the nails, and
there's some nail changes to ittoo.
We treat those the same.
(04:11):
But what's important, and whenwe talk about treatments, the
inflammation of psoriasis alsoaffects other parts of the body.
We see it in the skin and thenails, but it can really affect
the joints, which causesarthritis or psoriatic arthritis
, which is very important totreat, and it can cause
inflammation in the bloodvessels.
It can be related tocardiovascular disease.
(04:32):
That's why we see morecardiovascular disease in people
who have psoriasis.
But the inflammation is notjust in the skin and the nails,
but internally in the body too.
How common is it?
Well, psoriasis affects men andwomen equally and it occurs
(04:54):
both in children and adults.
We certainly see it more inadults, but we still see it in
kids too.
I've seen psoriasis in kids asyoung as six months.
It's much less common.
Really, overall, the peak agesof onset are between 30 and 39
years or in between 50 and 69years old.
So it is something more of anadult onset.
But lots of people do get it asa kid or in their 20s.
That can happen too.
(05:14):
But overall, about 3 out of 100Americans or adults in the US
have psoriasis and again, thatseverity degree may be very mild
or may be very severe, but 3%overall.
So it's really quite common.
Why does it occur?
And, like I said, we know it'san immune dysregulation, but the
real wise, we don't totallyunderstand all the parts of it.
(05:38):
We believe that there's a bigpart that's by genetics, the
immune system as well as theenvironment.
Psoriasis plaques occur againbecause the immune system is
overreacting and it speeds upthat skin growth.
Normally skin cells completelygrow and shed off and the skin
turns over about once a month,but in psoriasis that happens
(06:01):
every three to four days.
And the other thing is you getthat complete growth but it
doesn't shed off and that's whythe skin thickens and that's why
it's flaky.
And who develops psoriasis wejust talked about one of those
key factors is genetics andmaybe a family member having it.
So 40% of people with psoriasishave a family member, but 60%
(06:25):
don't, you know.
So we know that there's afactor, but it's not the whole
thing.
And someone with a familymember is more likely to have
psoriasis, but it doesn't meanthat they're going to.
Either family member is morelikely to have psoriasis, but it
doesn't mean that they're goingto either, and I think we don't
.
Again, it doesn't mean that ifa mother or father has psoriasis
, that their child willdefinitely.
But we do see it a little bitmore.
(06:46):
We talked the other slide talkedabout genetics, the immune
system and environment, and theenvironment like sometimes
there's a triggering agent thatmay change the immune system and
cause or trigger the onset ofpsoriasis, and we see this
especially with strep infections.
Someone who may have a familypredisposition to psoriasis they
(07:08):
have a family member with it,but they've never had it they
get strep throat and they breakout in a rash.
Sometimes you just think it'spart of that, but sometimes
there's something about thatstrep infection that can trigger
someone who is alreadypredispositioned to have
psoriasis, and then that's thestart point or that's the age
where it comes on for them.
We also see that with HIV andsome medications.
(07:29):
We do see more psoriasis inpeople who smoke or are
overweight or have high alcohol.
It's not the trigger or it'snot a total, it's an
exacerbating factor.
We see it more often, but it'snot a direct, but it's a risk
factor overall.
And so what does it look like?
(07:50):
So we just talked aboutpsoriasis can happen anywhere on
the body.
It can be varied in severity,from mild to nearly all over.
Those common locations are thescalp, elbows, knees and the
groin.
The plaques can be red or brown.
They can be sometimes there'sguttate psoriasis, in which
little tiny.
.
.
guttate is like Greek or Latinfor dew drops, so they're little
(08:12):
drops in their little, littletiny psoriasis plaques.
And other times, and what wesee most often, is large plaque
psoriasis.
Where the plaques are larger,some areas may feel thick and be
raised and have that white, dry, flaking skin and sometimes,
especially over areas of bend,that thickened skin will kind of
fracture or break and it canbleed and that can be very
painful too.
Skin with active psoriasis canfeel itchy or irritated,
(08:35):
sometimes burny or stingy, andwe mentioned that.
It can also change nails.
Sometimes to the nails we'llsee like a what's called.
We call it an oil stain andit's just a yellowing underneath
the nail plate.
Sometimes we'll see nail pitsor little things.
They're not specific topsoriasis because we do see them
in other conditions.
So I can't always look at nailsand know it's psoriasis, but
(09:00):
it's a clue.
Another thing that's a clue inanother location is like the
crease of the buttocks is supercommon in psoriasis.
So if I'm looking at someoneand I'm trying to figure out if
it's eczema or psoriasis, and Ilook there and it's more likely
to be psoriasis.
So sometimes those locationsand those nails are clues to
what's going on.
So in diagnosing, a lot of timeswe're looking at the appearance
of the skin and nails.
There are times that I can walkinto a room and I know it's
(09:21):
psoriasis, just experience andseeing it and it's classic and I
don't have any doubt.
And there are other times Ilook and I'm like this could be
lots of other things, becauselots of other rashes are red,
itchy or scaly.
I'm looking at the locationsfor those and where they may be
and the history of it, thefamily history and stuff like
(09:42):
that, and I'll talk a little bitmore at the end.
The location and the locationstend to be classic, like, for
example, eczema, commonly, andthere's no absolutes.
But eczema tends to be in theflexures where we flex at our
arms, so the flexures of ourarms and the flexures of the
back of the leg, where psoriasistends to be on the extensor
surfaces, so it's on the back ofthe elbows and the fronts of
(10:02):
the knees.
And so again, there isoverlapping features with other
skin rashes, with the itching,and sometimes I can't tell.
You know what it is and I'll doa biopsy.
And sometimes, when I can'ttell if it's eczema or psoriasis
, sometimes the biopsy can tell,sometimes the biopsy can't tell
(10:23):
either.
Sometimes it comes back and itsays this looks like eczema and
psoriasis and I'm like that'swhat I thought.
You know what I mean.
And there's that overlap too.
But there are times that thebiopsy can push us in one
direction or the other when theyoverlap.
But there are definitely peoplewho have straightforward eczema
and there are definitely peoplewho have straightforward
psoriasis, but there's a smallgroup in between that have
(10:45):
overlapping features and that'sjust what they are.
They have overlapping featuresand so we always want to try to
put a label on it, and sometimeswe need to, but they're just a
little bit in between people orindividuals.
Why treat?
We treat the skin because ofthe itch and the irritation.
We treat the skin so thatpeople feel confident, because
sometimes it's really hard withpsoriasis, especially in when
(11:07):
areas that it shows and, like Isaid, people who aren't familiar
with it it's you know.
It's hard for them to shakehands or to do things or to wear
certain things or put bathingsuits on and that type of thing,
just to be out there, becausepeople who don't understand
psoriasis aren't always kind andI think that can be really hard
.
I have some patients who tellme that I am finally better
(11:30):
because I don't have to vacuummy bathroom floor every single
day, just because sometimesthere's just the shedding when
the skin is very dry withpsoriasis and it leaves that
shed and that mark and havingthat help and just you know.
We treat psoriasis so thatpeople aren't staring at your
plaques and you feel good andwhere you are, and so there's a
whole range of where people are.
Some people are very acceptingof their psoriasis and it
(11:52):
doesn't bother them at all andit's not itchy, and and other
people it affects them a lot andalso in their self-confidence,
and so that's the one, one ofthe reasons we treat.
The second reason we treat isjust to go back to the other
slide that it's not just aboutthe skin, that inflammation is
inside the body, to the amountthat that inflammation is in the
(12:13):
body also varies, and and itmay be very, very mild or it
could be more severe, but weknow that the skin psoriasis is
a sign of inflammation occurringin the body, and people with
mild psoriasis, which isconsidered less than 3% which is
, you know, if you put all theear plaques together and all
their psoriasis, it would equalthree palms that they may have
(12:35):
some inflammation in the bodytoo.
And even though there's no curefor psoriasis, systemic
treatments meaning takingsomething by mouth or by
injection, something affectingthe whole body versus a topical
can help improve the skinsymptoms as well as lower the
risk of the psoriatic, arthritis, heart disease, obesity,
diabetes and depression thatsometimes we see more in people
(12:58):
with psoriasis.
So currently our treatmentoptions we have a lot.
When I started in dermatology 15, 20 years ago, we had like
topical steroids, light box andEnbrel or Humira.
We had like two things.
You know what I mean, and Iremember the first time
prescribing one of those becausethey were new and they seemed a
(13:18):
little bit scary.
But over the last 15 to 20years it's so different.
The other thing is my goal fortreating patients when I first
started was like so they weren'tmiserable, you know, and that
they weren't itchy and I got itas better as I could.
But like I didn't even dream ofclearing anyone you know what I
mean or really controlling it.
I was just trying to control itas much as I could for them.
(13:41):
But we have both steroidal andnon-steroidal topicals.
The non-steroid ones are alsovery new and it's exciting to
have new things that work well.
Phototherapy is light therapyand in general dermatologists,
we all tell you to stay out ofthe sun, right.
But we use the light box totreat things that are red and
itchy and different things.
So we use it for psoriasis, weuse it for eczema.
(14:03):
It is different than a tanningbooth.
It is very.
It's a narrow spectrum so thatyou you're actually trying to
get a little bit ofimmunosuppression to the skin to
have to decrease theinflammatory response of the
psoriasis, but we're trying todo it without giving the risk of
skin cancer.
So we protect other areas.
(14:25):
And it's a special.
The lights are special.
A lot of times we talk about UVlight in a spectrum so it was,
you know, 200 to 400 nanometersand this is just 311 to 313.
And that's why the phototherapythat we use in dermatology is
safer than a regular tanning bed.
But there are times, living inFlorida, we have I'll have
(14:49):
people say my psoriasis is fineall summer long.
You know what I mean.
Or when I'm out in my shorts,you know, and I'm not covered up
because of getting a little bitof sun can help it, so you can
use natural light too.
The systemic treatments includesoral pills and the biologic
agents, which are injectables,and those are really what has
transformed and changed so thatwe can get people more clear and
(15:10):
in a good spot, and those arethe ones that also, if there is
internal inflammation from thepsoriasis, those are the only
ones that are going to addressthat part.
So recent research in psoriasishas led to all these new things
which are revolutionizing it,like I said, where my goal of
getting someone to better justto not be miserable, literally,
(15:30):
and that's true, I mean I didn'tthink of it in that way until
looking at it in retrospect, 20years ago, and now we the treat
to target is really kind ofstringent, and this is what the
American Academy of Dermatologyis kind of putting out, like our
goal should be that thepsoriasis affects less than 1%
body surface area and withinthree months of starting the
(15:55):
treatment Does that alwayshappen?
No, you know what I mean.
But when we're thinking abouttreatment or evaluating where
are you with treatment?
I think a lot of times it's avery personal decision.
Like I'll try to tell patientsI don't want to over-treat you,
I don't want to under-treat you.
You know where are you withyour psoriasis and my psoriasis
is controlled, but I spend twohours a day putting cream on my
(16:16):
body.
You know what I mean and youknow and how much homework you
have at home to do that and tomaintain it, and you know, so I.
It looks good, but is it toomuch work?
Do we need to be doingsomething else?
Or, um, somebody who, um, has it, uh, psoriasis, and not a lot a
high body percentage area, butit's on their palms or it's in
their groin and it itches likethe location really matters to
(16:38):
feet.
The hands and feet, um, I thinkare hands, feet and groin are
harder to treat and have more.
Not that elbow psoriasis isn'timpactful, but it can sometimes
have more impact.
But the impact of psoriasis isalso very personal and I think
that's something that you haveto work with your doctor.
Be like how much is thisbothering you?
These are our options.
What do you want to do?
(16:58):
And that there are lots ofoptions.
But that target to treat issetting a whole new bar for
psoriasis that we didn't haveyears ago.
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