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This episode digs into cutaneous (skin-related) disease with a focused discussion on plaque psoriasis. The hosts explore how psoriasis develops as an inflammatory condition, how it affects the skin, nails, and joints, and why it should be viewed as a systemic disease rather than just a rash. The episode also reviews common triggers, clinical presentations, and modern treatment options. Including topical therapies, biologics, and coordinated care with rheumatology, while emphasizing patient education, prevention, and long-term management.
00:00 Introduction to Cutaneous Disease
01:00 What Is Plaque Psoriasis?
03:00 Autoimmune vs Immune Dysregulation
04:30 Triggers for Psoriasis Flares
06:00 Clinical Appearance and Types of Psoriasis
08:30 Severity Spectrum and Emergencies
10:00 Nail Changes and Early Warning Signs
12:00 Psoriatic Arthritis
14:00 Importance of Coordinated Care
15:30 Topical Treatment Options
17:00 Oral Systemic Medications
18:30 Biologics and Targeted Therapies
20:00 Phototherapy and Additional Treatments
21:00 Cost, Insurance, and Patient Assistance
22:00 Final Takeaways
Creators and Guests
Host
Host
What is Skinside Out?
Welcome to Skinside Out, where science meets beauty, the ultimate dermatology podcast! Dive deep into the fascinating world of skin health with expert insights, evidence-based discussions, and myth-busting truths. Each episode explores the medical, cosmetic, and surgical aspects of dermatology, while keeping you informed about trending skincare topics. Whether you’re a skincare enthusiast, medical professional, or just curious about how to achieve your best skin, Skinside Out is your go-to resource for staying informed and inspired.
43 - Skinside Out - Psoriasis
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Courtney: [00:00:00] Do you suffer from moderate to severe plaque psoriasis?
Heather: You know the commercials where somebody is suddenly hiking, smiling, and living their best life,
,
Courtney: While the voice calmly lists 47 possible side effects, including death
.
. .
Dr. Zain: Yeah. Today we're talking about that plaque psoriasis.
Dr. Zain: Welcome back everyone to another episode. I'm Dr. Zane with Courtney and Heather, and today we're gonna be talking about plaque psoriasis. From the inside out, we're gonna be talking about what plaque psoriasis is, what the etiologies are, what the symptoms are, and also the treatments. So let's get right into it.
Heather, what is plaque psoriasis?
Heather: So plaque psoriasis is a chronic inflammatory autoimmune condition. Um, we, so in normal skin, our skin cells turn over once a month. In psoriasis, they turn over like within a few days. And so that dramatically thickens the skin and causes [00:01:00] that plaque to form and it's really.
Thick. And scaly. And inflamed and it's usually pretty itchy too.
Dr. Zain: You know, one of my favorite terms from residency, that's silvery scale. Micacious.
Heather: Yeah.
Dr. Zain: Thank you.
Courtney: I'll be here all
Heather: week,
Dr. Zain: micacious. Um, and you know, I know that people describe it as an autoimmune condition, but is there really an allergen that there's an antibody to No.
Heather: No, it's um. We'll kind of get into this more when we talk about treatments, but we use different treatments to target that immune response.
Mm-hmm. And that is what's kind of cause causing that turnover rate to happen so quickly.
Dr. Zain: Yeah. That's just what a, a minor point, but I think it's an important point. Yeah. Um, it's not like a true autoimmune
Heather: condition. Yeah. 'cause people say like, oh, I have an autoimmune condition, but it's different.
Dr. Zain: Mm-hmm.
Yeah. Um, it's a pro-inflammatory condition.
Heather: Yeah.
Courtney: I tell everyone about my autoimmune. My psoriasis, I tell every I, [00:02:00] I have autoimmune.
Heather: And your er, Danlos, and what else?
Dr. Zain: Uh,
Heather: self-diagnosed.
Courtney: Yeah. Yeah. Um, your
Dr. Zain: fibromyalgia.
Courtney: We have a list. Don't worry. Uh,
Heather: we literally do in our office. Courtney's medical history,
Courtney: it gets longer every day,
Dr. Zain: especially under the mental health category.
Courtney: So rude, so nasty. It's so rude. Um, but it does affect this. Skin, it does affect the joints. Everyone has probably at this point heard of, uh, psoriatic arthritis. Um, it can affect the nails. Mm-hmm. And other body systems, there's been studies to show its influence on the cardiovascular system. Mm-hmm. So I think, you know, it does need to be taken seriously as more than just a skin rash.
Heather: And it is chronic. I mean, it will kind of wax and wane, um, for a while. Even though it looks pretty, um, dramatic, typically it's not contagious, so you don't have to worry about that.
Dr. Zain: Yeah. Um, so what. Is the cause of [00:03:00] psoriasis.
Heather: So I think it's a number of things. Mm-hmm. I think it can be like the dysfunction of the immune system.
Um, genetics, we often see people who have psoriasis do have a strong family history. Um, and so. From that immune standpoint, we see certain white blood cells, especially like T cells, become very overactive. Mm-hmm. And I guess that's what I kind of mean by that immunity.
Dr. Zain: Mm-hmm.
Heather: Dysregulation, um, almost that creates the, yeah, I love
Dr. Zain: that term.
Heather: Yeah. And then it causes that redness, the scaling and the itching,
Dr. Zain: . , So let's talk about triggers for psoriasis. So what are some of those triggers that we see?
Courtney: Stress. Mm-hmm.
Heather: Big one. Yeah, that is a big one. We see it with, um, eczema a lot, but I think we see it with psoriasis more. Mm-hmm.
Courtney: I agree. Yeah.
Heather: Yeah.
Courtney: Um, definitely some people notice in the winter the cold, dry weather again.
Um, skin trauma. Um, so there's a, [00:04:00] um, kefler effect where if, let's say you're scratching at the knee or something, it will become a little bit more thickened and bring out that scale. .
Dr. Zain: Soner with the the Ebner phenomenon,
Courtney: Kepner, But also, um, I think a huge one is smoking.
Um, I feel like there's a lot of psoriasis patients we see. Who are smokers and
Heather: or alcohol.
Courtney: Mm-hmm. Heavy alcohol use. Definitely. Um, you just wanna like shake them and be like, stop it. Um, you know, especially the smoking.
Dr. Zain: Yeah.
Courtney: Alcohol,
Dr. Zain: even, even infections can lead to psoriasis. Um, specifically strep infections.
Um, it has a strong correlation with guttate psoriasis. Mm-hmm. Especially in kids.
Courtney: Mm-hmm.
Dr. Zain: So that's something we do see, um, frequently
Courtney: and certain medications too.
Dr. Zain: Mm-hmm.
Courtney: Um, we've seen it with like beta blockers and. Certain, um, mental health drugs
Dr. Zain: also with certain biologics mm-hmm. Um, can actually mm-hmm.
Lead to psoriasis flares. Mm-hmm.
Heather: Yeah.
Dr. Zain: Um, and then I [00:05:00] do think that if you can identify the triggers, like with many skin conditions, avoiding it is probably the best option. Um, but, you know, sometimes these triggers are like, you know, unavoidable as part of life.
Heather: Mm-hmm.
Dr. Zain: Yeah. All right. So what symptoms are we seeing with these psoriasis patients?
Heather: Um, so the itch, but as far as the rash goes, usually it's pretty well-defined deep. Pink, maybe even like salmon, like color, um, patches that get really scaly. Yeah, that's a very classic, um, photo of psoriasis. And you can have it generalized like this, so pretty much everywhere on the body. But you can also have it in very classic areas, which are like on the backs of the elbows.
Mm-hmm. On the fronts of the knees, like the top of the buttock area. Um, belly button, scalp. Those are like kind of the tried and trues. You can also have. A type of psoriasis called inverse psoriasis, where you get kind of like in the fold, so like in the [00:06:00] underarms, like in the groin, um, maybe under the breasts.
And so, and then you mentioned guttate or guttate, which is these tiny little.
Dr. Zain: Raindrop, like,
Heather: yeah, raindrop, like psoriasis. Mm-hmm. And they, they're still pretty scaly like that, but they're not as geometrical.
Dr. Zain: Mm-hmm.
Heather: Um, and that's the one that typically flares after strep.
Dr. Zain: Yeah. And just like with eczema, we see a varying severity.
So you can have just very limited, like a single plaque. And you can go all the way to derma where you're like head to toe covered
Heather: mm-hmm.
Dr. Zain: In psoriasis, flaring, having systemic symptoms, and that is also a medical emergency. You need to be hospitalized and you need to be cooled down.
Courtney: Mm-hmm.
Dr. Zain: Mm-hmm.
Courtney: Yeah.
Can also affect the nails. Mm-hmm. So sometimes we'll see nail pitting, which, um, it almost looks like if someone took a little ice pick mm-hmm. Into the nails. Mm-hmm. They, [00:07:00] um, you know, disfigured the nail. So sometimes when you're going in for your appointment, if you have a rash or you think you have psoriasis, your dermatologist might go ahead and take a look at your nails mm-hmm.
And see if they're seeing any of that pitting.
Dr. Zain: Yeah.
Heather: That's a very classic sign that you, your joints could be involved too.
Dr. Zain: Mm-hmm. Mm-hmm. And in addition to pitting, we can see thickening of the nails and oil stains. Um, so that yellowish, um mm-hmm. Kind of appearance to the nail. So these are all signs of psoriasis.
Heather: Mm-hmm. Um, and like we've alluded to, um, you can have joint pain. So you can have psoriatic arthritis. Mm-hmm. Um, you can get dactylitis, which is, um, so much inflammation in the joints that you get, kind of like sausage, like fingers. Um, which Courtney has a lovely, so this is pretty classic, the
Courtney: real sausage
Heather: finger.
Yes. This is a real dactylitis or sausage finger, but, um, Courtney loves her. Movies [00:08:00]
Courtney: not to be confused with hot dog fingers.
Heather: Yes.
Courtney: Like in the Academy War or the Oscar nominated movie. Everything Everywhere. All at once. AKA Courtney's favorite movie. Um, that's all I can, she might
Heather: have dactylitis.
Courtney: Every time I hear sausage digits, this is what I think of.
Oh, it's the hot dog fingers.
Heather: Yeah.
Courtney: Um, they're thick, you know, uncomfortable. I'm sure
Heather: they, it looks pretty. Mm-hmm. If the joints are involved and you have psoriatic arthritis, it looks pretty classic on x-ray. Um, it's like a, um, it kind of looks like a pencil in a cup. Mm-hmm. Like your joint is, that's the kind of.
Kind of remodeled like this, and then the, the bone on top is kind of sitting in like a pencil in a cup, if, if I'm describing that.
Dr. Zain: Yeah.
Heather: Well,
Dr. Zain: I remember having a boards exam question where they showed us the x-ray.
Heather: Yeah. It's, it's very easy to, yeah.
Courtney: A lot of times people with the psoriatic arthritis, it's more so in.
In, in activity. So for example, [00:09:00] most people with psoriatic arthritis, they'll feel more in the morning, let's say, when you've been kind of, you know, laying down all night, not moving, not active. Mm-hmm. You get up in the morning and it's like taking a long time to really get settled into your body kind of feeling where you're like, Ugh, I'm just so stiff, so sore.
Um, sometimes like, you know, if you're sitting in the same position today, I was sitting in a Cris. Um, position for 30 minutes. And I feel,
Heather: but rheumatoid arthritis is similar too. Mm-hmm. Like your hands are very stiff in the morning.
Dr. Zain: And that Yeah. That raises a good point where we co-manage a lot of these patients mm-hmm.
With rheumatology.
Heather: Yeah.
Dr. Zain: So rheumatology colleagues are very good at, you know, diagnosing, detecting and treating psoriatic arthritis. And we often co-manage these patients and many of the medications that we use to treat psoriasis also. Have protective effects and treat psoriatic arthritis, which is really nice.
Mm-hmm. Um, so I have had a lot of interesting cases that, you know, I always get, you know, [00:10:00] rheumatology involved, even if the patient doesn't say they necessarily have joint involvement. I always like getting an evaluation because oftentimes with cutaneous or skin, um, psoriasis. We see the skin manifestations first, and then oftentimes, like even by a decade later, you start seeing the psoriatic arthritis.
So I like getting them plugged in, making sure that we don't see any joint damage, and helping to prevent that too.
Courtney: And I think it's important to tell your doctor if you are experiencing, I think a lot of patients tend to dismiss symptoms like that.
Dr. Zain: Mm-hmm.
Courtney: Oh, I'm getting older. Or, oh, I, I had a knee injury when I was younger, things like that.
When in actuality it could be related. And again, that's. Something that you wanna go ahead and address as early on as possible?
Dr. Zain: Yeah. When I see a patient with psoriasis, that is a pointed question I ask. Mm-hmm. Are you experiencing a joint pain?
Courtney: Mm-hmm.
Dr. Zain: And then we do a deeper dive if they do say yes, what joints and we can kind of tease apart and you know, we can [00:11:00] have a good idea of whether they're experiencing psoriatic arthritis or not.
Heather: Yeah. And I think it's really good to let your primary care provider know that you have psoriasis as well, because I think it's so easy for people too. Kind of categorize the skin into one folder and then every other organ into another folder. And that's kind of why we try to bring the inside and the outside together.
And I think, you know, you're at increased risk for other inflammatory conditions too. And like you said, people might. Feel like they have joint pain, but they may never even think about associating it with the skin. Mm-hmm. And yeah, there are great treatments for the skin, but the A cream is not really going to help your joints.
Dr. Zain: Yeah. So let's go into treatments then. I mean, there has been an explosion of new treatments for psoriasis. So let's start off with the basics. Um, what do we have, um, in terms of the treatment?
Heather: [00:12:00] Um, so a lot of topicals that we use for eczema, um, like our previous episode, we do use for psoriasis. So very commonly, um, topical corticosteroids.
So these are steroids that we can use to help. Calm down flares. Um, ideally you don't wanna use them long term because they can thin the skin, but with psoriasis we often pair them with vitamin D analogs. So for example, calci pot trying and that's gonna make the treatment more effective. They work synergistically better together.
Um, that's something that's very different from eczema. We don't often use the calci trying with eczema.
Dr. Zain: Yeah. Interestingly we also see a lot of vitamin D deficiency in psoriasis patients. So I often talk about, um, you know, vitamin D supplementation.
Heather: Yeah. There are other, um, more like maintenance creams that we use.
So the steroids are great for flares and then there are non-steroidal anti-inflammatories and they're tackling different immune pathways to help control the rash and the itch and the inflammation.
Dr. Zain: [00:13:00] Yeah. So, um, we can obviously go into more depth about these medications, but, um, let's dive into some of the more systemic medications that, you know, we use for more severe cases.
Um, so let's talk about the traditional oral medications. So steroids, right? That was a mainstay of treatment. However, what we see with psoriasis, um, and we don't really like using, uh, steroids because it can cause a huge rebound effect.
Heather: Mm-hmm.
Dr. Zain: So even though. The patient may temporarily get relief. Um, the inflammation's reduced because the steroids are reducing all inflammation.
The many come off of it. I have seen the worst rebound effects. Yeah. From that. So it's typically, uh, something that I stay away from. Mm-hmm. For most of my psoriasis patients.
Heather: Yeah. There are other kind of like. Old school, oral medi medications.
Dr. Zain: Outdated.
Heather: Yeah. Um, methotrexate, cyclosporine, I don't know the last time you prescribed methotrexate.
Dr. Zain: It's, it's been a while. Like
Heather: since resident [00:14:00] sake, it's harsh. You have to do blood work.
Dr. Zain: Mm-hmm.
Heather: You, I mean, it's a, we
Dr. Zain: used to use it a lot though.
Heather: Yeah. Yeah. I've definitely seen good success with it, but,
Dr. Zain: and it's one of those medications that did protect the joints. One of the few, yeah. Back in the day. So yeah, it was a mainstay of therapy because of that joint protection.
But now we have. Way better medications. Mm-hmm. Yeah. So let's go into those biologics.
Heather: Um, so we have some oral options that can help target those immune pathways. We also have a lot of injectables. Um, so they, it depends on which class you're using and there are multiple receptors that are affecting.
Psoriasis. So if we can block certain receptors mm-hmm. We can block that. Immune dysfunction. ,
Dr. Zain: So as we've understood the, um, pathway of psoriasis more, we've identified a lot of different molecules and their receptors in that [00:15:00] pathway, and that's been the target for a lot of these pharmaceutical companies.
They're trying to find a medication that blocks that to shut down the inflammation. Mm-hmm. Which is much more targeted, less side effects, and overall much better outcomes.
Heather: Yeah. Yeah, we, I think the first one that was on the market was Humira for biologics. Mm-hmm. We've come a long way. Um, I haven't even ever counted, but we probably have
Courtney: at least 20.
Heather: I was gonna say 10 to 15. But
Dr. Zain: yeah, I mean they're, you know, like with Humira, the TNF um, inhibitors. Mm-hmm. And then now we have specific molecules like IL seventeens, IL 20 threes, IL twelves. I mean, it's, it's really phenomenal. Mm-hmm. What, um, we have to offer our patients and, you know, there are certain medications now that we're seeing are better for certain types of patients, so we're trying to stratify.
Mm-hmm. Um, and. Understanding like which medications will give the patient the best outcomes [00:16:00] and more personalized.
Heather: Mm-hmm. Do you ever think there will be some sort of. Like test to see.
Dr. Zain: I think there's gonna be a
Heather: test. What? I think so which one's best for you
Courtney: think so they do that with, um, like antidepressants.
Dr. Zain: Mm-hmm.
Courtney: They, they take yours, they do a saliva swab and I guess they can see which one would work best for you. Yeah. Um, so I, it's funny, I was having this conversation with a patient the other day and, um, I think. That would be ideal. Yeah. To be able to find that pathway, be able to put them on. Mm-hmm. You know?
Dr. Zain: Yeah. As we're getting more data and more, um, tests are developing, um, I do think that, you know, there's gonna be a genetic panel that we'll be able to order.
Courtney: Mm-hmm.
Dr. Zain: We'll be able to target which medications will work better. Mm-hmm. And, you know, that'll, you know, contribute to more targeted medicine.
Courtney: I think the medicines, the biologics, you know.
It is so nice that there's so many different [00:17:00] ones. A lot of them do have different dosing schedules, so I think it's important working with your provider to make sure that you find one that works with your schedule. Mm-hmm. Some are more frequent than others. There are some that are every three months, some that are every two weeks.
So I think making sure that you find what works best for you and then hopefully it physically works for you. Um, and you're able to kind of continue. But there's so many options that. You'll find one,
Heather: and some of them are better and approved for. The psoriatic arthritis. Mm-hmm. And joint involvement. Some are really good for scalp psoriasis.
Mm-hmm. And
Dr. Zain: some are good for patients who have inflammatory bowel disease.
Heather: Mm-hmm. Yeah.
Dr. Zain: Some of them are better for, you know, just a variety of other different comorbidities. Mm-hmm. So I do think that, you know, getting a good history and then, you know, just making sure that you know, all the checks are, you know, ticked off and, you know, we're able to give our patients the best care possible.
Joe: Mm-hmm.
Dr. Zain: Unfortunately, these medications are very expensive. [00:18:00] Insurance can be quite a challenge to get these patients coverage as Courtney, um, can attest to.
Courtney: Yeah. You know, it's funny because, um, these medications are not medicines that you go to your local CVS mm-hmm. Or local Walgreens to get, they're, they're class of specialty drugs, meaning they go to a specialty pharmacy that handles, and most of these biologics.
The injectables anyways do have to be refrigerated, so that's also something to keep in mind. But, um, the nice thing is. Even if your insurance doesn't approve, which I think tends to be a really, I think the main question patients ask upfront, what is this gonna cost me? Mm-hmm. And it is scary. It's, it's injectable that you don't know.
You've heard that it's so expensive and you don't know how much you might be liable for. But the nice thing is a lot of these companies, um, these drug companies have. Put together patient assistance programs where they have copay cards. So maybe, you know, you're only spending five or $25 a month, or you get free drug until your insurance approves it, or different, [00:19:00] um, ways to make sure that you are getting treated.
And I think that's the main thing is as long as you're getting that medication. Don't worry about how
Dr. Zain: mm-hmm.
Courtney: Just keep getting it.
Dr. Zain: Yeah. Um, aside from biologics, there are some other treatment options. Phototherapy can be very helpful for psoriasis. I mean, it's a very, um, photo responsive, um, you know, disease.
Courtney: Mm-hmm.
Dr. Zain: We see, you know, some patients just going out in the summertime mm-hmm. In the sun and notice their, you know, psoriasis improve. Although I'm not a huge fan of that. Some of them go to tanning beds and I. Don't really advocate for that, but it is an option for patients who really have no other means sometimes.
Heather: Mm-hmm.
Dr. Zain: Um, and there is also, um, an exer laser that we use to treat psoriasis, obviously for more targeted localized areas. Um, but it is another option that, and insurance does cover that for some patients.
Courtney: Yeah. [00:20:00]
Dr. Zain: All right. So. Psoriasis is obviously a very complex disease. A lot of people suffer from it, but you don't have to suffer in silence.
We have a lot of different options. It's important to make sure that if you do notice that you're having psoriasis get evaluated by your board certified dermatologist. Um, also make sure that you discuss any other symptoms like joint pain. Because that can be debilitating and it can also help us with steering the treatment choice.
So psoriasis is something that is extremely challenging to treat sometimes, but we have a lot more options today.
Heather: Yeah.
Dr. Zain: Any other final comments?
Heather: Um, just reiterating that it's not, um. There's not just one treatment, I think.
Dr. Zain: Mm-hmm.
Heather: Based on you and based on your needs and your type of psoriasis. There are different, lots of different treatment options.
Dr. Zain: And from our psoriasis patient, [00:21:00]
Heather: personal feedback,
Courtney: personal. Um, now just again, being I think honest and transparent with the symptoms that you're feeling disclosing some of your medical history. I think those are all pieces of the puzzle that gives insight to your provider. Um, and then I think also, like Dr.
Zane mentioned earlier, following through with a rheumatologist I think can be so important for a lot of patients. And again, really connect the dots and help them feel better. More than just skin wise, so.
Dr. Zain: All right. Well thanks for listening to this episode on psoriasis. If you have any questions, feedback, comments, please reach out to us.
Please follow, share and like. But until next time, skin side
Courtney: out out.
[00:22:00]