You enter your clinic and see that the first patient of the day is Michael. He is on your schedule for a “rash”. Michael is 26 years old, has not been able to keep a job or have an intimate relationship due to this “rash”. His skin is a Fitzpatrick 5/6 scale. He has scaly plaques on his trunk, extensor extremities and scalp. Michael’s co-morbid conditions include depression, anxiety, insomnia, sleep apnea, obesity and hypertension. He complains of chronic joint pain (usually in the morning) involving the fingers, wrists, ankles, and knees. Occasionally he has low back pain that is worse in the morning. Michael is on a beta blocker for his hypertension and takes NSAIDS routinely for his joint pain. He is on a CPAP.
Michael wants his usual monthly steroid shot that makes his rash a little better, but it always comes back. Your impression is psoriasis with psoriatic arthritis, and you are correct. Identification of this disease process and recognition of the comorbid processes will dramatically improve this patient’s prognosis. Avoiding excessive steroid use is also wise. You refer the patient to a dermatologist and a rheumatologist.
Psoriasis affects 3% of the US population over the age of 20. In 2020 this translated to 7.5 million adults. Psoriatic arthritis affects 10-20% of the patients with psoriasis. Psoriasis occurs in the pediatric population but at a much lower rate. Psoriasis is a chronic disease. Patients with psoriasis, similar to diabetes and other chronic disease state, have reduced quality of life. While oral and injectable steroids can temporarily reduce the symptoms, the disease process can rebound, and steroids delivered in this way can cause serious side effects and not help the underlying disease.
The cause of psoriasis is an immune process where the immune chemicals cause the skin to regenerate at a rapid rate. Genetics and environmental triggers play a role. There are systemic and topical treatments to control the skin/disease. Comorbid conditions are numerous and some of the therapies may help the associated the disease states.
Congratulations in your management of Michael. After seeing his dermatologist and the rheumatologist and due to your insights, Michael was started on a biologic agent, had his beta blocker discontinued, is using fewer NSAIDS and he was started on a biologic agent. His skin is dramatically better, his joints are better, and he is on a diet and exercising. He thanks you. He is going on a date and has a job interview this week. Kudos to you.
Join me in Virginia Beach, Atlanta, Pensacola and/or Chicago this year. I will be presenting on dermatology. We will dive into rashes, skin cancers, benign skin disorders, connective tissue disease as well as a host of skin conditions. I love bringing my actual case studies accompanied by actual treatment and outcomes.
We can move dermatology cases from the most dreaded to the most exciting and fun cases on schedule.
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