Answers to Your Questions About Treating Psoriasis

“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”

Shiva: My name is Shiva Mozaffarian and I’d like to extend a sincere welcome to Sandri Johnson, a board-certified Family Nurse Practitioner with Midtown Dermatology in Raleigh, North Carolina. Sandri has over 21 years of experience in treating dermatological issues associated with the skin, hair and nails, and participates in numerous advisory boards and is involved in research. Sandri is passionate about treating psoriasis and speaks about this topic at various regional and national conferences. In fact if you attended our April Healthier Together Community Conference in Washington, D.C. you heard Sandri address scalp psoriasis as part of our panel discussion. Sandri is so amazing we thought we’d ask her here today to answer questions NPF has received from you our listeners about treating psoriasis. Listen and you might hear the answer to your question! Please remember as we discuss different medications, your experience is unique and may differ from someone else. What works for one person may not work for everyone. But it is possible your solution might be here too.

Welcome Sandri! I wanted to start with the questions we’ve received about the use of topicals. Our first question is from Chris in Bellingham, WA who was recently diagnosed and asks “do you have any tips for staying consistent with topical treatment application? It can be hard to remember to apply it daily, especially if I am not actively flaring.” 

Sandri: Thank you so much Shiva for having me here today. This is truly a pleasure to be here and answering some questions. The treatment of psoriasis can be very difficult and a long journey, so the clearer it gets the more successful we can be. And Chris, in Washington, I hear you loud and clear on this one. As human beings, we are creatures of habit, but it really takes quite a while to engrain our brains into adapting new habits. So my best recommendation of course is to set a routine and always apply your medication at the same time every day. You can use an alarm on your cell phone and that can be quite helpful. I actually for my personal use I have a little post-it note on the mirror in my bathroom to remind me. I also keep my medicine in plain sight, so to avoid that out of sight and out of mind problem that we run into. I find it pretty helpful to carry extra medicine as well because sometimes you remember later on that you didn't put it on and if you have a little bit with you, whether it's a sample from your doctor's office or whether it's a little bit that you put in a small Tupperware container that can make a difference. Another strategy that people use is to scratch days off in a calendar. I'm not that organized and don't use paper calendars, but if you do, that might work really well. Also, pharmacies can have like reminder services or even an app that you can program to send you a reminder to use your medicine. But most of all, don't be too hard on yourself if you miss a dose. This is not really too big a deal if you miss one day a week, especially if you're not flaring. We find that if you miss a day it doesn't really affect much of your results. But you can restart applying when you either remember or when you start flaring again, or if you feel itching. Some folks cannot prevent the psoriasis from coming back after they have calmed it down. And instead of using the medicine on a daily basis, then they cut it back down to perhaps three days a week, like Monday, Wednesday, Friday. Some people establish a routine where they will use it during the week, but then they take the weekends off and if you feel like you immediately flare if you miss a day, then you should probably maybe consider another treatment, because if you're dependent on that one topical that you need, daily or otherwise you're not controlled, then perhaps something stronger or something completely different. Maybe a better option. We know that it is just hard to remember something every day, especially something that is time-consuming, like putting on a cream. So I usually tell my patients that long term topical treatment is not always a realistic or sustainable expectation of treatment. So if you feel like you're dependent on that daily application, definitely think of other treatments, including some of the systemic treatments. 

Shiva: And from Mark in Parker, CO, Dovonex or Calcipotriene has been my go to medication to treat plaque psoriasis for years. Without the use of Ilumya, my psoriasis is severe and the psoriatic arthritis is out of control. I still have facial plaques and psoriasis in my ears. Beyond Dovonex, are there better topical treatments now available to safely treat facial psoriasis or other associated lesions?

Sandri: Ah ha, yes, Mark there are. First of all, Dovonex is a great medication to use in combination with a biologic. Also, Ilumya is a fantastic and super safe biologic, but sometimes we need a little extra help to help that biologic work better for some of those areas that are stubborn or hard to treat. The lovely part of using Dovonex is that it doesn't contain any steroids, right? So it's super safe for the treatment of all body parts, and that includes sensitive areas like the face or the genitalia. I however, seldom prescribe Dovonex anymore. It is kind of expensive. It's difficult to get and it's not as effective as some of the other therapies that we now have. Fortunately, in the last year we've had the approval of two new non-steroidal medications that are safe to be used on the face and on sensitive areas. They're by different companies and they were approved last year. The first one is called Tapinarof and goes by the name of Vtama. The brand name is Vtama and the company that makes it is Dermavant. The interesting thing about it is that the mechanism of action of this medication is completely new. We don't have anything else like it in the market. It is a cream. It's not an ointment, and people like that because it's not greasy and it's only once a day. So that makes a big difference when remembering how and when to use it. The way that it works is that it targets the aryl hydrocarbon receptor or AHR and AHR is needed in higher quantities to downregulate inflammation in the body or on the skin and to repair the barrier function of the skin.  The other new topical cream is called roflumilast and it goes by the branded name of Zoryve and the company is Arcutis. This molecule doesn't have a new mechanism of action but is most definitely a new and much more potent version of a PDE-4 inhibitor. The goal of this cream is also of course to decrease inflammation and the vehicle that delivers this once a day cream is a very cool, super smart technology that allows that active ingredient to stay inside the skin for a few days. Kind of like a reservoir. And what that helps us achieve is that people can use them for a while, get under control, but stay controlled longer without having to continuously treat the skin. Of course, these medicines are new, so they don't have a generic and they carry the price of a brand name medication. Also the companies have their copay cards that are can be used for commercial insurance patients and Arcutis particularly the one that makes Zoryve, they have a patient assistance program for their cream. So individuals that don't have insurance or that are covered under federal policies that are not allowed to use copayment cards by manufacturers, they can still get the medicine from a specialty pharmacy at a reasonable price. I think it's $35.00. So those are two that I would recommend checking out. They're not ointments, they're not greasy, they're creams. They're once a day and they're just as effective as a potent steroid without being a steroid. 

Shiva: Thank you! Such a great recommendation for Mark. So from Bill in Tampa, FL, we have a question. He asks, “what’s the most effective over-the-counter medication cream to stop the itching sensation” and a similar question from Phyllis in Portland, OR who asks, “can you treat psoriasis with over-the-counter topicals?” 

Sandri: Oh, my gosh. Bill, Phyllis, that is a tough question, because itch is the one part of any rash and that will completely drive you nuts, right? People can withstand pain much more that they can withstand itch. They don't call pain the mad pain, but you will call that itch the mad itch. The problem is that the itch that comes from psoriasis is very different from the itch that comes from, let's say, an allergic reaction, right? Allergic itch is histamine driven, so you can use antihistamines for it. But the psoriasis itch is driven by inflammation, so this is very different underneath the skin. So those usual or typical anti-itch medicines like Benadryl or antihistamines don't quite perform against the itch from psoriasis as well as they do for allergies. Now, that being said, antihistamines do help some of the itch of psoriasis, especially those older sedating ones like hydroxyzine or even Doxepin. Mostly because they kind of make you sleepy but they do contribute to an anti-itch effect. Just not as well as it does for allergy. Overall, treating itch in psoriasis is challenging and we have not found one single drug that can be specifically effective. And some of the general measures that we used to control itching application require more creams, right? So we're talking about some of the really good over-the-counter anti itch lotions, specifically things that contain menthol like Sarna, a cream. Also, wearing light clothing or loose clothing, maybe cotton and avoiding hot baths or avoiding hot showers. Cool compresses can be helpful. Other topical therapies like capsaicin, which is that hot pepper substance that jalapenos have is used for arthritis, but it's actually quite helpful for itch as well. We have a few other prescription non- steroidals that can help with itching tacrolimus, the calcineurin inhibitors. Of course steroids help with it and other formulations of like salicylic acid or topical anesthetics like pramoxine. There's some lotion by CeraVe. They're anti itch that has pramoxine and the patients in my office really like this because it helps repair the barrier function but at the same time the pramoxine helps calm down the itch. But if it's extremely severe then you might need to go for some of the oral antihistamines or even menthol containing formulations.

Shiva: Yeah, that could definitely be a problem. 

Sandri: Yes. 

Shiva: So Sandri here's a question from Mee Mee in North Charleston, SC, “I have really bad scalp plaque psoriasis. What are some do's and don'ts when putting things on my scalp?” 

Sandri: That is such an excellent question and it has a long answer. Mostly because that depends on the hair texture, on the overall dryness of the scalp, on the individual triggers that set off your psoriasis. One of the biggest problems with scalp psoriasis is how much it can itch. It is just a warm area of part of our body and it's really easy to scratch, but we know the problem with scratching right is that it causes more itching #1, but it actually worsens psoriasis. You've probably heard of the Koebner phenomena, where you injure the skin and the psoriasis, of course, gets worse in the response to that injury. So the final goal is to calm down itch of the scalp and to reduce plaque thickness and flaking. Let's first talk about the do’s. Number one do: Do use a good, medicated shampoo. There is a plethora of shampoos out there. So this is unfortunately a trial and error thing and a very individual decision of what you like. We do see the best results with shampoos like the Neutrogena T cell or T gel or even nizoral shampoo. There's a couple of prescription shampoos that I really like, that's Ketoconazole Shampoo and ciclopirox. I do recommend washing often two to three times a week if you can, if you're not too dry, but definitely don't wait too long or more than a week in between shampooing. We know that the longer that you wait to shampoo, the more inflammation, the more yeast, oils, dead cells, and products build up into your scalp and this is a disastrous combination. So shampoo very important so you can clear those things away. Dove also has a good shampoo that is for more sensitive skin or damaged hair. They call it their DermaCare, so that's really cool. Look for shampoos that contain either salicylic acid, ketoconazole, zinc, menthol in the products like that. Tea Tree has become pretty popular as well, but I have seen some allergic reactions to tea tree. Also, the National Psoriasis Foundation has a great list of products and their stamp of approval on their website, so check them out then. Then beyond shampooing, we also need treatments that stay on the scalp. If your scalp is very dry, a prescription oil like fluocinolone oil people mostly called Derma-Smoothe oil. We love that. I swear that is the most popular prescription in my office. Derma-Smoothe oil is like an addiction. It's fantastic. It's very soothing. Scalp moisturizers are another do, especially moisturizers that are glycerin based. Now more oily hair might do better with scalp solutions and foams, but I do believe that a leave in treatment for scalp psoriasis is a must. Mostly because shampoos are just a short contact therapy and they don't perform very well on their own, so they need something that stays on the scalp to kind of help throughout the day. Now as far as the don'ts, the list is a little bit long here too, but the first one is avoiding that scratching, avoiding picking. It backfires big time because of that Koebnerization issue. Always wash your hair gently with the finger pads of your fingers, the pads, and not your nails. Brush very gently too. We try to avoid chemicals. We try to avoid excessive heat. We try to avoid excessive tension like tight ponytails and braids because all these will increase inflammation. Also, find ways of releasing stress right? Stress kind of comes through our head. We get hot headed with stress and so things like exercise and meditation and mindfulness can be very helpful. Using scalp sunscreen. That's a big one also because the sunburn in your scalp is another injury that will worsen psoriasis. Think about medications that you may be on that can aggravate psoriasis, like beta blockers, antimalarials, lithium, and also take it very easy with alcoholic beverages. They increase inflammation, too. And lastly, don't let your weight get out of control. The more fat cells that we have in our body, the more inflammation that we make. So we know that one of the comorbidities of psoriasis is metabolic syndrome and weight increase in this also backfires. But the one important point that I wanna make here about scalp psoriasis - specifically if you feel like your psoriasis and your scalp is that severe, is that scalp psoriasis is a major marker or risk factor for psoriatic arthritis. We now know that the correlation is really high, so if your scalp psoriasis is severe and especially if you have joint issues, definitely treat with systemic medications, not just topical.

Shiva: Such important information, thank you Sandri. And from Stephanie, from Evanston, IL, she asks “my topical treatment isn't working that well to treat my psoriasis and I have tried multiple other topicals. What should I do?” 

Sandri: Ohh, shout out to you, Stephanie in Illinois. I used to live there. Stephanie, I think you probably know the answer to your question. In this day and age of extremely efficacious and safe medications for psoriasis, nobody should be uncontrolled. We have such good stuff out there, but the navigation of this journey can definitely be very, very challenging. Of course, the treatment also has to jive with your comfort. If your comfort zone is staying with topicals, then we have, some good new topicals out there in a lot of different formulations. I spoke earlier about those new topicals in the market Tapinarof and Roflumilast or Zoryve and Vtama, and they are a good option if you haven't tried those already, since they're pretty new. Now if your psoriasis is more moderate-to-severe than once again, definitely consider a systemic if you're not having success with the topicals that you have tried. If injections are not your preferred treatment, if you're not comfortable with that, we do have two oral options and more coming in the future that could work really well for you. The first one is apremilast, right? We know apremilast for a while. It goes by the name of Otezla and it's been on the market for almost a decade. This is a PDE 4 inhibitor that when taken twice a day can really reduce plaques of psoriasis quite nicely. And it's also approved for psoriatic arthritis and we use it across the severities, whether you have mild, moderate, severe psoriasis. Otezla is approved for all conditions. It does have side effects, right? Some of the things that we see most commonly is the nausea, diarrhea, headaches. So a lot of people don't like that if they can't overcome in the first few weeks of treatment. We do have another newer oral option for any type of psoriasis, but mostly moderate-to-severe and that one is called deucravacitinib, Sotyktu. Maybe you've seen the commercials for Sotyktu. And this medicine is a different mechanism of action is the TYK2 inhibitor and it has the advantage of working better than Otzela. They did a head to head study with Otezla and it definitely performed better. It is a once a day dosing instead of twice a day and it doesn't have the diarrhea, the nausea, the headache, side effects that we see with Otezla. Sotyktu is becoming a really popular option in our practice. But please, Stephanie, don't suffer in silence. Talk to your provider about these options. 

Shiva: Yeah, that’s a great recommendation. So Fred from San Diego, CA would like to know “what can be done to reverse skin discoloration from the use of topicals?” 

Sandri: Ohh so yeah, discoloration can come both from the condition of psoriasis (the inflammation itself can change the pigment of your skin) but yes, the use of topical steroids does lead to a dyspigmentation of the skin, mostly lightning, of the skin. If the discoloration is coming from scratching so deeply that the color making cells are destroyed, then there is no way to reverse that, right. Then the color is gone and that's the end of that. When folks have scratched so hard, we see that a lot in especially in the lower extremities of folks that have scratched so deeply that they just scarred their skin and you end up with these white scars on your skin. But if the discoloration is from a steroid cream, this is reversible. Naturally, stopping the steroid is step number one. In our office, we're trying to replace steroid treatments with nonsteroidal's as much as we can. Steroids are becoming passe. They are just not great. I mean, they're good rescue and cheap medicines. Well used to be cheap, some of them are not anymore. So we're trying to use mostly nonsteroidals. Secondly, moisturize your skin heavily, repair that barrier function. We recommend CeraVe for the repair of the barrier function, that works best. We try to use lotion in the summer when it's really hot and you want something light. Creams in the winter when you need something a little bit thicker. But the one and most important thing to remember about discoloration is that this is the first sign that your skin is starting to thin. And although the discoloration can fade, if the thinning is allowed to continue and these stretch marks start developing in that excessive capillary formation, then that is not reversible. So yes, please try to do away with the steroid creams if you're seeing discoloration, that means your skin is thinning and it's time to back it off or replace. 

Shiva: Howard in New York asks “are there any non-steroidal topicals I can use?” And I know you alluded to some of these earlier. 

Sandri: Hi, Howard. Yes, we have a lot of nonsteroidal topicals out there. The older nonsteroidals that we mentioned earlier are more ointments and the vehicles are not as elegant as the ones that we have now and the effectiveness of the newer ones is definitely better with once a day applications. But we still have people that love their older medications that are ointments and those, you know, include the vitamin D analogs like the calcipotriene that we were talking about earlier, Dovonex. We also have the calcineurin inhibitors like tacrolimus. That one some folks complain a little bit about burning, but at least it doesn't contain any steroids in there. I'm with you, I’m into the non-steroidal topicals all the way. The greasiness is what really sets back the folks not wanting to use ointments, so the new creams, the foams that are out there, especially the emollient foams. There are a couple of foams that are steroids sadly but that are emollient if you need to use a steroid for short term treatment. But the creams are definitely gaining more favor, getting smarter, getting more efficacious, and a whole lot easier to use with once a day applications without having to continuously treat. You can actually take breaks from these medicines. They have some studies that show that after you gain control, it might take three or four months before your psoriasis plaques shows up again. So once again I'm talking about Vtama and Zoryve as the newer medicines. If you have insurance that can cover them or commercial insurance that where you can get the copay card from the manufacturer, they work great. So that would be my recommendation is stick to the new and better products. That's what innovation is for.

Shiva: So, here's a challenging question from Elizabeth in Plymouth, MA, “I have psoriasis on my scalp and have been told nothing can be done for it. Is this true?” 

Sandri: It is true that scalp psoriasis can be extremely challenging. And of course, there's nothing that will cure it yet, but hopefully you got to hear my answer on the subject earlier that even though scalp psoriasis does require much more attention, there are many things that we can do to treat scalp psoriasis, especially if we are suspecting that it's associated with psoriatic arthritis as well. I've had patients that have tried everything under the sun and still flare often. So I feel that frustration and that fear that nothing could be done. But we always tend to find a trigger. Something might be triggering the scalp psoriasis that you might not be aware of. We talked about chemicals. We talked about heat and sun exposure, medicines, stress, overall health, and all that can make psoriasis hard to control but especially scalp psoriasis. Sometimes we even have to resort to injecting liquid steroids directly into the scalp plaques when everything else fails, we definitely do that because it gives you relief. However, we are seeing a paradigm shift. With scalp psoriasis being so deeply linked to psoriatic joint disease, we are now focusing more in systemic treatments for this subset of population where the scalp psoriasis is severe because we know the risk of joint destruction is so much more higher. So do please pay close attention to your joints. Be on the lookout for stiffness and swelling and talk to your provider about what options would work well for you. Whether it's something newer in topical foams, et cetera to use on the scalp and shampoos or injectable or oral medications that will treat from within. We are talking about a condition that is a systemic condition, right? Psoriasis is not a skin problem. It's an immune system problem, so going to the core of the problem in treating the immune system is always ideal.

Shiva: Such incredible questions and responses! Thank you Sandri for providing such helpful information and guidance! For our listeners, stay with us for more tips and information about treating psoriasis from Sandri following this quick announcement about the Seal of Recognition program through the National Psoriasis Foundation.

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 for people with psoriasis, psoriatic arthritis and/or individuals living with severe skin sensitivity or joint mobility limitations. All products earning the Seal of Recognition provide scientific data that demonstrates products are safe for sensitive skin and data has been reviewed by a panel of board certified dermatologists for NPF approval. Check out the list of products that have earned the Seal of Recognition at psoriasis.org/seal.

Shiva: Welcome back everyone! Be sure to take time to check the list of products that have earned the Seal of Recognition. You may find something that might help you. Sandri, thank you again for all of the amazing information you’ve provided so far. Let’s now turn to a discussion about systemic medication and biologics. A question from Tim in Florida is “When you feel your biologic is no longer working, how much time before you should change?  What is the difference between a flare and the drug losing its effectiveness?”

Sandri: WOW, I love this question! It goes so deep into the million dollar question that we all ask ourselves. The first part of the question kind of gives you the answer. If you feel your biologic is not working, then it's time to move on. Years ago, with the older biologics like Enbrel and Humira, I'm not sure what systemic you're on Tim, but back then I would give those biologics at least six months to show me what they could do. Now, I definitely don't think we should wait that long. We learned way back then also that control can be achieved much earlier when we had Stelara come into the market. Those studies were showing their endpoint at 12 weeks and people were doing amazing at 12 weeks. So that really shifted how we were looking at the time frame that we should allow these medicines to show us what they can do. So even now the newer biologics that even faster onset of action and much higher efficacy than any of the three that I just mentioned. Better efficacy than Enbrel, Humira or Stelara. So those are Tremfya, Skyrizi, Taltz, Cosentyx. So for extremely severe psoriasis, I still think that 12 to 16 weeks is plenty of time to show you how you're trending and if you're trending in the right direction, right. You should be seeing quite a bit of improvement. Of course, you can still expect further improvement past that point of 12 to 16 weeks, but those first 12 to 16 weeks should be dramatic. It should be a dramatic change, if it isn't, move on. We have so many choices now that if you're a candidate for any of them, then you shouldn't waste time waiting on one of the other ones to kick in. Now differentiating a flare from a fail, that definitely takes longer time. You are in Florida and your weather is pretty consistent throughout the year. So we would expect that a flare would be tied to a trigger like an injury and infection, an illness, medicine, or travel to another climate that is cold, or a sunburn, or smoking, or alcohol, weight gain, all these things. So modifying the trigger should get you back in course. However, if you find yourself constantly flaring and barely regaining control, then that current biologic might not be for you. It should perform really well consistently, and if it isn't, I would definitely look into different options.

Shiva: So another similar question from Dolores in Jolistco, Mexico, “I want to know which is the best medicine for psoriasis? My son uses secukinumab but it is no longer having much effect. How can I know which one is right for him?”

Sandri: Oh and how I wish we had a way of knowing or testing which biologic would be more effective in every individual. I think that technology is probably gonna be in our future where we can measure cytokines that are predominantly affecting your psoriasis and then you can choose wisely. Will there be a test that measures if it's tumor necrosis factor? Is it an interleukin 17 problem? Is it an interleukin 23? But unfortunately, the only way we can know now which one is the best biologic for him is by trial and error. Now Secukinumab or Cosentyx is considered a very highly efficacious biologic. But if he has been on it for a while, let's say a year or two and it's not controlling his psoriasis, then it's perfectly acceptable to try a different one. The one thing is that not all biologics are approved for all ages and I do not know the age of your son. I can tell you that Taltz is a great option that I find to be more effective than Cosentyx in my practice. There are no head to head studies comparing Taltz and Cosentyx, but in my office we do see Taltz performing better, so this is a great choice that is also approved for people that are under the age of 18. If your son is over the age of 18, the IL-23’s like Tremfya and Skyrizi are a great option. These things have incredible skin clearance. So please also make sure that you and your son are applying all the other recommendations that we talked about earlier as far as overall health because all these things can have a high impact on the severity of your psoriasis as we had mentioned in the previous questions. So it's kind of unfair to make the medicine do all the work and us just kinda lean back and not apply healthy habits to our lifestyle. But if the Cosentyx is no longer having much of an effect and he is younger than 18, I would recommend Taltz. And if he's older than 18, then he can use Taltz or Tremfya or Skyrizi.

Shiva: So from Isobel in Frederick, MD, “How long is it safe to use biologics? I want to start a biologic but I am terrified of the side effects.”

Sandri: Oh Isobel, please don't be afraid. Now, I would never tell you how to feel about something, but I would also never want you to live with the terrible impact that we know psoriasis can have in your whole life. We don't have a cure for psoriasis. So the goal of biologics is to implement a therapy that has way more benefits and it's less dangerous than the disease itself. So the answer to the question is forever. The goal of treatment is a forever treatment until we either have a cure or until you're no longer comfortable using a biologic, or if you become a non-candidate for one. Biologics have now been around for 20 years or so and there are hundreds of thousands of people on them. The safety that we have as far as the data is extremely comforting with the rates of any adverse events being very close to the placebo groups or even what is generally expected in the population. What we do also know is that psoriasis carries a major risk to your health itself. We see higher rates of cardiovascular problems like strokes and heart attacks in people with psoriasis and a bunch of other comorbidities that can cut your life short. So treating the underlying inflammation actually decreases these risks and that includes your mortality risk. Nobody should live in fear, but in complete honesty I fear the disease of psoriasis more than I fear the treatment itself. So yeah, definitely don't be afraid of the biologics. They’re such safe options out there that could help you feel comfortable at night. On top of that, we also have of course the oral medications that maybe that would be a better place for you to start since they have a short half-life and they come out of your body quickly as you just stop taking the pill. But whatever decision you make, it's all about that risk stratification, right? And what will help you feel better or sleep better at night. And of course, the people that I see in my office, they are there and they keep coming because they're getting treated and they want the treatment. So I don't see the people that don't come and are fearful of the treatment. But please do have a candid conversation with your provider and seek the opinion of others who are already in treatment and see what they say. There’s so many blogs out there that are there to help you make a good decision. The one source, of course, that I always tell my patients to look into and tap into is the National Psoriasis Foundation website, psoriasis.org. There's a plethora of information there with a completely unbiased in their recommendations, so definitely advocate for yourself and move forward. If your psoriasis is severe, you don't have to live with it like that.

Shiva: Thank you for such a reassuring response. Steve in Seattle, WA is wondering “my dermatologist said that Stelara’s patent was due to expire sometime this year and that he expected new biosimilars might be available soon. Do you have any updates on this?”

Sandri: Yes, we do. The patent for Stelara does run out this year actually next month, September of 2023. We do have some biosimilars already in the market, but they are not for Stelara. I don't think the biosimilar for Stelara will be here as soon as next month, but we will probably see that by early 2025. So another year and a half or so, January, February time frame. Now the company that makes Stelara, Janssen, which is part of Johnson and Johnson, they still support their products. So it's just that they actually have a better product now that they promote and that is Tremfya, which is taken every eight weeks instead of every 12 weeks. But it has a much higher rate of efficacy than Stelara does, even though Stelara is fantastic. So you can still get Stelara, the company still makes it. They still produce it. It's used for a lot of other conditions, so you should still be able to get it as a prescription. However, I don't know that their patient assistance program is gonna still be in effect and we certainly don't get samples of Stelara in the office. I think eventually your insurance will have a preferred option and if Stelara stays as a preferred option and it's working great for you, then stick to Stelara until somebody else makes you switch, whether it's the insurance company changing their formulary or if you feel like you might need something different than Stelara at that time.

Shiva: So Steve's question brings up another from Emily in Hood River, Oregon “what are biosimilars medications and are there any benefits to taking a biosimilar instead of a biologic?”

Sandri: This is a hot topic. First of all, a biosimilar is not the same thing as the generic. Generic medications are made for small molecules that can be swallowed in a pill or applied to the skin. But a biologic is a very large and complex molecule. It's a protein that is made out of a living system. So to make something similar to it, it's not an easy task. It requires years of dedication and a very expensive process. This is because you're dealing with a molecule that is not easy to copy. It's large and it can fold in ways that can make it behave differently. The biosimilars that we have now are to infliximab, which is Remicade, and to adalimumab, which is Humira, and they do have to go through similar testing. Not the rigorous trials that the parent molecule did, but they basically have to prove that they are almost similar to the reference molecule. The testing is just not as rigorous and that is what in turn saves money in the development of these biosimilars. The manufacturing is still expensive, but with more competitors in the market making biosimilars that will also drive the price down. So that can make therapies available to more people that otherwise wouldn't have been able to get a biologic. So biosimilars, they have shown to work very similarly to their reference molecule. And what we hope is that we have that lower cost option and have more access to treatments. But there is no benefit other than a financial benefit in taking a biosimilar instead of a biologic.

Shiva: So from Susan in Huntsville, AL “I’m interested in learning about treatments for psoriasis in the nails. I’ve been on Enbrel (long term) but my nails have not improved. What are my options?”

Sandri: Not Enbrel. That is your number one option. If Enbrel is not improving your nails and we know that nails are also associated with joint involvement, then I would definitely recommend a newer biologic. The newer biologics, especially the IL-17’s, have proven superior to Enbrel, to Humira and to any other biologic when it comes to treating nails and treating psoriatic arthritis. Their nail studies look really, really good. The nails are basically your window to the joint so they're an extension of your joint. So if your nails are not doing well, likely your joints will not be doing well either. And as great as Enbrel was 20 years ago, it was revolutionary, right? TNF alphas paved the way of what we're seeing now for biologics. They are definitely kind of falling out of favor because we have better targeted medications. IL-17’s specifically in this case that can really, really make a big impact on your nails and your joints.

Shiva: And that seems to be the way. We always have newer medications coming up that perform better. And now a question more about causes from Magdaline in Lagos, Nigeria: “Why does psoriasis remain dormant from birth, and then start manifesting at a certain age?”

Sandri: Ah, Magdaline, another million dollar question. The short answer is we don't know. We know there is likely a genetic predisposition to psoriasis, right? A genetic mutation that you inherit, but still there are people that develop the condition and they have no family history of it. However, having family members with the disease definitely increases your risk. If you have one parent with psoriasis then your chances are about 10%. But if both of your parents have psoriasis, then your risk is more like a 50% chance that you will have it too.  To me and how I explain it to my patients says that having this genetic mutation is like carrying a loaded gun. Something has to pull the trigger for it to go off. The problem is that we don't know exactly what these triggers are. We have identified some triggers that may be linked to the manifestation at this point, and of course we've talked about infection. We've talked about beta blockers, medications, antimalarials, lithium beta blockers. We've talked about injury, trauma to the skin, infections like strep throat, right. We've seen strep throat be one of those big triggers that pull the trigger in your gun. But we still don't have that specific exact cause and effect. Sometimes a trigger cannot be identified, so the loaded gun might be more of a ticking bomb to where it just has a countdown until boom it appears and once it goes off there's no way to reverse the subsequent cascade of inflammation that defines psoriasis. So there's so much more that is yet to be learned about what causes psoriasis and its genetics, but also the effect of triggers in its manifestation. Stay tuned. 

Shiva: Such a great answer. So Shahzad from Lahore, Pakistan asks “can psoriasis have long lasting control with nutrition?”

Sandri: Another hot topic, right? After all people say we are what we eat or what we eat, eats. Multiple studies have been done on the subject of diet and inflammatory disorders, especially psoriasis, but also gluten sensitivity. And the bottom line is that pretty much all the studies have concluded that no, we cannot with the knowledge that we have now control psoriasis with nutrition. For example, there have been multiple studies done in the supplementation of like polyunsaturated fats, your Omega 3’s and these have not shown to really decrease the disease or improve much of psoriasis. But there was an interesting study that did show that patients with psoriatic arthritis who were supplementing their Omega 3’s, like fish oil actually use less NSAIDS and less ibuprofen, less pain medicines, et cetera. So that was interesting. Gluten free diets, we have shown that they basically only help those patients that have gluten sensitivity but are not having an effect in patients with other inflammatory disorders like psoriasis unless you also have gluten sensitivity. We also have done a lot of studies on special diets like the ketogenic diet or Mediterranean diet, and these themselves have not shown to improve psoriasis to a significant degree. Although the Mediterranean diet does seem to be of some benefit over our heavily sugar, carb containing Western diet. What we do know is that overall weight reduction definitely has proven to be beneficial. There have been studies done on nightshades as well. Tomatoes, Peppers, white potatoes, etcetera. And once again, no link to psoriasis flares. There has been studies on vitamin D as well. Vitamin D has been known to be low on people with psoriasis, but if you supplement vitamin D, it has zero impact on your psoriasis. So what we do recommend, of course, is a healthy, balanced diet, perhaps more like the Mediterranean diet, watch your calories and weight reduction. That is definitely a key, but so far, I can't say that you can have any long lasting control with just nutrition for a immune based disorder. 

Shiva: Sandri, thank you so much for being here with us today. We've learned so much from you. Your amazing responses to the questions from our listeners and it's obvious you have a passion for treating psoriasis. Do you have any final comments you'd like to share with our listeners today?

Sandri: Yes, Shiva, I do. The thing I want to leave you the most with is to study. Study your condition. Study available treatments through a trustworthy resource like the National Psoriasis Foundation. The more you know, the more empowered you'll be to make great decisions for yourself and be able to advocate not only on your own behalf, but for others in your circle of friends, your family and community and never give up. Don't lose hope. The research continues. We find new information almost on the daily. Stay positive and find that provider that will enhance your journey. I really wanna thank you for the opportunity and the privilege to let me share my passion for the treatment of psoriasis with you today Shiva and your community.

Shiva: Sandri thank you so much for your meaningful comments and for answering the many questions we received from our listeners. This has been such a great way to honor Psoriasis Action Month. Whether you’re looking for treatment options, community, or tips to help live a more active, healthy life, contact the National Psoriasis Foundation by calling our Patient Navigation Center at 800-723-9166 or by emailing education@psoriasis.org. Get free resources, individualized recommendations, and answers to your questions. You can also share your stories about living with psoriasis and photos at #ThisIsPsoriasis. And finally, thank you to our sponsors who provided support on behalf of this program activity through unrestricted educational grants from Bristol Myers Squibb, CeraVe, Janssen, Novartis and UCB.