The Skinny On Psoriasis
Interviewed by Rasa Fournier
Wednesday - September 29, 2010
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Dr. Douglas Johnson
Dermatologist at Queen’s Medical Center
Where did you receive your schooling and training?
I went to the University of Nebraska for undergraduate and medical school. Then I came to Hawaii and trained in internal medicine at the University of Hawaii. I trained in dermatology at the University of New Mexico before returning to Hawaii to practice.
How long have you been practicing?
Twenty-eight years in dermatology. I’ve been a doctor for 34 years.
Can you talk about your practice?
I tell everybody I’m a “hand dermatologist,” and that means I’ll take anything they “hand” me. I’m a consultant to the state for Hansen’s disease and I have a large HIV practice. I also do a lot of psoriasis and eczema treatment. I take care of acne, skin cancers, warts and other common conditions. I have one of the largest psoriasis practices in the state. One reason is because I had the first UV light box in Hawaii for treatment of psoriasis. I also see Quest and Medicaid patients and I spend some time at the homeless shelter. I feel it is my civic duty to provide services to those who have limited resources.
What is psoriasis?
It’s a genetic autoimmune disease. You’re body thinks it recognizes a foreign substance in your skin and attacks it, resulting inflammation and hyper-proliferation of the skin, and it causes red, thick skin and scaling. It has a proclivity for certain areas. The most common places are the scalp, the knees and the elbows, but it can affect everywhere - head to toe. The average age of onset is about 35, although you can see the onset in infants and the elderly.
Is it easy to get rid of psoriasis?
There are cases where people get it and it goes away and never comes back, but that’s the exception. Most patients get it and keep it for life with variations in severity. Psoriasis severity is categorized into mild, moderate and severe. Mild cases are less than 3 percent body surface areas. It may only be on your hands and feet, making it hard to work with your hands or walk because of pain. From 3 percent to 10 percent is moderate. More than 10 percent is considered severe.
Exposure to sunlight helps 90 percent of the patients. Hawaii is a good place to have psoriasis. The humidity is helpful.
How do you treat psoriasis?
There are lots of treatments. We have topical steroids that are effective, helpful and very safe for limited disease. We have topical vitamin derivatives like vitamin A and vitamin D. We have tars; those are old-time remedies that can be used by themselves or in conjunction with other treatments like the sun or UV light. In cases that are moderately severe, sometimes we’ll use phototherapy. I have what looks like a tanning booth in my office and it has a special wavelength of light that has really helped a lot in treating psoriasis. And then we use medications that are systemic that suppress the immune system to help the patient control their disease.
What does “systemic” mean?
It goes internally in some way. “Systemic” means it affects every cell in your body to some extent. My favorite systemic medication is methotrexate. There’s another one we use called cyclosporine. It’s an immune suppressant that’s used to treat patients who have organ transplants to keep them from rejecting their new transplant. In the beginning days of transplants they used cyclosporine, and they noticed that if they had a patient who had psoriasis and they gave them this drug, their psoriasis went away.
Are there any new treatments?
The newest treatments are biologic agents. Previously psoriasis was thought to be a hyper-proliferative disease and now we know it’s autoimmune. It was noted that cyclosporine worked well on psoriasis while suppressing the immune system. While studying cyclosporine, they figured out exactly what pathways were causing psoriasis. Now they’re targeting specific inflammatory cytokines in your body and reducing those without affecting the whole immune system. It makes for a safer and more-effective treatment.
How do you decide what to give each patient?
Every patient is an individual, so you can’t give everyone the same thing.
I tell patients that it’s like opening a menu in a restaurant. I’m going to show them everything on the menu and they’re going to get to see the price and see how “delicious” or appealing it is, or how effective it is and what the risks are. I like the patients to “buy into” their treatment with knowledge. I like them to say, “Let me try this.”
Can a person with psoriasis live a relatively normal life?
They do surveys about the psychological impact of diseases, and psoriasis is right up there with malignancy and congestive heart failure. Sufferers can be depressed or alienated from society. If their skin has all these spots on it, they don’t feel comfortable being seen. They may wear clothing that covers everything up and may limit their social engagements. They would-n’t be able to work in a bank or a restaurant if they had it on their hands. Some of it becomes so severe that they can’t do housework, so it’s a very common cause of disability. It can happen on the genitalia, so it can effect your sex life. If it’s on your face - a common place for it - it can affect your social interactions. It can even be on your lips and your tongue. Sometimes we’ll have patients in the hospital with severe psoriasis from head to toe and there’s a significant mortality from it. Rarely, some have the disease so bad that they die from complications.
They die because their immune system is so compromised?
Sometimes, but it’s often because you lose your skin’s protective function, like if you have a bad burn and you can’t control your heat. So when they get really covered with red plaques, they may have hypothermia if the room is too cold, so you have to keep the room warm. Sometimes they’ll ooze serum from their skin and develop secondary infections. If they’re bedridden they might get pneumonia or sepsis, different complications. They’ve got a bad disease and you’re giving them strong medicines - they may have complications from the medicines if you’re not careful. The majority of the patients we see do very well with minimal complications. I have about 300 patients on strong treatment in my practice and most of them are doing very well.
Is psoriasis contagious?
It’s not contagious. Not at all.
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