Eric Metcalf, MPH
Louise Chang, MD
To describe his battle against psoriasis, Alan Eisenberg likes to quote John Paul Jones, the famed Revolutionary War mariner: “I have not yet begun to fight.”
For six years, the Portland, Ore., resident has been trying treatments for his skin condition. Methotrexate helped his nails, but didn’t cure the skin outbreaks. He says the prescription drug Enbrel worked for six months, then lost its effect. Another drug gave him hives. Yet another worked better, but put him at risk of infections. He had to stop using it when he had a hip replaced due to arthritis related to his psoriasis.
Still, the retired bus driver and union organizer keeps a sense of humor, joking as he reels off the highlights of his fight against the autoimmune disease.
In most cases, doctors can find a treatment that brings this disease under control, several psoriasis experts told WebMD. But the process can take trial, error, and time.
“A huge part of the first visit with patients is breaking the good news and bad news to them. The bad news is they have a chronic disease that is incurable. The good news is there are many treatments available to keep it under control,” says Andrew Blauvelt, MD, of the Oregon Health and Science University in Portland.
“The goal of therapy is to hit on something that works and is safe, and it sometimes takes several tries to find something that works for an individual without side effects,” he says.
During psoriasis, a person’s immune system acts up, causing skin cells to grow at a faster pace. This causes red patches, which may be rough and scaly. The disease is caused by different genetic glitches in different patients, says Blauvelt, a psoriasis expert who, like the other doctors quoted in this story, has done work on behalf of pharmaceutical companies. Not only does a person’s genetic makeup determine how the disease shows up, it also plays a role in whether treatments will work or not.
“Each person’s response is really individual and different,” says Abby Van Voorhees, MD, of the University of Pennsylvania Health System in Philadelphia. Doctors can offer about a dozen treatments, she says. “I caution my patients that while the first one might not be successful, they really need to hang in there. Most often we can find a modality that will work.”
When deciding which treatment to try first, a doctor will consider how much of your body is affected by outbreaks, says Lawrence Green, MD, a dermatologist in the Washington, D.C. area and a trustee of the National Psoriasis Foundation.
If just a small amount of skin is involved, you may be able to use a topical treatment, such as applying medicine to your skin. If more than 5% of your body is covered with outbreaks, you may need systemic therapy (treatments that go throughout your body, such as pills or injections). (The palm of your hand is the size of about 1% of your body’s surface area, Blauvelt says).
Other signs that suggest you may need a systemic approach include:
You play a role in the success of your treatment. So while you’re seeking a drug that will bring your psoriasis under control, the experts who spoke to WebMD suggested these strategies:
Depending on the treatment, you may need one to three months before the drug starts working, Van Voorhees says. Be sure to ask your doctor how soon you might notice improvement, and how you’ll be able to know if the treatment is helping, she says.
“There’s not a treatment that allows you to take a pill once and make psoriasis go away, like treating an infection with an antibiotic,” Van Voorhees says. If your treatment is to rub steroid medicine onto your skin, you may do it several times a day until your lesions have dwindled away, then hold off on further treatment until they start to return, Blauvelt says. You’ll then continue this cycle indefinitely.
Be sure to stick with your treatment, even when your skin starts looking better, Van Voorhees says. “When their skin is looking good, sometimes patients get more casual, and they need to remain conscientious about continuing their treatments.”
If your disease requires medicine that you put into your body, seek out a skin doctor who has a special focus on psoriasis, Blauvelt says. “The care of patients on systemic therapies can become complicated, and it’s probably best done by those with experience with newer medications,” he says.
In general, people with psoriasis are happy to use their medicines as directed, Green says. But if your doctor prescribes a treatment that’s hard for you to use, you’ll be more likely to drift away from it, and your disease can return.
Be sure your doctor gives you a treatment that suits your lifestyle. If you travel often, needing a UV light several times a week may not be a good choice, says Green, who has had psoriasis since he was a teen.
Your insurance company may want you to first try an older treatment that’s cheaper. For example, “Methotrexate is often a first-line systemic therapy for psoriasis, but it’s only 30% to 40% effective and has potential serious side effects," Blauvelt says. "Often it’s used first, because it costs about $500 a year, where newer, more effective treatments that go into the 80% effective range are around $20,000 a year."
"I encourage my patients to work on managing their stress levels, getting enough sleep, and eating a balanced diet. Most people think that psoriasis is made worse by stress. So anything patients can do for themselves is certainly helpful,” Van Voorhees says.
And by reaching out to others with psoriasis through a group such as the National Psoriasis Foundation (NPF), you can pick up more ideas on how to deal with the effects of the disease, Green says.
Eisenberg, 63, relies on meditation and music to help him stay relaxed and to reduce his chance of flare-ups, and he stays active with the NPF. “Try to deal with it and ask your doctor questions,” he says. “You’ll learn that there are no silver bullets. If you luck out finding a treatment that works, you luck out. But if one thing fails, I myself have learned to not give up hope.”
SOURCES:Alan Eisenberg, Portland, Ore.Andrew Blauvelt, MD, director, Center of Excellence for Psoriasis and Psoriatic Arthritis, Oregon Health & Science University, Portland.Abby Van Voorhees, MD, associate professor, University of Pennsylvania Health System, Philadelphia.Lawrence Green, MD, dermatologist, Rockville, Md.National Psoriasis Foundation: "Learn About Psoriasis."
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