Parental concerns for teens with severe acne are driven by worry about emotional and physical impact. Acne vulgaris is the most common dermatologic condition in adolescents and can considerably impact their emotional health. To learn more, view the PDF.
By: Richard G. Fried, MD, PhD
Life is a dangerous and unpredictable endeavor. Sadly, in the end, no one gets out alive. Prior to Covid-19, most of us consciously or subconsciously made peace with the reality that life comes with risks that cannot be completely obviated. Attempts to decrease our risks such as healthy eating, regular exercise, weight control, moderation in indulgences, safe driving, medication adherence, and avoidance of people and places that are known to be dangerous provide for us a sense of control. These “healthy and smart” behaviors have been statistically proven to decrease the probability of premature illness and death. We believed that we were mitigating risk. Sadly, in addition, there was always a concomitant threat to our wellness and viability. Viral, bacterial, fungal, and parasitic infections have been well known threats for many millennia. With the advent of the Internet and the plethora of information sources available, we regularly heard warnings and horror stories about hepatitis, HIV, meningitis, Zika, Ebola, SARS, MEARS, Herpes, gonorrhea, chlamydia, flesh eating Strep, MRSA. Somehow, most of us maintained our equilibrium prior to COVID-19. We managed to assimilate these threats in such a manner that allowed us to engage sufficiently with others in order to work, maintain our family relationships and functioning, sustain and nurture our friendships, and engage in recreational activities without undue or overwhelming fear and anxiety. Now, things are different. As we contemplate and navigate re-entry into our “previous lives”, examination of our risk tolerance consciously or subconsciously is mandatory.
Disengagement-isolation risks. In the early months of the Covid pandemic, the mandated forced quarantine literally overnight ripped people away from their jobs, families, friends, houses of worship, and recreational activities. It was in many ways analogous to being kidnapped and held hostage. For many, the emotional sequelae were very severe including debilitating anxiety and depression accompanied by feelings of anger, helplessness, hopelessness, confusion, and desperation. For some, as time passed, they responded to COVID-19 and its imposed human losses in emotional stages of grief analogous to those described by Elizabeth Kubler-Ross in her book on death and dying denial, anger, bargaining, depression, and acceptance. I believe that across the globe, it appears that many individuals are still progressing through these stages. Those who have successfully arrived at an emotional place of acceptance may be best suited to deal with their re-engagement into society. However, for others, arriving at emotional acceptance may be analogous to acquiescing to their COVID-19 capture and imprisonment, losing the drive for freedom. Clinically, this may be manifest by an apparent apathy. Many may have forgotten the simple joys of human contact and desires for it have been subjugated to ongoing fears and inability to even imagine taking the “risk” of re-engagement.
The early work of Spitz during the second world war with orphaned children who were unexplainably wasting away despite being fed led to the concept of “failure to thrive”. Once human contact was reestablished during the attention and physical handling that occurred during their evaluations, these children reversed their physical deterioration and began to thrive. The present geriatric literature is replete with similar deteriorative occurrences with isolation and/or loss of a loved one.
How many have been unable to see their parents, children, grandchildren, friends, coworkers, co-exercisers, waiter or waitress, grocery store cashier? A looming and distressing question is how much isolation, for how long, and in whom, until there is irreparable damage done to the psyche, body, family, friends, and vocational viability?
Contemplating re-entry. The occurrence of the COVID-19 pandemic has forced every one of us to re-examine and potentially redefine our risk tolerance. How safe must the world be before we reengage with the people, places, and activities that previously defined our lives. Both personally and professionally, most of us have observed a wide range of perspectives and behavior. We have seen via remote telemedicine those who have not left their homes since March 2020, unwilling to take any perceived risk of acquiring Covid and its potential ravages on themselves and their family members. At the other end of the spectrum, there are those who deny the existence of Covid and have not curtailed their behaviors one iota since the beginning of the pandemic. As each day passes and the numbers of vaccinated persons increase, returning carefully and abiding by CDC recommendations will likely be a relatively safe endeavor (unless a resistant and more virulent Covid 19 variant occurs).
Risk tolerance during reentry from Covid captivity. Obviously, no matter how we redefine our risk tolerance, a “risk-free” life is not an attainable goal. Even if we stay confined to our own place of shelter and isolated lives, there are risks. Fire, carbon monoxide poisoning, burglary, falls, and meteorites crashing through the roof occur. Aspiration, myocardial infarction, fatal arrhythmias, cerebrovascular accidents, and ruptured aneurysms can and do occur. Thus, we are not necessarily “safer” living isolated from the outside world. Hugs, smiles, breaking bread with others, scintillation of the visual-auditory-gustatory-olfactory-tactile senses, all are hallmarks of meaningful engagement in life. Perhaps it can be stated succinctly: do we wish to “exist in life or live our life”. Human connectedness extends the quality and length of our lives. The pace and extent of re-entry into the outside world is a difficult and nuanced process for each of us. For some, “existing” in a largely isolated place removed from others with perceived personal safety is sufficient. For others, existence without engagement is intolerable. It is my sincere hope that each of us choose our re-engagement strategies carefully and judiciously allowing reasonable protection for ourselves and others. I also wish to assure you that with gradual re-engagement, your comfort level will return allowing you to find a “new normal”, which may or may not include contagion precautions that were not part of your pre-Covid 19 life.
I urge you to not be disheartened by the ubiquitous chants stating that “things will never be the same”. This is a truism as it always has been. Historically, as time and life move on, things change both for the better and worse. Fear not, change is good and can be exhilarating for the mind and the body! Take a deep breath, look out your literal and metaphorical window. Carefully contemplate what are you willing to “risk” for your sustenance and happiness today and tomorrow.
You obviously have survived today’s perils associated with venturing out of your bed and carrying out your morning routine and the necessary activities of the day. All other events and endeavors are relegated to your “daily possibility plate” for contemplation. Please remember that all of today’s contemplative decisions are not etched in stone. Each step during the reentry often does not necessarily “feel right” at first. And then before you know it, these steps feel natural and liberating. Please recall and be assured that the mind, body, and psyche have an amazing ability to bring us back to a comfortable place of health and happiness. Allow me to reiterate, life is a risky business. May each of us safely dip our toes, noses, and hearts into the post COVID-19 world of opportunity and reengagement.
You may be a candidate for treatment with PRP, an innovative new therapy which uses your body’s own natural growth factors to stimulate hair growth. For more information read the article below, and feel free to schedule a consultation in our office (215) 579-6155).
Platelet Rich Plasma for Hair Loss
According to estimates from the National Institutes of Health, androgenic alopecia affects 30 million women and 50 million men in the United States.1 Oral finasteride and topical minoxidil comprise the currently approved non-surgical therapies for this condition. However, finasteride has been linked to undesirable adverse effects and is not indicated for female patients, and the long-term required daily use of minoxidil can become burdensome.2
These limitations underscore the need for additional treatment options for androgenic alopecia. Emerging research suggests that platelet-rich plasma (PRP) — an “autologous solution of plasma prepared from a patient’s own blood…. containing 4 to 7 times the baseline concentration of human platelets” — may be effective for this purpose.3 Some providers are already offering PRP in clinical practice and its popularity as a hair restoration therapy is growing.2
“The secretory α-granules within platelets release various growth factors…. [that] …induce tissue regeneration, collagen formation, re-epithelialization, and angiogenesis,” according to a 2018 review of PRP research.4 The investigators reported positive results for PRP as a treatment for androgenic alopecia, as have several other reviews and meta-analyses.,6
A 2018 meta-analysis by Gupta, et al, focused on studies in which PRP was directly injected into the scalp of human patients and that used quantifiable measures of treatment success (in this case, hair density).2The final analysis, based on 4 studies with a pooled sample of 60 participants, revealed an overall standardized mean difference of 0.51 (95% CI, 0.14-0.88; I2 = 0%) in favor of PRP compared with baseline.
In another meta-analysis published in the Journal of Cosmetic Dermatology in 2018, the investigators examined 6 studies (pooled N=177) describing quantitative outcomes of PRP vs controls in the treatment of androgenetic alopecia.7 Compared with the use of control treatments, PRP was associated with significant increases in hair number per cm2 (mean difference [MD], 17.90; 95% CI; 5.84-29.95; P =.004) and hair cross-section thickness per 10−4 mm2 (MD 0.22; 95% CI, 0.07-0.38; P =.005).
Across studies, PRP was linked to minimal adverse events and high patient satisfaction.2
Original article can be seen here
Yardley Dermatology’s Richard Fried, MD PhD takes the microphone on ‘Doctor Radio’ – NYU Medical Center’s Health and Wellness Channel with Dr. Evan Rieder. They discuss cosmetic treatments, sunscreen, eczema, and more. Listen to a 1 minute clip or the full episode below.
Listen to a short audio clip (01:07) of Dr. Fried’s interview:
Listen to the entire episode (53:12)
Yardley Dermatology Associates is proud to announce our very own doctors as winners in the Philadelphia magazine Top Doctor™ 2019
Dermatology – Dr. Rick Fried, M.D., PhD.
Dermatology – Dr. Fern Fried, M.D.
by Maryanna S. Phinn
People with skin and dermatologic disorders, from common to complex, chronic to rare, or cosmetic to age-related, often describe how the condition can negatively affect their daily life until it is successfully treated, managed or resolved.
Yardley Dermatology Associates and Skin Enhancement Center cares for patients of all ages with skin problems of any kind to greatly reduce or eliminate the impact skin conditions frequently have on a person’s emotional and psychological well-being.
“One of my areas of expertise is the interface between the skin and the mind,” explains Rick Fried, MD, PhD, a board-certified dermatologist and clinical psychologist.
He founded the practice with his wife, Fern Fried, MD, who is board-certified in internal medicine and dermatology and specializes in acne treatment, cosmetic dermatology and skin rejuvenation.
“It has been known for many decades now that many common skin problems are made much worse by stress. Conversely, living with many common skin problems can be very stressful,” he notes. Examples of common skin problems may include acne, psoriasis, rosacea, hives, eczema, allergies, fever blister outbreaks or skin cancer. Other skin problems are categorized as” life spectrum” disorders such as wrinkles, brown spots, warts, spider veins, moles, unwanted growth, or changes in the skin’s feeling, appearance or sensation.
“Our practice has maintained from day one a more holistic approach. We don’t see the ‘rosacea patient.’ Rather, we see the person who happens to have rosacea. What distinguishes us from other dermatologic practices is that holistic philosophy. In our practice, the person matters and what matters to that person is important to us too. We’ve been enormously fortunate in that all of the clinicians that have joined us are like-minded,” he says.
The clinical staff includes eight board-certified dermatologists providing medical and surgical treatment for most skin, hair and nail disorders. The practice also has two certified physician assistants specializing in dermatologic conditions and two licensed medical estheticians trained in skin care and cosmetic treatments including laser. The medical staff and physicians regularly participate in formal peer presentations, equivalent to “Grand Rounds” at major medical centers, as an interactive approach for sharing expertise and emerging treatment options and as an added benefit and service to their patients.
Yardley Dermatology Associates is a major outpatient surgical center in Bucks County for patients requiring Mohs Micrographic Surgery, an advanced surgical technique for treating skin cancers including squamous cell and basal cell carcinomas.
As an active clinical trials center, Yardley Dermatology Associates participates in ongoing research studies for acne, psoriasis, rosacea and cosmetics such as injectable fillers and Botox. The physicians and clinical staff also train medical students from local academic medical centers.
“We incorporated clinical trials and clinical teaching into our practice as a way to stay well-informed and experienced with the latest medical and surgical treatments, advanced technologies and therapeutic approaches,” Dr. Fried says.
Yardley Dermatology Associates was recently recognized by the Bucks County Courier Times as “The Best of Bucks” Dermatology Practice in 2018.
“It is a very comfortable place for us to work together because we all do what we are passionate about. It is an exciting time right now with the major advances being made in treating skin cancer, psoriasis, rosacea, eczema and skin rejuvenation. We love our work and we love caring for our patients and their families. We’ve cared for several generations of families here. Our patients are just wonderful people,” Dr. Fried adds.
Yardley Dermatology Associates is located in Yardley at 903 Floral Vale Professional Park.
The Mohs Surgery Center is located at 803 Floral Vale Professional Park. Office hours are Monday and Tuesday 8:00am to 7:00pm, Wednesday 8:00am to 4:00pm, Thursday 8:00am to 6:00pm, and Friday 8:00am to 3:00pm.
For more information or to schedule an appointment, call 215-579-6155. To contact the Mohs Surgery Center for information and appointments call 267-759-6240.
Both clinicians and patients living with psoriasis know that the chronic and capricious disease can have deleterious effects on the psyche. The literature is replete with studies that substantiate the contention that psoriasis has negative effects on the way patients feel and function. Depression, anxiety, anger and feelings of futility and helplessness are commonly reported by those afflicted with psoriasis. They are often sad, mad and anxious about the way their skin looks, feels and behaves. Pruritus, burning, pain and other dysesthetic symptoms are frequently reported. The unpredictable nature of flares leaves patients feeling vulnerable and lacking in control, a combination fraught with opportunity for psychological pain. In addition, from a functional perspective, psychosocial and vocational impairment are more commonplace among psoriasis patients. New research elucidating the medical comorbidities including coronary artery disease and diabetes further burden those with psoriasis with a Damocles-like harbinger of future medical illness.
The utility of an article on the negative psychosocial issues associated with psoriasis is not simply to substantiate their existence. In some ways that would be akin to validating the assertion that a group of patients have debilitating pain with ambulation but offering no suggestions for intervention or amelioration. This article provides several concrete suggestions to help clinicians and patients to enhance their emotional well-being and clinical outcomes.
Therapeutic Alliance-Mutual Development Agreement
There is little doubt that a therapeutic alliance characterized by patient belief that their clinician is competent, caring, understanding and compassionate increases the likelihood of medication adherence, positive therapeutic outcome and patient satisfaction. This is quite a tall order to accomplish in the brief minutes allotted in the typical patient encounter.
A few key ingredients necessitating little elongation of the actual encounter can often be efficacious in achieving this therapeutic alliance coveted by most patients. A smile, a few seconds of eye contact and the physical touch of a handshake are crucial elements to initiate the cascade of acceptance and warmth desired by both clinician and patient. Simple and clear empathic statements such as “I know living with psoriasis can be very difficult” or “I am sure it must be very frustrating and upsetting at times to deal with the demands and intrusions of psoriasis” can be extremely effective in exhibiting to patients that you are sensitive and understanding and that you are one of those doctors who “get it.”
A very brief explanation of the pathogenesis of psoriasis accomplishes several things. It substantiates for the patient that you are indeed an up-to-date psoriasis expert and also that you view them as intelligent enough to be offered an explanation of their disease. Quickly explain that it is known that psoriasis is a condition where molecules called cytokines are released in the skin causing the skin cells to turn over at a much more rapid rate than normal causing elevation, redness and flaking.
The clinician might say, “These molecules with odd sounding names such as tumor necrosis factor, interleukin 17, interleukin 23 and many others specifically instruct your skin to misbehave in this fashion. We have learned so much about psoriasis, but still have to figure out why it is happening in these spots in your skin. The good news is that we have so many effective, new and emerging treatments for psoriasis that alone or in combination are better than ever.”
This can help provide a better understanding of what is happening in their skin together with an optimistic outlook for their future. Mission accomplished! When well-rehearsed, this entire process takes approximately 2 to 3 minutes. To borrow an advertising slogan from a clothing retailer, “an educated consumer is our best and most satisfied customer.”
Cognitive behavioral psychologists and psychiatrists contend that “self-talk” is a more important determining factor of how we feel then the actual objective events in our life. Self-talk is the ongoing internal dialogue or what I call the “background noise” that is ever-present throughout our waking hours.
“Catastrophizing” self-talk such as “it would be awful,” “I can’t stand it when,” “it is horrible” and “it is the most horrible thing that could happen to me” are the cognitive perpetuators of negative feelings, negative interpretations and psychosocial impairment. These “awfulizing” and “catastrophizing” proclamations are repeated over and over internally and often become integrated as mantras leaving no room for other interpretation. Specifically, a common internal mantra of “I can’t stand it when I have psoriasis on my elbows, it is awful, it controls my every moment and ruins any chance at happiness that day” is indeed a rigid prescription and near guarantee that the occurrence of psoriasis for that individual will “ruin” their likelihood of experiencing happiness or pleasure. This can be an unrecognized self-imposed punishment.
While I recognize that the dermatologic clinician is not a cognitive behavioral psychotherapist in the usual structured and organized fashion, I do believe that we do have the power to modify the severity of this “self-defeating self-talk.” Most of us recognize that actions can speak louder than words. For example, gently touching or stroking a psoriatic plaque while examining the patient is a huge psychocutaneous intervention. Simultaneously, explaining that the vitamin D analog or topical corticosteroid that we are prescribing will slow their skin cells down and reduce inflammation conveys a powerful message of acceptance and can help diminish the patients’ feelings that they are ugly or even repugnant to others. Providing samples or a prescription for higher potency corticosteroid for “angry skin days” can enhance feelings of control and decrease anxiety. Telling patients that they have the opportunity to schedule an “emergency visit” for intralesional triamcinolone injection provides additional feelings of control and hope that can be used to internally refute the pessimistic and doomsday self-talk.
Encouraging dialogue and sensory exchange through “skin talk” can be an interesting idea for the patient and therapeutically useful. Application of topical medications is often distasteful for patients. It is a time intrusion, sometimes cosmetically messy and most of all forces patients to face their psoriasis plaques. “Out of sight out of mind” is often a preferable strategy (albeit ineffective unless receiving ultraviolet (UV) light or systemic therapy). Skin talk during topical application involves asking patients to silently repeat a new mantra consisting of 3 words: allow, restore and refresh. Using an analogy of rebooting the computer when it is misbehaving, the gentle strokes and effective ingredients within their topical preparation can allow the skin cells within a given plaque to restore and refresh their proliferative activity to a more normal rate. I have often asked patients to be a bit less judgmental and be a bit nicer to their skin. The few seconds of gentle touch during application do in fact allow for some degree of therapeutic touch and self-acceptance.
Concrete, reality-based self-talk regarding emerging therapies and improved efficacy of existing treatments can further diminish negative self-talk, negative emotional reactions and decrease inflammatory physiologic stress reactions.
Explanatory euphemisms for psoriasis also can be helpful for both the patient as well as others who are unfamiliar with the disease. “Fast skin, runaway skin, excited skin, happy skin, too comfortable to flake off skin and snowflake skin” are a few of the explanatory euphemisms I have heard patients use to alleviate the anxiety of others. I used to believe these were only helpful for children, but am now convinced they can be helpful for adults as well.
When suggesting these euphemistic descriptors to patients, I make it clear to them that I am not minimizing nor diminishing the seriousness of their skin problem. It does both directly and subliminally reinforce that psoriasis is not a premalignant, malignant, infectious skin disease and they are entitled and need human touch (their own and ideally others).
Modulation of Dysesthesias
Troubling, subjective dysesthetic symptoms accompany the clinically objective lesions of psoriasis in some patients. These dysesthesias are intrusive in their own right, but also represent a source of anxiety for some patients; they are fearful or interpret them as signs of infection, infestation or malignancy. Asking patients about the presence, type and severity of dysesthesias is important. Assuring them that they are common and not harbingers of illness can sometimes diminish the severity and intrusiveness of the symptoms by simply allowing them to become less preoccupied and defocus their attention from the sensation.
Further, providing topical or oral agents to ameliorate this instance such as topical corticosteroids, topical calcineurin inhibitors, lidocaine cream, topical doxepin, topical amitriptyline, oral antihistamines, oral doxepin, oral amitriptyline, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors and antiseizure medications can be important and helpful.
Stress management techniques and interventions have been shown to benefit psoriasis patients. Improvements in clinical outcomes and quality of life have been consistently demonstrated. Specifically, they are believed to diminish the inflammatory response via both central and peripheral effects. These interventions can be conceptualized as “steroid sparing” and “UV sparing” modalities because studies have demonstrated decreased steroid use and reduced total UV exposure when modalities, such as mindfulness meditation, progressive muscle relaxation, cognitive behavioral psychotherapy, yoga, tai chi and biofeedback have been used as concomitant complementary therapy.
In previous decades, these interventions were believed by many simply to be “feel good interventions” making patients feel better and thus, have the focus, energy and sufficient degree of optimism to adhere to their medical regimens. However, their usefulness and efficacy is now better understood to be a combination of self-regulation, insight, cognitive restructuring and physiologic training, together with the direct modulation of the inflammatory cascade.
Exploring the Landscape
Many patients are confused, overwhelmed and cynical regarding their short- and long-term prognosis. They are frequently fearful of treatments and tired of the emotional roller coaster of elevated hope and expectation followed by clinical disappointment or recurrence. Leaving the therapeutic encounter with 2 prescriptions can be daunting. Suppose they are minimally effective or even make the psoriasis worse? Is the patient then left with the assumption that this was the last hope and they are now doomed to a lifetime of worsening and crippling psoriasis? This scenario can be easily avoided with a simple brushstroke painting the landscape of therapeutic opportunities. Assure them that this landscape is replete with effective, gentle and new treatments that can be used to help them reach their satisfaction threshold of clinical control.
For some, that threshold is a Psoriasis Area and Severity Index 75. For others, it is control of pruritus or minimization of visible lesions on the dorsum of the hands. This assurance of options and adequate control of disease is a significant gift for many patients. The heartfelt belief and reassurance that we will be there to hold and guide their hands through the plethora of therapeutic choices is a powerful intervention in its own right.
The negative psychological sequelae of psoriasis are well-recognized and appreciated. The reciprocal interaction of skin and psyche is better understood and support the incorporation of psychocutaneous techniques into clinical practice. It can be argued that all clinician–patient interactions have psychocutaneous components and repercussions. Using simple behaviors, targeted comments and specific treatment recommendations can improve subjective symptoms, clinical expression of psoriasis and quality of life.
Dr. Fried, who is a psychologist and dermatologist, is clinical director at Yardley Dermatology Associates in Yardley, PA.
Disclosure: The author reports no relevant financial relationships.
Sidebar: Doctor–Patient Relationship Impacts Psoriasis Outcome
Sabrina Skiles, 30, of Houston, TX, talked to The Dermatologist about her psoriasis journey. “I was diagnosed with psoriasis in 2001 when I was a junior in high school. I knew a little about the disease because my mom had it. She was diagnosed at the same age I was,” she recalls.
When psoriasis first appeared on her elbows, Sabrina researched dermatologists who specialized in psoriasis in Houston and then went for her appointment. “It was great to have the dermatologist sit down with me and explain the disease and how it was affecting my immune system. She explained the current treatments that were available at the time,” she says.
Soon after seeing the dermatologist, the psoriasis spread to about 90% of Sabrina’s body. On her doctor’s recommendation, Sabrina began using tar baths for her entire body. “Although it was messy, it was very helpful and it worked. It cleared my entire body and it is very rare to find something that works this well,” she says.
Remission lasted for several years, with periodic flare-ups brought on by the stress of college. “My dermatologist then suggested biologics. I educated myself and I wasn’t too crazy about the side effects. I tried it for about 5 months and it pretty much cleared me. Then I stopped using them because of a change of insurance,” she explains.
While Sabrina experienced a period of remission, she moved to Maui, HI, in 2009 with her husband. “I had known that the environment has a lot to do with psoriasis, and so I was encouraged to know that the sun and environment would hopefully be helpful and it was. I didn’t see any flare-ups or triggers in Maui,” she says noting that she did not use many treatments while on the island.
In 2012, the couple moved to Seattle, WA. “Within 2 months of living in Seattle, I had a flare-up. I was stressed. I didn’t have a job. It was cold and rainy and I started making notes that environment was a big effect for me,” she says.
Sabrina located a Seattle dermatologist who specialized in psoriasis and she suggested light therapy for her severe scalp psoriasis. “Within a few weeks of the light therapy, I was almost 90% clear of the scalp psoriasis. I was a completely different person and it was just great to talk to her,” she says.Sabrina now lives in Houston and her most recent dermatologist has suggested she restart light therapy. “I am excited to try that again,” she says.
Overall, Sabrina explains that it was key that the dermatologist took the time to ask what treatments she had been on before, how happy she was with the treatments and what she wasn’t happy with. The dermatologist asked about quality of life. “I realized it is important to be really open with my doctor — what kind of stress I am under, any big event in my life and quality of life,” she says.
1. Kimball AB, Jacobson C, Weiss S, Vreeland MG, Wu Y. The psychosocial burden of psoriasis. Am J Clin Dermatol. 2005;6(6):383-392.
2. Scharloo M, Kaptein AA, Weinman J, Bergman W, Vermeer BJ, Rooijmans HG. Patients’ illness perceptions and coping as predictors of functional status in psoriasis: a 1-year follow-up. Br J Dermatol. 2000;142(5):899-907.
3. Han C, Lofland JH, Zhao N, Schenkel B. Increased prevalence of psychiatric disorders and health care-associated costs among patients with moderate-to-severe psoriasis. J Drugs Dermatol.2011;10(8):843-850.
4. Vanaclocha F, Belinchón I, Sánchez-Carazo JL, et al. Cardiovascular risk factors and cardiovascular diseases in patients with moderate to severe psoriasis under systemic treatment. PSO-RISK, descriptive study. Eur J Dermatol. Published online ahead of print October 21, 2014.
5. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735-1741.
6. Takeshita J, Wang S, Shin DB, et al. Effect of psoriasis severity on hypertension control: A population-based study in the United Kingdom. JAMA Dermatol. Published online ahead of print October 15, 2014.
7. Sommer DM, Jenisch S, Suchan M, Christophers E, Weichenthal M. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res. 2006;298(7):321-328.
8. Hunter HJ, Griffiths CE, Kleyn CE. Does psychosocial stress play a role in the exacerbation of psoriasis? Br J Dermatol.
Many people with psoriasis know from personal experience that depression, anxiety and other mental health issues often go hand in hand with this inflammatory disease.
For many years, explains dermatologist and psychologist Rick Fried, M.D., Ph.D., both clinicians and patients thought they understood why.
“People are living with a condition that is often very physically uncomfortable, limits physical activities and intimacy, and can result in sufferers being stigmatized, bullied, and otherwise discriminated against. So, it makes intuitive sense that the potential for anxiety and depression are much higher because of the realities of living with the social and physical burden of the illness,” says Fried, clinical director at Yardley Dermatology Associates and Yardley Clinical Research Associates in Pennsylvania.
Mounting evidence points to an additional reason, a “second hit to the psyche,” Fried says that underscores how critical it is to get adequate treatment for psoriasis, a disease in which under-treatment is “epidemic.”
Inflammation is the culprit
“In people with psoriasis, certain inflammatory cytokines, such as tumor necrosis factor and various interleukins, are elevated; we see a remarkably similar increase in these inflammatory cytokines in depression,” says dermatologist and psychiatrist John Koo, M.D., professor in the Department of Dermatology at the University of California, San Francisco Medical Center.
Cytokines are proteins involved in the inflammatory process of the immune system.
Koo and his colleagues reviewed the raft of evidence for this “cytokine theory of depression” in a 2017 Journal of the European Academy of Dermatology and Venereology (JEADV) article. They concluded that ongoing systemic inflammation likely causes physiologic and biochemical changes that drive the development of depression and other mood disorders.
“These inflammatory cytokines cross the blood-brain barrier,” explains Fried. “In the brain, they send biochemical messages that deplete neurotransmitters such as serotonin, norepinephrine and dopamine, which are intimately involved in our ability to think, to act, to feel, and to function.”
Treatment is the answer
Biologics, which target and block specific inflammatory cytokines, may have a direct biochemical effect on depression.
“By blocking these inflammatory cytokines and calming inflammation, you are changing the cytokine profile for the better – not just in the skin, but in the brain,” says Koo. “In clinical trials of biologics, investigators commonly report that participants with severe psoriasis often experience significant improvements in mood even before you can see any visible difference in their skin.”
A 2015 JEADV review found treatment with biologics significantly decreased depressive symptoms in people with moderate to severe psoriasis. Similarly, a study published in Medicine in 2016 found people with psoriasis experienced lowered rates of depression and insomnia after treating with biologics. Participants also decreased their rate of antidepressant use by 40 Percent after two years.
Therapies such as phototherapy and conventional systemic medications also decrease body-wide inflammation.
“As long as the treatment is adequately treating the person’s psoriasis – so that they have minimal to no symptoms – it should help the mind as well as the body,” says Koo. “When people are treated adequately and aggressively for psoriasis, their depression often goes away.”
Treating “adequately and aggressively” is the goal of NPF’s Treat to Target initiative, which aims to reduce psoriasis to no more than 1 percent of body surface area after three months of treatment. But this goal remains a challenge for far too many.
“Topicals are overused for psoriasis patients, many of whom need potent systemic therapies, not only to treat their skin disease, but also to lower the risk for the many conditions that occur more often in people with untreated chronic inflammation, including diabetes, cardiovascular disease, heart attack, stroke, and obesity, as well as depression,” says Koo.
Koo and Fried advise psoriasis patients who aren’t satisfied with their treatment to discuss more aggressive therapeutic options with their dermatologist. “Many dermatologists are still uncomfortable using biologics despite their effectiveness and safety. If you encounter this, you should seek a second opinion,” says Koo.
“There are safe and effective medications for psoriasis that will make you feel and function better on a day-to-day basis and will decrease the likelihood of some of the real and potentially devastating and life-threatening effects of untreated disease,” Fried adds.
Talk to your health care provider
An open conversation will help you and your provider determine the best treatment option. To get ready, you should first assess how psoriasis impacts your life. Take our quiz to find out.
As many of you are aware, prices for brand name and generic drugs have both skyrocketed over the last few years. Your providers at YDA are doing their best to make sure that you have access to the most effective medicines at an affordable price. This can be difficult since often only your pharmacist has access to the list of drugs covered by your insurance, (your formulary) and their prices.
Please let us know immediately if you are told by your pharmacist that a given medicine is unavailable or unaffordable. We can often substitute another similar medicine which is covered, or provide you with samples if the pharmacy is out of stock.
Here are some tips for helping to keep your drug cost down:
- Let us know if you have no drug plan, a high deductible, or you are in the “doughnut hole” with Medicare.
- If your insurance plan makes your drug formulary available, (under Dermatology, skin or topical medicines), please print out a copy and bring it with you to your appointment so we can choose a drug that is covered.
- Shop around for lower drug prices (see table below).
As you can see, there can be a more than tenfold difference in the cost of a given generic depending on which pharmacy you choose. For more information, go to the article in the 04/2018 issue of Consumer Reports: https://www.consumerreports.org/drug-prices/shop-around-for-better-drug-prices
- You can also look for the lowest pharmacy prices in your area at GoodRx.com, or try an online discount pharmacy such as healthwarehouse.com.
- For certain medicines, the out of pocket cost may be less than your insurance co-pay. Ask your pharmacist for the “cash price”.
- If you are over 65, a PA resident and have an income of less than $23,000 (single) or $31,500 (married) you may be eligible for PACE or PACENET which offers most medicines at very low cost. For information, call 1-800-225-7223 or visit https://pacecares.magellanhealth.com/
- We have a small number of inexpensive generic dermatology medicines available for purchase in our office. Ask your provider if one may be appropriate for you.