In this episode of DDx, Dr. Eamonn Maher and Dr. Adam Friedman share how a common skin condition affects much more than a patient’s skin, and how misinformation only exacerbates the stigma.
Adam Friedman, MD, FAAD
Adam Friedman is Professor and Interim Chair of Dermatology and serves as Residency Program Director, Director of Translational Research, and Director of the Supportive Oncodermatology Program in the Department of Dermatology at The George Washington University School of Medicine & Health Sciences.
Eamonn Maher, M.D.
Dr. Maher is a second year dermatology resident at St. Louis University. He treats skin cancers and inflammatory skin diseases using topical and systemic medications in conjunction with minor surgeries. When he is not seeing patients he enjoys jiu jitsu and playing soccer.
DDx SEASON 2, EPISODE 6 TRANSCRIPT
Psoriasis and mental health
Raj: This episode is brought to you by Novartis Pharmaceuticals Corporation.
Raj: Two cases today: one patient is a 53-year-old man who presents to a clinic with an irritated, flaking scalp and a red rash on his genitals. The other is a 33-year-old woman who presents with constant fatigue and pain who also has a widespread rash, and complains of being constantly tired and in pain.
Raj: This is DDx, a podcast from Figure 1 about how doctors think. This season is all about dermatology. I’m Dr. Raj Bhardwaj. Today’s cases come from Dr. Eamonn Maher…
Eamonn Maher: I’m a third year dermatology resident at the St. Louis University Department of Dermatology.
Raj: … and Dr. Adam Friedman. Dr. Friedman is a paid presenter for Novartis.
Adam Friedman: Professor and chair of dermatology, residency program director and director of translational research at the GW School of Medicine and Health Sciences.
Raj: For Dr. Maher’s patient, the symptoms had only recently developed, and the patient didn’t seem too distressed at first.
Eamonn Maher: I got the sense this is one of those people that doesn’t sort of like foist his troubles on other people where if you ask him how he’s doing. If you ask them how they’re doing they’ll be like, oh you know, I’m doing great. How about you? Right, they, they don’t immediately dive into telling you the six things that went wrong during their day. So I think he was doing that. He was just being conversational, you know.
Raj: But his calm demeanour was masking a deeper concern. People with psoriasis may have up to 2 or 3 times the risk of developing mental health problems compared to people who don’t have psoriasis.
Eamonn Maher: We started directly addressing his problem, then he kind of let some of that anxiety come out. Apparently his sister in law had told his wife that it was an infection or something and that it could be spread. And as a result of that, because he had it on his genitals, his wife had been refusing to have sex with him for months. So he’d kind of been like putting on this happy face. But he had clearly been… This not knowing what was going on with his skin. And then also how people were treating him as a result of his skin was really, really affecting him. And he kind of, you got the sense, it came through that he was sort of like starved for love from his wife.
Raj: A picture started to emerge of a patient tormented by his own body. He didn’t know where this rash had come from, and he was being ostracized for something he felt he had no control over.
Eamonn Maher: I think people tend to take their understanding of events based in part based on how other people treat them so like if everybody’s mad at you when something happens, you might start to ask yourself, oh, is this my fault? And kind of like this thing, people are telling him that this is gross and this is bad. And he probably started to think about it, that I think about himself that way, too.
Raj: The patient clearly had psoriasis. In dermatology, instant visual recognition of a skin disorder as common as psoriasis, often means that doctors can make the diagnosis in seconds. Dr. Maher already knew what he was looking at, but also suspected that he wasn’t just treating a skin disorder in this patient.
Eamonn Maher: And so I said, OK. So I’ll just kind of start from the top. Meaning his head and work my way down. And we’ll take a look at those spots. So when you’re practicing as a dermatologist, psoriasis for the most part is, it is an entity that you just sort of you recognise on sight. And you don’t need to really you don’t need to take any history whatsoever. You just know it when you see it. And so it’s pretty clear that this guy had psoriasis in his scalp underneath his hair. He had this well demarcated, bright cherry red plaque with some silvery scale over top and then like some scattered dandruff inside of the rest of his hair, which is pretty common. He had some other psoriasis plaques on his elbows, which is a classic place. And then he also had it on his penis and genitals as well. So psoriasis in that area, for whatever reason, tends to be less scaly and it’s more sort of shiny, red, smooth and sort of raw looking. And so I reassured him, I was like, hey, this is just psoriasis.
Raj: The patient was immediately relieved. He had assumed that he had a infectious disease, and had no idea where it came from. But psoriasis is a common condition. Dealing with a patient’s feelings and fears is an important part of effective treatment.
Eamonn Maher: It’s not anything bad. It’s not a sign of any sort of internal malignancy or anything, because I find a lot of times when patients present with a rash on their skin and they don’t know what it is, they always think that it’s coming from something inside. So I made a point to reassure him about that. And he was immediately very relieved. And he’d just started like effusively, you know, saying how relieved he was and how thankful he was.
Raj: Managing any chronic medical condition can be challenging for patients, so many choose to keep it private… With skin conditions, privacy is sometimes not an option.
Eamonn Maher: When someone has diabetes or high blood pressure or they’ve had a stroke or a heart attack, that’s all internal and, you know, that’s private. And other people can’t see it or know about it. But when something’s on your skin, you can’t. Other than like wearing covering clothing, there’s no way to prevent other people from knowing about it. And so I think that it makes people very, very self-conscious, and especially they’re in an area where there’s not high health literacy and people don’t know about psoriasis. You can imagine that if someone’s never seen it before and you see this big, angry, red, scaly, weird plaque on someone’s skin, you might be kind of revolted or repulsed.
Raj: Whether it’s acne, eczema, or any other common derm condition, part of the treatment is to explore how the patient’s rash is affecting more than just their skin.
Eamonn Maher: Because they can develop such self-consciousness and shame about their skin. And I have seen several patients who, when their psoriasis is flaring even in the summer, they refuse to wear short sleeves or shorts because they are so bothered by other people seeing it.
Raj: But that takes time…
Adam Friedman: I think with your new psoriasis patients be ready to put in the time. You know, I find that when my MA comes in and presents a new patient and they have psoriasis and they really know nothing about it, I think I kind of split in two. Kind of like, what was that? I think Superman 3, where he kind of splits in two from the red kryptonite.
Raj: That’s Dr. Adam Friedman. He wants to remind other doctors to be patient when it comes to new psoriasis diagnoses.
Adam Friedman: So part of me separates and goes, oh, god, this is gonna take forever, I’m going to get so behind. And another part of me goes, oh, great. I’ve an opportunity to really change their perception and really make them think about this condition as a systemic illness, because that first visit should take a while. It is not an autoimmune disease. It is not contagious. And it will not go away either. So I think taking that time will save you time down the road.
Raj: Dr. Friedman’s patient had a longer history of psoriasis.
Adam Friedman: A 33 year old woman with a well-established history of psoriasis affecting her scalp, elbows, under her breasts, groin, and her fingernails, which have a yellowish discoloration. Her total body surface area affected is roughly 7 percent. Disease started around the age of 15 and has persisted since. She notes all of her joints are stiff and hurt all the time and it may be possibly worse in the morning. She also notes severe social embarrassment, leading her to spend a great deal of her time trying to conceal her psoriasis.
Raj: The patient knew she had psoriasis, but was incredibly self-conscious about its presentation.
Adam Friedman: And that itself can have some societal impact in that people think, oh you’re dirty, you have an infection when clearly she she did not. And certainly in women, nails, just like hair can be a very important part of their overall kind of presentation. And so that can be very disabling for patients
Raj: But the rest of her symptoms — the aches, the pain, the fatigue — hadn’t been properly diagnosed. She didn’t realize that the same things that were causing her psoriasis flare ups were also triggering psoriatic arthritis.
Adam Friedman: She was never told that. She thought it was more related to her weight, to be honest. And I think it was that that probably added to it that. She’s: “Oh, I’m achy all the time. It’s because I’m overweight”. She wasn’t aware of psoriatic arthritis when I met her. And I mentioned that there are features of what she’s telling me that fit. And, you know, she… it’s funny very often when patients have no clue about this and you start asking questions about the pest tool, morning stiffness or stiffness at rest, lower back pain at night.
Raj: Giving a name to the host of symptoms she was facing helped her to put it in perspective, and to address her anxiety.
Adam Friedman: It was very helpful for her to hear about the disease state overall, that it’s more than skin deep. It’s not just a rash that’ll go away and never come back. This is a systemic illness that can affect every organ system. Most probably the joints. But truthfully, every organ system can be involved as well as the fact that I was able to probably link some of her established diagnoses, obesity, hypertension, depression, that that actually made a… made a big difference for her. You know, that kind of lump it all together. This is all part of a bigger picture. And certainly with the emerging data that treating this disease systemically may have an impact on these comorbidities as well. That I find is actually a useful tidbit to get a patient on board with systemic therapy that, you know, we’re not just putting a cream on one little plaque. We are treating this holistically. And if we treat holistically, we then treat the whole problem and the problems that come along with this disease.
Raj: One of the hardest things to keep in mind, when you’re very familiar with a condition, is that your patient is seeing it for the very first time. Remember slow down…
Eamonn Maher: It’s very confusing and sort of things being unknown creates anxiety. So going through all of that and making sure to reassure the patient that this isn’t a sign of cancer. This isn’t something that they did to cause it. It’s not due to something that they’re eating, all these kind of these worries that patients can project onto the condition. I think that touching the patient in a comforting way is important. And psoriasis, a lot of times, especially like your typical run of the mill plaque psoriasis is very responsive to the topical treatments and especially the biologic drugs that we have. There are biologics now where people can get 100 percent improvement, whereas psoriasis sort of used to be this this orphan disease that no one wanted to mess with because there wasn’t anything that worked that great. And so I think one of the things that I like to do is that you can just confidently tell them, like, we will make this better for you. We will get you, we’ll get your skin clear. And it’s really gratifying to me to see how good that makes them feel, to hear someone say with confidence that like we’re going to improve this for you.
Thanks to Dr. Eamonn Maher and Dr. Adam Friedman for speaking with us.
This is DDx, a podcast by Figure 1.
Figure 1 is an app that lets doctors share clinical images and knowledge about difficult-to-diagnose cases.
I’m Doctor Raj Bhardwaj, host and story editor of DDx. You can follow me on Twitter at RajBhardwajMD
Ddx is produced by David Crosbie for Earshot Podcasts.
Sound design and mixing by Chandra Bulucon.
Our theme music is by Nathan Burley.
The executive producers of DDx are Jesse Brown and Kevin Sexton.
Head to Figure1.com/ddx, where you can find full show notes, photos, and speaker bios.
This episode was brought to you by Novartis Pharmaceuticals Corporation.
Thanks for listening.