Beyond Psoriasis

Back in 1963, the first commercials on television came out for a coal tar product named Tegrin. It was a coal tar preparation made to combat “the heartbreak of psoriasis.” The commercials have graduated to include stars (singer Cyndi Lauper among them) and biological treatments that go far beyond topical use. While psoriasis is generally a benign (if not inconveniencing and troubling) skin condition that has little mortality complications, both an extension of the disease into a systemic component and the use of medication that has significant potential side effects have to be evaluated and monitored aside from the skin component of the disease itself.

Psoriasis is a common inflammatory skin condition that is characterized by bright red plaques, generally looking like silver scales, and most often present on elbows, knees and scalp. Its major symptoms are itching and sometimes bleeding from the lesions if scratching is too intense. Psoriasis may take several forms, from the common plaque type to the eruptive type (called guttate psoriasis) to actual life threatening forms (generalized pustular psoriasis, fortunately rare). The diagnosis is generally a simple one made by a trained dermatologist.

Treatments of limited disease were with coal tar preparations, topical corticosteroids, or ointments which contain Vitamin D analogs. More moderate disease was often amenable to Ultraviolet light phototherapy. Generalized disease (more the “heartbreak” type) was treated with photochemotherapy and drugs originally used in the diagnosis of cancer or neoplastic disease (like methotrexate) which helped reduce skin turnover and the severity of scaling. The drugs however had significant side effects (long term methotrexate for instance was associated with the development of liver cirrhosis) and this mode of therapy is now rarely used.

At times psoriasis is accompanied by systemic symptoms. Psoriatic arthritis is a symmetric polyarthritis that mimics the more severe rheumatoid arthritis. Fewer joints are involved with psoriatic arthritis, but joint destruction can occur in both conditions. Psoriasis generally proceeds the arthritis in most cases, and the severity of the skin disease mirrors the severity of the arthritis. Joint pain is a common finding, and lab tests aren’t always specific for the disease. Severe cases may be accompanied by anemia and spinal involvement.

Newer medications have come out to treat psoriasis and belong to a class of drugs known as tumor necrosis factors (TNF). They include medication known more commonly by their trade names of Humira, Enbrel and Remicade. The medications have significant side effects and have to be monitored carefully. Newer medications such as Otezla and Stelara are often being used even for what are characterized as “resistant” cases of psoriasis even when there is no systemic involvement, and in effect they are cosmetic treatments.

Additionally, older patients who take the medications have a high prevalence of polypharmacy effects, with medications being used for different conditions interacting with the ones given for psoriasis. The medications are directly advertised via television and journal advertisements directly to the consumers, and many now ask their doctors for the drugs at the first sign of a persistent skin condition. While they have a good degree of effectiveness, the side effects of even the newer medications must be watched for closely.

Most cases of psoriasis are not ratable. When psoriatic arthritis and other systemic conditions coexist, the disease is underwritten for the underlying condition. Those under treatment with biologics must be followed regularly for potential side effects from their medication.

Robert Goldstone, MD, FACE, FLMI, board certified internist and endocrinologist, was most recently vice president and chief medical officer for Pacific Life and Pacific Life and An­nu­ity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life.

Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endo­­­crinology and has written monthly for Broker World since 1991.

Goldstone does consulting full or part-time as well as on a fill-in basis for companies who need a medical director/physician. He can be reached by ­telephone at 949-943-2310. Emaill: drbobgoldstone@yahoo.com.