Psoriasis is a chronic disease that requires persistent management and doesn’t have a cure. Managing the condition can be difficult for a variety of reasons. Here’s a look at the top six challenges that experts identified.
1. Current treatment methods have drawbacks. While individuals can often manage moderate and severe psoriasis with systemic medications, mild psoriasis—the most common form—is usually treated with topical creams. Using topical creams requires patients to be diligent with applying them. These medications contain steroids—which have side effects, such as thinning of skin or lightening of skin color—so patients must interchange steroid and non-steroid topical treatments on specific time schedules, says Gideon P. Smith, MD, PhD, MPH, director of medical dermatology at Massachusetts General Hospital in Boston. Some patients are discouraged from using creams because they are messy, psoriasis can occur in hard-to-reach areas, and response to treatment is often slow. Because the thick scales caused by psoriasis can be hard to penetrate, creams may be less effective.
While systemic medications may seem easier to use, they place other burdens on patients. They often require lab monitoring and can cause side effects such as fatigue, injection-site reaction, upset stomach, or increased rate of infections such as the common cold, Smith says. Patients may develop antibodies to some of the new biologic medications, making them less effective over time and requiring them to change therapies.
Matthew Reeck, MD, a dermatologist at St. Luke’s Dermatology in Ketchum, Idaho, says most newer medications involve self-administrating injections. “For many patients, the idea of giving themselves an injection is not appealing,” he says. “Some patients will have injections performed at a clinic or hospital.”
Furthermore, some things that are out of a patient’s control, such as stress, or are hard to manage, like weight gain, can make psoriasis worse. Common medications like beta-blockers, which are used to control high blood pressure or heart rate, or lithium, a mood stabilizer, can also cause psoriasis to worsen, Smith says.
2. Medications can be pricy. One of the biggest challenges in obtaining medications, particularly newer ones, is cost. Health insurance companies can refuse to cover a new medication or require that a patient fail cheaper or older medications first, Smith says. Covered patients can also face higher copays on more-expensive medications, which can also create an access barrier.
Some biologics cost tens of thousands of dollars annually—and insurance companies don’t like to pay for them, adds Apple A. Bodemer, MD, a dermatologist at the University of Wisconsin School of Medicine and Public Health in Madison.
3. Patients forgo treatment. National surveys by the National Psoriasis Foundation between 2003 and 2011 reported that approximately 37% to 49%, 24% to 36%, and 9% to 30% of patients with mild, moderate, and severe psoriasis, respectively, didn’t treat their condition.
“Some patients forgo treatment because they are not concerned with the rash,” Smith says. “Others don’t know how the disease can impact their health, such as increasing their risk of heart disease. Some are concerned about the short and long-term side effects of medications, many of which suppress their immune system, so they don’t take prescribed medications.”
4. Limited treatment options exist. Some areas of the skin that can be affected by psoriasis have limited treatment options. One example is patients with nail-predominant psoriasis. The area involved is not enough to warrant systemic medication, and topical creams have no effect. Genital or inverse psoriasis is also problematic because topical steroids can cause skin thinning—which is particularly problematic in these areas. Individuals with scalp-only psoriasis can have difficulty getting topical creams through hair, or they can make hair appear greasy. Phototherapy can’t penetrate hair, and patients with scalp-only psoriasis often don’t qualify for systemic medications.
5. Conditions can fluctuate. Changes in the disease’s severity are hard to predict. Stress, diet, weight changes, changes in seasons, and changes in health status all contribute to how psoriasis will manifest at a particular point in a person’s life. “Not every medication works for everyone, and even with diligent, regular use, what worked well at one point for someone may not work well later on for that same person,” Bodemer says. “Individuals often have to try and retry different treatment options. This is time consuming and frustrating for patients, as well as physicians trying to help them navigate the condition.”
6. The condition has many comorbidities. Psoriasis is associated with a host of other significant health conditions including heart disease, metabolic disease, diabetes, obesity, and depression, Bodemer says.
Patients may not only need to see a dermatologist, but also a primary care physician and other specialists to work in tandem with the dermatologist to address comorbidities, Reeck says.
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.