Traveling Near and Far with Psoriatic Disease Transcript

LB: That was a great shout out for the Patient Navigation Center on the NPF site. Thank you.

Kaitlin: Agreed.

LB: So some of the issues I've encountered are with plane travel. I'm curious what your thoughts are on how to best prepare for airline travel when you have psoriatic disease. Like, how do you navigate medication use with delayed flights, long flights, the lost luggage we all dread, or even the limits on how much fluid you can carry. Any tips you have for that?

Rosemary: I think that as a general rule of thumb, anything you really don't want to get lost or damaged should be as a part of your carry-on items. And the travel containers I mentioned earlier, there's this cooling wallet, Frio Cooling Wallet, that's like definitely TSA friendly that you could keep in your personal items and it holds like one or two pens worth of medication. So you definitely want to have anything you don't want to lose with you on the airplane. I've seen some recommendations saying like you should carry a psoriasis passport, which is to say maybe you get a letter from your doctor along with like a list of your medications to show to a security agent. And then also you always want to maybe bring an extra dose if you know you can rely on being somewhere where there's a refrigerator or invest in one of the temperature stable storage options. And then it’s also a good idea to have a list of medicines in generic form you have that you could also find in other places and it might also be a good idea to consider getting travel insurance that covers pre-existing conditions. But in general you probably want to have whatever you need with you because throwing it in your checked luggage is just generally kind of just hope it'll make it, cross your fingers. So anything important, definitely keep with you. If you have topicals, it might be a good idea before your trip to ask your dermatologist to let you have some samples that way they're like travel size samples of medication that can kind of get you through. And then if you wanted to keep the larger item in your checked luggage, you could. Hopefully that's temperature stable and it doesn’t get lost, but maybe taking enough samples to bring with you for your trip. And in general, the fluid ounces are, it's up to 3 ounces, which can actually be quite a lot of medication if you needed it. Like that's a pretty sizable quantity of any topical drug. If you're going through that much in a two week period, it might be time to talk to your doctor about other treatment options. But in general, if you think it's important enough that you can't go without it, you should keep it with you.

LB: Good advice.

Kaitlin: Yeah. Thanks, Rosemary and you just reminded me when you were talking about a psoriasis passport how I definitely will be traveling with one moving forward. One of the times I had flown, TSA didn't know what psoriasis was and mine's very visible, my plaques and they thought I was having an allergic reaction and didn't let me board right away.

Rosemary: Oh Lord.

Kaitlin: So I appreciate you giving our listeners that advice because if I had my letter that day, it would have been a lot quicker for me to move along.

Rosemary: And that is like another layer of planning, right 'cause it’s like

Kaitlin: Yeah.

Rosemary: I can relate to someone that's just like, I just want to go on a trip. And presumably

Kaitlin: Yep.

Rosemary: people listening to this episode are interested in travel and have an adventurous spirit, and I think if anything, maybe just creating it and stuffing it in your normal go to bag so that way you don't forget it. As I've grown up and traveled a lot that's the only way I'm gonna get to ever remember something is I'm just gonna have a separate one and put it in my bag and not even have to worry that I left it behind. But I mean I get it's like another thing you have to think about, but yeah.

Kaitlin: It's invaluable and I appreciate you bringing that up and I know our listeners will appreciate it too, because man, that would have came in handy.

Rosemary: Right, yeah.

Kaitlin: So you know it's the life of living with psoriasis, right?

Rosemary: Yeah, it's tough.

Kaitlin: So plane travel could also mean traveling outside the country, which I think a lot of us want to explore the world. And that adds a whole other layer to the issues that we just talked about. What are your thoughts on how to prepare for traveling out of the country with different climates and different brands if you need to buy over the counter products while you're gone? Do you have any tips or help to make travel easier for people that want to explore outside of the US?

Rosemary: Oh yeah, so definitely speaking from some personal experience. Again, the doctor's note, and have that with you as part of your psoriasis passport. And if there's any medications that you take here in the US that's over the counter, I would recommend getting a list of those drugs in generic form, not their brand name and have that available. And an interesting tip is if you're going to Europe, you cannot buy over the counter drugs in just your normal kind of convenience store like you can here where if you go into say a CVS which is a pharmacy, they sell shampoo and toiletries and all of that. In Europe, they have a special apothecary as it were, usually demarcated with a green cross where drugs specifically are sold. So a personal example, I went to Germany in the fall. I did not take any of my antihistamines with me and I'm an allergy sufferer. I thought “I'm going to be fine. I'm going to a different place” and it was fall in Germany. So I needed my Allegra or fexofenadine, which is what it's called here and I learned that you cannot buy drugs at your kind of CVS equivalent and wound up going to one of the apothecary’s and found Allegra there. And I asked them. I saw it behind the counter. And so as a clinician, I know what I'm looking for. But for average people who are not familiar with a lot of formularies, I definitely recommend having a list of your generic medications. And pharmacists in these countries are actually pretty knowledgeable, and if you can't find the exact drug because interestingly, the version of Allegra that I bought in Germany is not a drug that's available in the United States and I looked it up and saw that it's a Class 2 for non-sedating antihistamine, but it's not in the US market. So I would say if you can't find what you're looking for because it's not available or it's only in the United States, then ask the pharmacist and having those generic medication names is important.

LB: When traveling out of the country, you might need up-to-date vaccinations, correct? Something like COVID-19, yellow fever, cholera, or measles. Any guidelines you have for people with psoriasis and psoriatic arthritis?

Rosemary: So the American Academy of Dermatology as well as the National Psoriasis Foundation, recommend that inactivated or non-live vaccines may be administered safely to patients with psoriasis while they're on biologics. You definitely can't receive a live vaccine prior to biologic treatment. But let's say you want to go traveling further afield to countries like in Africa or Asia where there are things like yellow fever, Dengue, Japanese encephalitis, that are things you might wanna be vaccinated against. What is a person on immunosuppression to do? There are some ways around that, which is to say, if you're planning that trip, you'd want to plan for really far in advance. And so you can collaborate with your doctor to consider being off the medication for up to two to three half lives so that you can receive those vaccines and then wait up to four weeks before restarting it while you can actually basically mount an immune response to whatever the vaccine is you need. And kind of depends on each drug's biological half-life. And then in that case, you'd also probably want to involve an infectious disease specialist, which again adds an extra layer of planning. However, if some of us are planning on going further afield, let's say to Cambodia or someplace in India or parts of Africa, which should be a trip of a lifetime kind of opportunity, it's definitely worth planning in advance so that you can be as safe as possible and really enjoy the time while you're there. Another interesting thing is there are strategies that are simple to avoid mosquito exposure like clothing that's actually been pre-treated with Permethrin or DEET. And then if you really just can't actually get one of the vaccinations for whatever reason, you might try to get a medical exemption letter from your doctor which is sometimes accepted at borders.

Kaitlin: Thanks Rosemary. Another wonderful tip to our listeners. So we've been talking a lot about sun protection, the heat. Something I wanted to turn to now is the opposite. Not everywhere we travel is going to be hot or warm, and I know that because where I am, you can go from hot up into the mountains really quickly where it's freezing and snowing. So my question for you would be what should be done to protect your skin from the cold weather? Because I know that affects my psoriasis sometimes more.

Rosemary: So some of the recommendations from the American Wilderness Medicine Association recommend you should protect your skin from the cold, wind, and moisture. So if you have anything that's exposed, like your hands or your face, there are lots of different types of items that are excellent coverings, like mitts or windproof materials that can protect you just from like the actual wind or cold. I'm sure you've heard of the expression cotton kills which is to say that cotton, once it gets sweaty or you sweat in it, it stays wet. So if you stay wet, that can actually increase your risk of skin damage and frostbite. So that's where synthetic fabrics might be better. Those things that are usually breathable and can wick away moisture. Stores like REI, I'm a big fan. You can find a lot of clothing that fits the bill for that, and they always have a good sale around Memorial Day and Labor Day. So just stay tuned on that. There's also these if you're doing skiing or winter sports, there are a lot of these chemical hand and foot warmers, but you need to be careful because obviously you don't want to have them directly against your skin because you could actually probably burn yourself and if you have impaired circulation, that's not great. And of course, if you start feeling numb, that's a sign that you need to maybe get somewhere where it's warmer. As far as emollients go, using emollients is important because in dry or cold climates, usually it's pretty dry particularly if you're indoors and there's a heater going, it's extremely dry. So rich emollients that have ceramides or dimethicone can help kind of reduce the water loss or evaporative loss from your skin and will help with the inflammation. And definitely you don't want to actually rely on moisturizers for frostbite prevention. That's definitely not the way to go. But in general you want to keep your core warm. You want to try to stay hydrated as reasonable, and make sure you're actually eating properly. But definitely, I'd say if you're going to be doing a lot of winter sports or being in cold places, it might be worth investing in some good, breathable but insulating socks, layers like thermal underwear. Good jackets that are windproof and something I discovered recently when I went on a trip again in Germany, if you want a raincoat, check on to see whether it's water resistant or waterproof because there is a difference. Those are some tips that I have to offer.

LB: I'm also curious about precautions we can take to reduce exposure to, say, infection while we travel. And do you also think that travel insurance is needed?

Rosemary: So I think it depends on where you're going, and definitely if you're more fragile, I think a travel insurance policy would be something I would consider. I like going on trips with sometimes organized groups. I enjoy horseback riding and they require travel insurance because it's inherently a risky activity. So if you're going with a group, usually some kind of insurance will be offered, and I think it's reasonable to consider that particularly if you're doing some kind of adventure sports, definitely I would consider investing in a policy like that. But also if you are thinking of an insurance policy, you want to make sure that it includes more than just your basic trauma and make sure it actually has pre-existing conditions, like your psoriasis, as a part of that. And then if you're going someplace really far-flung like Africa, or you're going to the ends of the earth and camping and adventuring, you might want to plan the trip with your doctor in advance so that you can update your vaccines, consider infection prevention strategies like your hand hygiene, your mask, like all the things we had to do during the pandemic. And I found that the US State Department usually has useful information about countries that you're going to prior to travel and kind of give you ideas about, like, what sorts of infections or endemic diseases there are. If you're on immunosuppressive therapy, which I think a lot of psoriasis patients are, the general rule of thumb is that you probably need to stay away from raw milk, raw produce, or water and ice cubes. That's kind of the general thing that you learn if you travel in Latin America, like, don't get a drink with ice cubes in it unless you know where it actually came from. And if you're in, say, in Southeast Asia and there's a food stall, probably you want to avoid that simply because a friend of mine mentioned her trip to Indonesia and she saw them use some plates with a dish, and then the person turned around and rinsed the dish off in a ditch beside the road. So obviously if you are immunosuppressed, that's definitely not an option even for people not on immunosuppressive treatment. Our GI tracts and immune systems are not prepared for exposure to the kinds of bacteria and viruses and other things that you're going to get in a more developing country. And like we talked about, consider planning the trip in advance with your doctor. Update your vaccines if you need to. And just do your best and try to have some fun.

Kaitlin: Thanks, Rosemary. Again more incredible information for our listeners. Something as you were talking, I'm thinking about stress. The stress of getting to our destination or sometimes we're traveling for a stressful reason like I was. And with that, we know that stress often triggers psoriatic disease and plaques, and like me, inverse psoriasis. Do you have any tips to help reduce stress while traveling?

Rosemary: So if you were traveling for a not fun reason, I think that it would probably be a good policy to plan things in advance, like have a calm kit. Like if you can find or get some noise cancelling headphones or an eye mask to help you sleep in dark places or there is something to be said for having a fragrance that's comforting and familiar. On a tour I went on, one of the guides said that there is some kind of routine that was recommended by military in Great Britain to have a fragrance that reminds you of home because fragrances can be familiar and comforting. And so he always brought a block of this highly perfumed soap from Blush to any room he went to because it helped him kind of like, feel like it was a comfortable, familiar place. And I'm like, that's an interesting thing, 'cause when we're in different hotel rooms and in different places, it's really hard to feel relaxed. So perhaps having a kit of some sort to help you relax as much as possible and try to sleep as well as you can. If you're going for a vacation, it's definitely a good policy to try to build in buffer time. So sometimes really cheap flights will, it seems too good to be true, and then when you realize, like, oh, I didn't really build any time for error. Like if you have really tight connections, that's extremely stressful because that could throw off the whole entire trip. So basically plan for buffer time. If you can, the one thing that you can always access for relaxation is your own breath. And there's something called box breathing, which, if you visualize the four parts of a square or a box, you can breathe in for four or five seconds. Hold your breath for four or five seconds. Release for four or five seconds and then take that again and doing that very deliberately actually has the effect of slowing down the heart rate. And why that is, is because our vagus nerve is connected to the diaphragm, and when you intentionally breathe, it actually slows the heart rate down. The vagus nerve is a really huge nerve that innervates lots and lots of different things. And it among other things, goes to the heart. It goes to our diaphragm. It goes down to our intestinal tract, and when you intentionally slow the heart rate, it actually intentionally puts us into a state of relaxation. I understand that the US Marines actually use this or the SEALS will do it to prepare or like relax on the way to battle. And then if you're on vacation, I think that it's important because we're in the United States and we get such a limited amount of time to actually go on a vacation, we feel like we have to try to squeeze every last drop out of vacation. And so if there's something we have this plan and we have this vision of how it's supposed to go, I think that it's easy or good to try to remind ourselves that it's not as important. It's OK if things don't go according to plan. You could try and reframe inconveniences or disruptions as a part of an adventure. Maybe consider a plan A, B or a C. And interestingly, keeping a travel journal might help you relax. I heard a tidbit about depression on one of the newspapers I listen to and read about how even just journaling about symptoms of depression can help people feel better. So, keeping a travel journal could actually help you sort of process your emotions, even if it's like a single line a day. I know I aspire to be able to do things like that. I can never actually keep up with the journal, but that is one way to help you sort of process your feelings and maybe have time to reflect. And then if you are traveling with a group, try to let other people know if you're struggling. If you know if you need to take a rest or have some special food, just tell people to like, let you kind of step away. And then it's always fun to travel with others. So if you have someone that's got your back, I think having a travel buddy can help you kind of process and get through the really frustrating aspects of travel. And then of course like maybe consider having a backup plan. So if you are worried about a medical emergency, maybe have an idea about where you could go. But of course, if you're traveling for business or something that's unpleasant, I'd say consider the calm kit. Consider packing cubes. Try to stay nourished and hydrated. Make sure you're feeding yourself well. Those are all things to try to reduce the stress, but at the end of it, if you're going for fun, try to remember to have fun. And if you're not, try to do the best you can to take care of yourself.

LB: Rosemary that's great advice. I know when I travel I try not to overdo it on day one and then not enjoy the rest of the trip. So I go in with somewhat of a plan just to make sure I can get through it all and enjoy it and not stress that I won't enjoy it later. Do you have any recommendations on any places or things that we might want to avoid when traveling? So kind of that thinking ahead of what not to do?

Rosemary: So I think there's kind of the common sense stuff, but then there's also stuff that like you may not have considered and we take for granted a lot in the United States. So having access to refrigeration is something that Western countries take for granted. But in a lot of parts of the world, the cold chain doesn't exist. Interestingly, there's a great book called Frostbite by Nicola Twilley that talks about the history of refrigeration. So if you're going someplace tropical or perhaps for a mission trip, or a humanitarian trip, it might be good to really plan in advance and invest in good refrigeration for anything you need. You definitely do not want to try to take your chances with unfiltered water or certain kinds of raw food. Again, even in parts of Latin America our closest neighbors, the water is not necessarily something you can rely on or trust in every different region of, say in Mexico, I’ve been to Cabo and the tap water is OK to drink. But I've been in other parts of Mexico where I definitely do not want to take my chances and not even the locals will drink the water. And things in general that are not ideal would be like crowded or poorly ventilated spaces. So I can think of like a subway, or regions where you know there is an active outbreak and that is where the Department of State or even the CDC might have information about areas where they're actually active outbreaks of things like TB, or measles, Dengue. And again traveling in developing countries is, I think a little bit of a toss-up. And so if you're going for humanitarian reason or a mission trip, the group that you're going with presumably can help you kind of figure out what's the safest thing to do or not or maybe even consider going somewhere else. Of course, there's always the raw seafood or undercooked meats, unpasteurized dairy, some of the things that kind of make travel fun. And the exposure in the environment. Some medications can actually make you more photosensitive. I don't know how many people are still on methotrexate, but methotrexate can actually increase photosensitivity. If you're sunbathing, as a derm person, we're always going to tell you to avoid sunbathing. And then if you're in a high UV index area, like at high altitude without proper sunscreen, you can definitely get heat stroke and hurt from that. So I would say using prudence and common sense. But then maybe checking places before your trip to see if there's anything you need to be aware of.

Kaitlin: And for all of us, as we wrap up our time together, are there any final comments, advice, that any of us would like to impart to those with psoriasis, psoriatic arthritis who would like to travel but fear managing their disease on the go?

Rosemary: Well I would say I have compassion for someone that might be worried about it. You know as I was

Kaitlin: Yeah.

Rosemary: preparing for this, I thought about just someone that's like, wants to go on an adventure. And I would say that for the average American, that may be considering going to Europe, I think that you should do it. Like your life is short. We should all go on an adventure and enjoy ourselves. And part of the adventure is there is always an element of danger, but in places where you know that things are pretty reliable and stable, you're going to be able to find the things that you need very much similar to here and then you come home with an interesting story. If you're going with a group, say for humanitarian reasons, just try to prepare as best you can in advance. Like we mentioned, you know, go off the biologic for a while. So you can get your vaccines. Invest in protective clothing. Consider again a travel insurance policy, and presumably if you're listening to this podcast, you probably are interested in traveling. And just a parting word about life. I think that they've shown that at the end of lives, people don't regret the things that they did do. They regret the things they did not do, and so if you're worried about things and you're really afraid, try to pick something that fits within your own risk tolerance level. But you know, I love traveling. I live for traveling and I'd say like you may as well take a chance and enjoy it. Life is short. Try to enjoy it the best you can.

Kaitlin: That's so true. Thank you so much and I agree and echo those words and just because we have psoriasis or PSA, we can be free to experience life at its fullest.

LB: Exactly, yeah.

Rosemary: Amen.

LB: Well, thank you Rosemary, for being here with us today.

Rosemary: Sure thing. Thank you.

LB: I've loved all the tips you provided and hope our listeners learn tips to help them feel like they can travel safely with fewer issues by planning ahead and taking some precautions.

Rosemary: Thank you for having me. I appreciate it. Ciao.    

Kaitlin: Thank you again from all of us here and for our listeners. If you need help finding a dermatologist and rheumatologist or are looking for more information about treatment options, contact our Patient Navigation Center at education at psoriasis.org. And finally, thank you for listening to Psoriasis Uncovered.

We hope you enjoyed this episode of Psoriasis Uncovered for people living with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through our podcast you’ll gain information that inspires you to lead a healthy life and look to the future. Please share the episode link if the content in today’s episode will benefit someone you know.

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