Even though psoriasis affects millions of Americans, there's a lot people don't know about the condition. Between the stigma of psoriasis and the number of different treatments available, many patients might not know where to begin. Dermatologist Paul Yamauchi, MD, answers some of the most common questions he hears from psoriasis patients. 1. Q: What is moderate to severe psoriasis? A: Psoriasis is an inflammatory skin condition characterized by red, itchy plaques on the body. I like to tell my patients psoriasis basically means their immune system is in overdrive, which creates the psoriatic lesions. There are several different levels of severity in psoriasis based on how red and thick the plaques are, which areas of the body are covered and how much of the body is covered. Think of the palm of your hand as 1% of your body’s surface. If 1 to 3 palms worth of your skin, or 1 to 3% of your body’s surface, is affected by psoriasis plaques, it’s considered mild. If 3 to 10% is affected, your psoriasis is considered moderate, and if more than 10% of your body is covered, it’s considered severe. Your psoriasis may also be considered more severe if it’s in areas that tend to be harder to treat, like the scalp, genitals or hands and feet -- even if it’s only on 3% of your body. Finally, you can assess the severity of psoriasis based on treatment. Typically, if topical cream alone is not working to relieve your psoriasis, it’s considered more moderate or severe. 2. Q: Who is at risk for developing moderate to severe psoriasis? A: It can affect people of every age. I’ve treated infants with psoriasis, and I’ve treated people in their 80s and 90s. However, in many patients, symptoms begin around 20 years of age, or after 50. In the US, psoriasis affects about 7.5 million Americans, or about 2% of the population. Because it’s such a visible, stigmatizing condition, patients may be too embarrassed to see a doctor about it -- especially if it’s in areas that are generally covered by clothing. 3. Q: What are the different treatment options for moderate to severe psoriasis? A: There are four ways to treat psoriasis: topical therapy, phototherapy, oral medications and biologic agents. Topical therapy includes things like creams, gels, foams and ointments that are applied directly to psoriatic lesions to reduce the itchiness, and thickness of the plaques. Phototherapy, or light therapy, is usually used in patients with more moderate or severe psoriasis. Phototherapy uses ultraviolet light to alter certain immune system functions. The biggest drawback to phototherapy is the time commitment -- patients have to receive phototherapy three times a week at their doctor’s office, and with work or school, that’s nearly impossible. The next line of treatment for psoriasis is oral medications like methotrexate, cyclosporine which are essentially broad-based immunosuppressants and Soriatane which is a vitamin A derivative. While effective, these agents require routine frequent blood testing because they can affect your liver and kidneys. Lastly, there are biologic agents, which completely revolutionized the way we treat psoriasis. 4. Q: What are biologics? A: I tell my patients that biologic agents work by normalizing your immune system and restoring it to a better balance, rather than totally suppressing your immune system. Since the introduction of biologics, we’ve seen vast improvements in patients, and the best part is there’s an extremely low rate of side effects. Biologic agents target the specific inflammatory pathways involved with psoriasis. There are three classes of biologics: Tumor Necrosis Factor-Alpha (TNF-Alpha) inhibitors like Humira (Adalimumab), Interleukin-12/23 (IL-12/23 inhibitors) like Stelara (ustekinumab), and IL-17 inhibitors like Cosentyx (secukinumab) and the newly FDA-approved Taltz (ixekizumab). In fact, ixekizumab is the only biologic thus far to have achieved a Psoriasis Area and Severity Index (PASI) score of 100% clearance in some patients, and a large majority of patients will see at least 75% clearance of their psoriasis. Each class of biologic operates on different biologic processes involved in your body’s immune response. Biologics are dosed as frequently as two shots a week to quarterly (every three months), and can be self-injected with a pen or syringe, or administered intravenously by your physician. 5. Q: What are some potential side effects of moderate to severe psoriasis treatment? A: One of the benefits of biologics is there are relatively few side effects, unlike the nausea, dizziness and fatigue patients can experience on methotrexate. However, any time you’re targeting part of your immune system (like you do on biologics), you’re at a greater risk of infection. If you’re on a biologic and start to develop flu-like symptoms, or a fever or cough, call your doctor. Certain lymphomas are also listed as potential side effects of biologics; however, as the psoriatic patients have a higher rate of lymphoma anyway, it’s hard to tell whether it’s actually a side effect of the medication. While both of these elevated risks are relatively uncommon, you and your doctor should take extra precautions to monitor for them. 6. Q: What are some reasons an individual might need to try a new psoriasis medication? A: There are three main reasons you might switch medications. The most common reason is the medication just isn’t working, and I usually give it about three months before I determine it’s time to switch or adjust the dose. Second, we’ll switch if you are experiencing side effects that you are not able to tolerate. While extremely rare, there is a potential risk of demyelination which is similar to multiple sclerosis symptoms such as weakness, tremors, blurry vision. This is an adverse event with TNF-alpha inhibitors like adalimumab. Lastly, cost or change of insurance is often a reason to switch medications, unfortunately. 7. Q: Beyond medication, what are some other ways individuals can manage their psoriasis? A: I’ve had patients tell me that they’d rather lose a kidney than have psoriasis. That, I think, is a testament to how physically and emotionally taxing the condition is. Because it’s so visible on the skin, it can cause people to be self-conscious, anxious or even depressed. So beyond treating with psoriasis medications, I highly recommend patients look into support groups they can attend in person, virtual support groups and counseling to keep their mental health in check, too. Stress tends to exacerbate the symptoms of psoriasis, just as it exacerbates symptoms of other chronic conditions. Manage stress with things like yoga, meditation and exercise -- really whatever is stress relieving for you. Lastly, you can use over-the-counter pain relievers, anti-itch cream and moisturizers to reduce symptoms during a flare. Paul Yamauchi, MD, is a clinical assistant professor in the division of dermatology at the David Geffen School of Medicine at UCLA, as well as an adjunct associate professor at the John Wayne Cancer Institute. He serves on the medical board for the National Psoriasis Foundation, and has been practicing dermatology for 16 years.