What to Expect From Your Psoriasis Medications

From healthcentral.com

There may be no cure for PsO, but top derms say there are many effective ways to treat this chronic skin condition 

If you’ve recently received a diagnosis of psoriasis (PsO), chances are you’re anxious to resolve your symptoms—the sooner, the better. The chronic skin condition, which causes your skin cells to grow too quickly, leads to inflammation that triggers itchy plagues, rash, and swollen, hot skin. Symptoms can range from mildly irritating to excruciating due to many factors, including the severity of your PsO and your overall health.

The good news? “The treatment options for psoriasis have continued to grow and expand and only get better,” says Aaron Farberg, M.D., a double board-certified dermatologist and dermatologic surgeon, in Dallas, TX. Since “no two cases are alike, every patient deserves an individualized treatment plan,” adds Allison K. Truong, M.D., a board-certified dermatologist specializing in psoriasis at Cedars Sinai in Los Angeles. So, having a range of treatment options for PsO to choose from is important.

Although you may feel like you’re alone with psoriasis, you’re definitely not—125 million people worldwide, or 3% of the total population, live with PsO, according to the National Psoriasis Foundation. It’s also normal to have lots of questions about the current PsO treatment options available. To help you better understand what to expect from your meds and how well you can anticipate today’s treatments working for you, we asked three leading dermatologists who specialize in psoriasis to clear up the confusion about treatment efficacy, potential benefits, and possible side effects.

Real Progress Has Been Made In Treating PsO

No one wants to live with psoriasis, but if you’re going to get a diagnosis of this s is that there are plenty of treatment options to help keep this skin condition under control, according to Dr. Farberg. Here’s why:

Improved PsO Understanding

Over the last few decades, researchers have made significant progress in understanding the genetics, immunology, and even associated comorbidities of PsO (which can include type 2 diabetes, Crohn’s disease, high blood pressure, and cardiovascular disease). Growing academic insight has led to the development of more effective PsO treatments with better efficacy, as well as a decade’s worth of research on PsO medications that enables physicians to “understand the safety profile and nuances in using these treatments clinically,” says Dr. Farberg. Such information can be particularly helpful when discussing treatment options with PsO patients with comorbidities, since the best treatment plan addresses a person’s entire health profile.

Biologics Can Treat PsO

There are now 13 FDA-approved biologics for the treatment of PsO, the newest of which hit the market in 2023. These agents are particularly useful for treating moderate psoriasis in which 3% to 10% of your body is affected, to severe cases, says Dr. Truong. They are also effective in treating psoriatic arthritis (PsA), a related inflammatory condition that affects roughly 30% of people living with PsO.

These newer, more effective drugs give people with both conditions more options for treatment, as well as the possibility of reducing the number of drugs they need to take. “Ideally, we can keep things simple with one maintenance medication,” says Christopher Sayed, M.D., a board-certified dermatologist in Chapel Hill, NC, of this approach. “However, there is sometimes a need to add topical treatments for a few stubborn areas, or layer on a second treatment in severe cases.”

New Topical PsO Treatments

Calcineurin inhibitors have been prescribed for years to treat PsO topically. However, Dr. Truong is particularly excited about two additional steroid-free options that recently hit the market: a phosphodiesterase-4 inhibitor (PDE4 inhibitor) that helps reduce levels of inflammation in the body and decreases symptoms such as pain, redness, and swelling, and a cream that works by activating the aryl hydrocarbon receptors and appears to slow the rapid build-up of skin cells and relieve inflammation.

Just like calcineurin inhibitors, neither option poses the same risks as long-term steroid use do, which can cause atrophy (or thinning) of the skin, and tachyphylaxis, in which medication suddenly becomes less effective. “Topical steroids still work best at calming down the inflammation quickly,” she explains, but these “newer topical agents and topical calcineurin inhibitors” can be “utilized as maintenance therapy” between flares or on smaller patches of skin that are particularly difficult to treat, versus the whole body.

Oral Medications for PsO

A new oral PDE4 inhibitor and an oral immunosuppressant that works by reducing the activity of your immune system have come onto the scene recently. Like biologics, they target widespread inflammation and are especially effective in people with moderate to severe PsO. What’s more, they’re taken in pill form—great news for those who have “needle phobia or are not responding to current available treatments,” says Dr. Truong. PDE4 inhibitors also treat PsA, which may reduce the need for multiple medications to manage both conditions.

Alternative Treatment Options for PsO

Beyond Rx medication for PsO, you can also try other approaches to help calm flaring symptoms.

Phototherapy exposes your skin to ultraviolet (UVA and UVB) rays at a dermatologist’s office, or even via a special in-home unit. This method can help shrink PsO patches and plaques and prevent new ones from forming, says Dr. Truong.

Lifestyle factors such as avoiding smoking, reducing stress, maintaining a healthy body mass index (BMI), sleeping well, and eating an anti-inflammatory diet can all help keep your symptoms under control and even prevent flares, she adds.

Side Effects and Possible Contraindications

When deciding on a treatment plan with your doctor, make sure to discuss side effects of the medications you’re considering, advises Dr. Truong. “The right individualized treatment plan often comes down to what side effects a patient might be willing to tolerate,” she explains.

Additionally, be sure to mention any comorbidities that you have. (Certain PsO meds are contraindicated for inflammatory bowel disease, for example.) And don’t forget to discuss your reproductive plans. If you wish to become pregnant in the near future, your physician will be mindful of the safety data that’s available for specific medications when making treatment recommendations.

You’ll also want to be aware of what your insurance company’s policies are on covering PsO treatments. Some providers, for example, only cover biologics once other treatments have failed to work. By partnering with your doctor and discussing all of your options, says Dr. Farberg, you’ll be able to come up with the best PsO possible treatment plan for you.

Can PsO Treatments End Your Symptoms?

Clear skin is within reach, says Dr. Sayad. Although, he adds, it’s important to know that there may be a trial-and-error period as your dermatologist works to find the medication (or combination of meds) that will deliver optimal results.

“Often, we can get patients’ [skin] completely clear with limited or no side effects,” he explains. “It’s not always possible, but we have a range of options now and rarely settle for less than 75% to 90% improvement.”

Does a Flare Mean That Your Treatment Stopped Working?

Not necessarily, says Dr. Farberg, who advises talking to your dermatologist about your symptoms and then together deciding on the best next steps.

“Small flares [while on your current treatment plan] can sometimes occur and be temporary,” notes Dr. Sayed. “We can often add a topical medicine for a few resistant areas. If it’s not possible to regain satisfactory improvement within a few months, I’ll usually consider making a bigger change.”

If a medication has stopped working altogether, “I get to assure my patients and say, ‘Don’t worry. I have several other options in my back pocket’,” due to the number of treatments available today, adds Dr. Farberg.

Additional Targeted PsO Treatments Are on the Horizon

Currently, Dr. Farberg is spearheading a research project that he hopes will reduce, or entirely eliminate, the trial-and-error process that some people with psoriasis must undergo to find the right treatment plan. With support from Castle Biosciences Inc., researchers are studying how gene expression profiling may help physicians better identify how to treat PsO, as well as other inflammatory diseases including atopic dermatitis. Results are expected to be reported in early 2025.

The bottom line: Psoriasis is a chronic illness for which there is no cure, but there are many treatment options available today, with more under review for the future, says Dr. Farberg. “We’ll always have a treatment that we can turn to in order to help alleviate, if not eliminate entirely, [your] psoriasis symptoms.”

© 2024 HealthCentral LLC

https://www.healthcentral.com/condition/psoriasis/what-to-expect-from-your-psoriasis-medications

Air Pollution Could Increase Psoriasis Risk Significantly, Study Finds

From verywellhealth.com

Carol Yepes / Getty Images

Key Takeaways

• Exposure to PM2.5 and PM10 significantly increases the risk of developing psoriasis.
• People with a genetic predisposition to psoriasis face more than four times the risk when exposed to high levels of air pollutants.
• Experts say those with a strong family history of psoriasis should consider living in areas with low pollution if that's an accessible option.
  

Air pollutants can significantly increase the risk of psoriasis, according to a recent study published in JAMA Network Open.

The study analysed data from the U.K. Biobank over a 12-year period, including 474,055 individuals who were psoriasis-free in the beginning. Researchers found that people exposed to air pollutants such as fine particulate matter (PM2.5) and particulate matter (PM10) were at a higher risk of developing psoriasis.

For every interquartile range increase in PM2.5 and PM10, the risk of psoriasis rose by 41% and 47%, respectively.

People with a genetic susceptibility to psoriasis had more than four times the risk of developing the condition when exposed to high levels of PM2.5 and PM10 compared to those with low genetic susceptibility and low exposure. However, the genetic analysis was limited to only White Europeans, who made up 94% of the sample.

“The concept that pollution could trigger psoriasis had been introduced in some other work. What is truly novel here is that the authors found that the risk of psoriasis in those with a susceptible genetic background was specifically increased by pollution,” said Alexa Kimball, MD, MPH, a professor of dermatology at Harvard Medical School.

Kimball said it’s unclear why pollution triggers psoriasis, but it could be direct skin irritation or whole-body inflammation from lung exposure.

Psoriasis is an autoimmune disease that attacks healthy skin tissue. It causes skin cells to reproduce too rapidly, often resulting in thick, red, scaly patches that can be itchy and sometimes painful. Over 7 million U.S. adults live with psoriasis.

Kimball said people with a strong family history of psoriasis might want to consider living in areas with lower pollution.

According to a 2024 report from the American Lung Association, some of the most polluted areas include locations in California and Oregon, while Maine and Hawaii have the lowest levels of pollutants.

More accessible ways to reduce psoriasis risk include avoiding smoking, excessive alcohol consumption, as well as skin injuries from tattoos and piercings, said Angela Moore, MD, an associate professor at Texas Christian University Burnett School of Medicine who has been a principal investigator on a wide range of clinical trials related to psoriasis treatment.

Medications like beta-blockers and lithium are also linked to a higher risk of psoriasis.

While the study was based in the United Kingdom, Moore said it’s applicable to U.S. psoriasis cases and the state of air pollution domestically.

In a commentary, physicians said data to support clinical recommendations are lacking despite accumulating evidence on the interactions between air pollutants and inflammatory skin disease.

“It is unclear whether topical moisturizers and treatments are likely to protect high-risk individuals or whether they may increase the penetration of air pollutants,” they wrote. “While it may seem intuitive to counsel patients to use protective clothing, there are little data to support the efficacy of such a recommendation.”

What This Means For You

Air pollution is strongly linked to a higher risk of psoriasis, especially if you're genetically predisposed to the condition.

https://www.verywellhealth.com/air-pollution-psoriasis-risk-8682646 

Why You Should Avoid Plaque Removal With Psoriasis

From healthcentral.com 

Despite what you may have read, experts discourage the practice of removing PsO lesions. Here’s why

Experts caution against picking at plaque psoriasis with your nails because it can damage your skin and trigger a flare. But, if your skin is itchy and uncomfortable, it can be hard to leave it alone, especially if it is on your face or in other sensitive areas. So, what to do? Start with these tips for managing plaque psoriasis symptoms and learn from top psoriasis experts why removing plaque psoriasis scales is not recommended.

                                                                          GettyImages/Ake Ngiamsanguan

When you feel something on your skin that shouldn’t be there, it’s a natural instinct to want to remove it. But picking the scales off your skin is not the way forward. “I wouldn't recommend directly trying to peel off psoriasis lesions as they are prone to bleeding,” says George Han, M.D., a dermatologist at Northwell Lenox Hill Hospital in New York City. “We actually use this fact clinically to prove psoriasis sometimes—it’s called the Auspitz Sign.” (The Auspitz sign refers to pinpoint bleeding under the skin’s surface, named after Heinrich Auspitz, a 19th-century Austrian dermatologist.)

Removing plaques from the skin raises concerns about potential bleeding, agrees Kurt Ashack, M.D., a dermatologist and assistant professor at Michigan State University College of Human Medicine in East Lansing, MI. Those raw, open wounds can become infected, leading to even greater pain. “You can exfoliate with things like salicylic acid, but I do not recommend removing the plaques,” Dr. Ashack says.

In addition to causing even more skin inflammation by physically removing a plaque, doing so provides only momentary relief, says Dr. Han. Without treatment, the plaques will continue to show up, he explains. So instead, you’re better off playing the long game. “I would say that appropriate treatment should help reduce the thick plaques gradually by stopping the inflammation causing the thickened skin to begin with,” Dr. Han says.

If your psoriasis symptoms are flaring, there are other ways to make the scales less troubling. “If topicals are not helping and you are not on a biologic agent, we can inject the plaque with a steroid to help it go away,” says Dr. Ashack.

Outside of the derm’s office, you can also reduce some of the skin discomfort, starting with avoiding common triggers that may be making your condition worse. According to the American Academy of Dermatology Associates, (AAD) things like unmanaged stress, skin injury (bug bites or sunburn as examples), alcohol, smoking, cold weather, and even shaving can increase inflammation and make the plaques worse.

Another strategy to help the scales is to apply a fragrance-free moisturizer. According to the AAD, extra moisture applied to the skin may change the reflective property of the scales so you don’t see the scaling as predominantly.

Because all moisturizers are not created equal, it’s important to choose one that will make things better, not worse. The National Psoriasis Foundation maintains a list of products that have earned their seal of recognition that are free from irritants and can be used on psoriasis plaques.

Lactic acid is a type of alpha hydroxy acid (AHA) that has been shown to be helpful in the treatment of plaque psoriasis. Using lactic acid to elicit changes in the skin is a very old practice, with reports of Cleopatra bathing in sour milk, which contains lactic acid, in order to give her skin a youthful appearance.

Salicylic acid is also a go-to therapy for plaques associated with psoriasis, says Dr. Han, noting that topical application of products containing salicylic acid may help reduce or soften scales. “Salicylic acid products in the 2% to 6% range may be helpful,” he says.

Both lactic acid and salicylic acid have shown to be beneficial for managing psoriasis plaques. In a two-week, double-blind trial testing the efficacy of a 20% alpha-hydroxy/polyhydroxy acid emollient versus a 6% salicylic acid cream, both treatments reduced the scales of psoriatic lesions. The 20% alpha-hydroxy/polyhydroxy acid cream yielded quicker results and less toxicity than salicylic acid.

To manage skin plaques, there are a variety of products and formulations available, including oils, ointments, creams, lotions, gels, foams, sprays and shampoos. Most people with mild psoriasis will start treatment with one of these topical medications. Even if you have more advanced psoriasis that requires a systemic treatment, your doctor may still recommend you continue with a topical treatment.

According to the Mayo Clinic, the most frequently prescribed topical medications include:

• Anthralin

• Calcineurin inhibitors (such as tacrolimus, pimecrolimus)

• Coal tar

• Corticosteroids (such as hydrocortisone, triamcinolone, clobetasol)

• Retinoids (tazarotene)

• Salicylic acid

• Vitamin D analogues (such as calcipotriene, calcitriol)

Even though the visible symptoms of psoriasis appear on the skin, it can impact the entire body. For this reason, it may be necessary for you to take a medicine that addresses the root cause of psoriasis—an overactive immune system.

There are many treatment choices available. Which one you choose will be a decision made with your provider based on factors such as which medications you have tried previously, potential side effects of medications, cost, and personal preference.

Some of the most-prescribed treatments include:

• Biologics (such as etanercept, infliximab, adalimumab, ustekinumab, ixekizumab)

• Cyclosporine

• Light therapy

• Methotrexate

• Retinoids

• Steroids

If you have plaques on your skin from psoriasis, it’s natural to want them removed. But direct removal is not something most dermatologist advise, due to complications and inflammation that can results.

Instead, talk with your doctor about alternate ways of managing skin plaques. Gentle exfoliation and moisturizing the plaques that may make them more comfortable and less noticeable.

Plaques can be very bothersome and a sign of undertreated disease, so proper treatment of psoriasis itself is the best way to reduce plaques and lower the odds of their return. With so many different treatment choices available, from medications that you apply directly to your skin to pills or injectables that work systematically, you will be able to find a way to control your psoriasis.

https://www.healthcentral.com/condition/psoriasis/plaque-psoriasis-removal?ap=nl2060&rhid=&mui=&lid=141093361&mkt_tok=NTQxLUdLWi0yNDMAAAGUfuAZ_8BHFfbp_2QisXns105iJSz8PKjpyw44K-KfmWu496h9iSlkMdIvGsGgUAm3oKEidhvkI9aTS98_nrUgmY2exhL9SOgiYnJcLXWkbxcfyvE

Phototherapy for the Treatment of Psoriasis: When Is It the Right Choice?

From medscape.com

Discussion with Tina Bhutani, MD, MAS, FAAD; Mona Shahriari, MD, FAAD; Jason E. Hawkes, MD, MS 

Tina Bhutani, MD, MAS, FAAD: Hi, everybody. My name is Tina Bhutani. I'm a board-certified dermatologist, practicing in San Francisco, California. I specialize in psoriasis and inflammatory skin diseases. 

Today, we are going to have a discussion about the role of phototherapy for the treatment of psoriasis. First, what is phototherapy? When would we use phototherapy? And what are some unique circumstances where phototherapy is our go-to treatment?

I'm very excited to be joined by my colleagues, Dr Mona Shahriari and Dr Jason Hawkes. Can I have you introduce yourselves? Mona, do you want to start? 

Mona Shahriari, MD, FAAD: Thank you so much, Tina, I'm really privileged to be here today. I'm Mona Shahriari. I'm an assistant clinical professor of dermatology at Yale University and the associate director of clinical trials at Central CT Dermatology Research. Just like you, I live and breathe inflammatory skin disease, in particular, psoriasis. I'm very happy to be here. 

Bhutani: Thank you. Jason? 

Jason E. Hawkes, MD, MS: Hi. Glad to be here and good to be with both of you again. I'm a medical dermatologist with a background in translational immunology and an interest in clinical trials and many of the inflammatory diseases. I really use everything for these patients with psoriasis as well as with other diseases, and I'm happy to have the conversation today. 

Bhutani: Awesome. Thank you both for joining us. In this day and age, we have many different therapies for psoriasis. Our toolbox is very full. Sometimes, it gets very difficult to make a decision. Which treatment do we pick for which patient? In this multitude of treatments, I think phototherapy is a little bit of a lost art. 

Today, I want to talk a little bit about what is phototherapy, the different types of phototherapies, and then, which patients would we choose phototherapy for. 

Mona, I'm wondering if you can start and tell us a little bit more about phototherapy and the types of phototherapies that you might utilize in your practice. 

Shahriari: Absolutely. I still consider phototherapy to be one of the safest treatments for inflammatory skin disease, in particular, psoriasis. The way it works is we use ultraviolet (UV) light to slow down the cell growth that's happening in psoriasis and decrease the inflammation in the skin. 

You can use it as monotherapy or in combination with topicals, orals, or even injectables for all severities of plaque psoriasis. When I think of the different types of phototherapies, there are the three main ones that come to mind. We have narrowband UVB, which is really the most common form of phototherapy. 

It uses that wavelength of 311 to 313 nm, which is the perfect wavelength to treat plaque psoriasis. We also have targeted phototherapy because there are some patients who might have smaller areas of plaque psoriasis, so they don't need their entire body treated like we do with narrowband. 

Lastly, I think of psoralen plus UVA therapy, or PUVA, as another treatment. That being said, I could go into it in more detail, but I feel like in the year 2024, PUVA doesn't have as much of a role because though it's much more effective than narrowband, I do think the side-effect profile makes it less desirable. 

Bhutani: I totally agree. Like you said, narrowband UVB is just so much more accessible than PUVA is. Although I, for example, love something like hand-foot PUVA for palmoplantar psoriasis for my patients. 

Jason, Mona just mentioned the side-effect profile for PUVA, but let's get back to narrowband also. How do you counsel your patients when you're talking to them about phototherapy? What do you tell them about the logistics of treatment, side effects, and what they should expect? 

Hawkes: When we're talking about phototherapy, we want to always set that up as one option among all the other available treatment options. I think the main difference is that with phototherapy, we don't expect the same speed of improvement that we're going to certainly see with traditional immunosuppressants, like cyclosporine. Biologics are really getting close to that rapid speed of onset, but phototherapy is slower and takes longer to have its clinical benefit. We need to set that expectation. 

The first thing I would probably do is just say that phototherapy has great safety and a long history in dermatology. If you want the treatment to get clear skin really quickly, this is not the go-to option. If you're really sensitive to light, we want to try to control for that. Certainly, we need to think about things like dyschromia or lack of efficacy with darker pigmentation. I like to set that up as this is one of many treatment options. I often will tell patients that I don't really care which direction they go or what they choose, I just want to make sure that they understand what they're getting. That's going to save us those unnecessary phone calls from patients saying, "I'm several weeks into my treatment, and I'm not really seeing much improvement." That's going to be a very different discussion now because of our setup.

Overall, I mostly just tell patients that phototherapy is quite effective and that we're not really worried about much in regard to safety. We're going to follow established protocols and algorithms that are going to help you slowly wean into this treatment. That's really the way I set it up. The biggest drawback, I think, for some patients can be the copays with each visit. That's often limits it. Additionally, in some situations, it's just not convenient. COVID-19 was a good example, when sending people to medical offices was the clear downside. For the most part, we can apply phototherapy pretty easily to many patients in many different scenarios, which makes it a really robust treatment option. 

Bhutani: I totally agree. As Mona mentioned, phototherapy, to me, is still one of the safest treatments that we have for psoriasis. When I counsel patients, at least in my neck of the woods, many of my patients want "natural" treatments. I always say that I don't think you can get any more natural than UVB light. 

I also tell them that because we're taking out these specific wavelengths, like Mona mentioned, we don't have any convincing evidence to show us that there might be an increased risk for skin cancer or anything that we might see from natural sunlight. Those are two ways that I appease my patients. 

At the same time, like you said, it is a big time commitment, right? They have to come into the office two to three times a week to start. We're talking about 3-6 months to see clearance of their disease. You really want to make sure that they're ready to make that leap and make that commitment. 

Mona, is there anything else that you talk to your patients about? 

Shahriari: I do talk to them, actually, about very similar concepts that you guys discussed: some redness, itching, blistering, or burning. As you mentioned, this is safer than natural sunlight, so I do try to emphasize that with patients. I do get the question of why can't they just use a tanning bed? Why do they have to come to the office to get the narrowband treatment?

I do reiterate with them that not only are tanning beds not effective for plaque psoriasis but also, they're using a completely different wavelength that could lead to skin cancer and melanoma. We, as dermatologists, don't recommend that for the use for psoriasis treatment. 

Bhutani: Absolutely. I think that's a great point: Our medical-grade phototherapy boxes are not the same as getting a tanning-bed treatment. 

Although, getting back to Jason's point, patients will get a suntan when they get phototherapy. For some patients, that's actually an added benefit. For some patients, they hate that. It is something that we want to, again, counsel patients when we're talking to them and setting expectations for them. 

Getting to access to phototherapy: We mentioned that during COVID-19, it was hard to get into an office. We also know that phototherapy centers just aren't available in a good part of our country, unfortunately. Most of them are centered on the coasts — the East Coast and West Coast — when we look at maps of phototherapy centers or around major urban hubs. 

How do you implement home phototherapy? How do you use that in your practice? Jason, do you want to get started? 

Hawkes: Phototherapy for the home gives people options. It's sometimes a bit of a dance to try to figure out coverage. Cost can be an issue, so you're always navigating that. I think working directly with the phototherapy unit manufacturers can certainly be helpful. 

Even where I am, in the outskirts of Sacramento area, there are many individuals in rural areas that don't want to come into the cities. They have ranches, or they're busy. Home phototherapy gives that extra layer of convenience where, again, you're removing the travel and treatment copayments. You're also removing the doctor's visits, and that gets back more to the “natural” side of treatment for some patients. 

Less interaction with the healthcare system, for some patients, is preferable. I think, particularly, hands and feet can be really good body sites for home phototherapy treatment because they're harder areas to treat due to the thickness of the acral skin. You have to select the right patient though. 

There are some patients where unsupervised treatment, like home phototherapy, is not an ideal situation. I'm a little more cautious in the selection of patients to whom I would say, "Let's just get you this treatment option at home" because you lose the protective guardrails. It makes me a little nervous with certain patients. It’s about proper patient selection. 

The reason we have many available therapies is that injections or biologics aren't great for everybody. Pills aren't great for everybody either. We're trying to personalize that treatment approach, and removing tailored treatment plans is very problematic. 

I also find that the community physicians, who may be a little closer to patients than many academic centers, are great phototherapy advocates. One thing we know about phototherapy is that it's very good from a business standpoint. It works in the background of usual patient care. It can help some of these smaller practices survive financially. It also keeps us off the radar from some of the big insurance companies that are watching for providers with high biologic utility. We know that it is a balance. I think this treatment diversity is good for everybody. And patients can choose their own treatment adventure if you want it to look a certain way. 

Bhutani: Agreed. My favorite way to utilize home phototherapy, although it's not always possible, is for them to do phototherapy with us in office, even if it's just for a month or 2. Then, they can learn a little bit of that art, how to do the dosing, what to expect, when to decrease the dose, and when to increase the dose. 

Again, that's not always possible. I also like that because then we know whether it is working before we make the investment into trying to get them a home phototherapy box. That's how I utilize it in my practice. I'm curious to know about the accessibility where you practice. 

For me, here in San Francisco, our Medicare patients, sometimes Medi-Cal/Medicaid patients, have really tough access to systemic therapies. Phototherapy is actually really well covered under these plans. Is that what you are seeing where you're practicing as well? 

Shahriari: In the northeast, we have a very similar issue. If patients have commercial insurance, it's very easy to get some of the systemics because of the access programs that various companies have. For Medicare and even Medicaid sometimes, it is a challenge. 

The problem we have in the northeast, which you have in the Bay Area as well, is that we don't have a lot of square footage in everybody's houses, depending on where they're living. Sometimes, the home light units aren't going to be ideal for patients if they're living in a high-rise in Manhattan, for example. We do have to tackle that aspect of things as well. I know for the longest time, I used to think that home light units weren't necessarily as efficacious as what we do in the office. 

There was that recent study that Joel Gelfand and colleagues put out that really showed that the home light units, when you teach the individuals appropriately, can actually be noninferior to what we use in our offices. For me, at least, that made a difference in terms of my prescribing habits for home light units. 

Bhutani: Totally agreed. Again, getting back to Jason's point about patient selection, if we can pick the right patient whom we know is going to be optimizing their dosing and be safe at home, then I think that home phototherapy can be just as effective as in-office phototherapy. 

Lastly, I think one of my favorite things that I have picked up doing phototherapy for a long time is social connection. I think there are patients who actually benefit from coming into the office three times a week and getting to know our nurses and having that handholding, especially some of my older patients who might be living alone or don't have family in the Bay Area. 

They truly become family in our phototherapy center. In the back of my head, I oftentimes do think about this for patients who might be really anxious or might need a little bit more handholding and a little bit more love in their therapeutic treatment. 

That's another time that I choose phototherapy because I think they really feel well taken care of when we're seeing them so many times a week and getting to know them. 

Hawkes: Tina, I was just thinking while you were talking: One interesting aspect that we need to consider as practitioners is that, obviously, we're hearing often about the systemic effects of untreated psoriasis and the inflammation. I always mention to my patients that we really don't have a good understanding of how effective phototherapy is in terms of potentially altering or modifying that risk with some of these comorbidities. It's an important research gap. 

We don't have the answers, but it's at least the other side of the coin to think about. As we consider this systemic inflammation in our patients, that might be a drawback of phototherapy for a patient with psoriasis who is at high risk for cardiovascular disease, obesity, diabetes, or some of the other psoriasis-associated comorbidities. Again, we're getting back to that proper patient selection. 

We want to understand how phototherapy might alter systemic inflammation. We're still learning whether we can still have those beneficial systemic effects with phototherapy, but probably not as much as other systemic agents. Again, maybe for those patients who have that higher burden of disease and inflammation, phototherapy may not be ideal as a monotherapy. This is something that we should be thinking about as practitioners. 

Bhutani: I think that's a great point. Again, I think that's an area where we still need to learn. We don't really understand exactly all the intricacies of how phototherapy actually works, right? What is the complete mechanism? 

Another shoutout to Joel Gelfand. We have two shoutouts to him in this talk. In one of his studies, when he looked at systemic inflammation in patients getting a multitude of different therapies — he did have phototherapy as an arm in one of those studies — and they showed a slight decrease in systemic inflammation. 

Again, I agree with you. Phototherapy probably does not have as large of an effect as some of our systemic therapies. I think we still are probably making an impact on inflammation, just by keeping the skin under check, right? Keeping that skin inflammation under control. 

Shahriari: I think the best take-home message is that we have to treat the whole patient and not just the skin. I know, for example, in my patients who are pregnant or who have a multitude of comorbidities and maybe can't take a pill or an injection is not going to be feasible, it's a great option. 

For the majority of patients, patient selection — really, Jason, you hit the nail on the head there — is going to be an important part. What I like about phototherapy is that you don't have to use it on its own. You can combine it. If someone's on an injection or if they're on an oral, maybe this gives them a little boost in efficacy. We have that ability to safely combine it with other therapies as needed. 

Bhutani: Getting back to your point, Mona, about special populations: I love to use phototherapy in pregnant women and pediatrics. Some people think that they don't want to put kiddos in a light box, but it's totally safe to do so as long as they're old enough to follow the instructions or can stand in there alone. 

I also love it in patients with many other comorbidities. Like you said, people who might not be able to take systemic therapies. Maybe they have active cancer, HIV, or active hepatitis B. These are other scenarios where I really love to use phototherapy. 

Let's talk a little bit about treating patients with skin of color with phototherapy. Mona, are there any special considerations that you think about when you're treating this patient population?

Shahriari: I know Jason alluded to this earlier, but melanin acts as a UV filter. The reality is that when we were doing our studies on phototherapy and trying to figure out optimal dose and duration of exposure, we really didn't study patients with skin types V and VI. It was just types I-IV. We don't really know what those optimal doses are to get the right result. 

In addition to that, for some cultures, being fair is valued, and being tan is stigmatized. They may not be in favor of going into a light box, with tanning being the adverse event that they have to deal with. It really does come down to a case-by-case discussion. Like we mentioned before, patient selection is going to be very important. 

Bhutani: I totally agree. I think we also have to remember that Fitzpatrick skin type or skin color doesn't always match up with someone's sun tolerance. I have had many patients with type VI skin, but they actually can't handle much UV light. 

I think we also have to be careful. You want to be aggressive enough so that we're not undertreating our patients with skin of color, but we also want to be cautious because they can still be sun sensitive.

Hawkes: To your point, Tina, it even changes over time, right? Individuals who say, "When I was a teenager and in early adulthood, I never burned and always tanned." All of a sudden, now, they never tan and always burn. They can have a UV response at one point in time, and over time, develop a different response. I think that's always important when restarting a patient on phototherapy who had treatment a long time ago to restart treatment a little bit slower to see how their initial response. 

Bhutani: I totally agree with that. It's important to treat the whole patient. I would like to thank Dr Shahriari and Dr Hawkes for joining me today. Thank you all for listening. We hope that you'll be able to utilize phototherapy in your practice. Thank you. 

https://www.medscape.com/viewarticle/phototherapy-treatment-psoriasis-when-it-right-choice-2024a1000cvw?form=fpf