I've been working in dermatology for 13 years now, and I've been treating and studying psoriasis patients the entire time. I trained at Mount Sinai, which has probably one of the most robust psoriasis programs. I do the full range of dermatology. I do medical, I do cosmetic. So I see a wide range of patients, many of which are psoriasis patients.
Classically, [what psoriasis looks like is] you're going to get these relatively well-demarcated, scaly, red patches. They can have a silvery scale on them. They can be quite thick. They can flake a lot. Sometimes they can be itchy, but oftentimes they're not as itchy as an eczema patient. You see [the patches] on the elbows. Oftentimes you can also see them in areas where you get trauma. That's called koebnerization — the phenomenon that a skin disease or skin dermatosis will follow areas of trauma. You can see that with psoriasis. Psoriasis also has another sign that if you pick off the scales, sometimes they'll bleed and they can bleed pretty quickly.
Pivoting to Virtual Appointments
Prior to the pandemic, I did very little telemedicine unless it was an absolute emergency. It wasn't a big part of my practice. Now it is. And it's interesting how this time forced us into a technology that now we really appreciate. I went from being slammed with patients to this abrupt halt with COVID-19, and rapidly — within days — adopting telemedicine. It was a steep learning curve and one that I'm glad was forced upon us because there are many things that we do quite well by telemedicine. We've kept [telemedicine], even as restrictions have loosened a bit, so we can still serve those patients.
We can do psoriasis through telemedicine for non-complex patients, so the patient who doesn't need a lot of oral medications doesn't need me to physically examine the area. They're pretty stable, they understand their condition well. I prefer follow-up patients to new patients [for telemedicine]. I'd rather see a new patient [in person] so that I can detail every centimeter of their skin and make sure that we're absolutely certain of the diagnosis.
The Benefits of Telemedicine
What I love about virtual medicine is the fact that it's easier for patients to get in. They're so thrilled they can do it from the comfort of their home. I think there's something really special about seeing patients in their home. And if they're like, “I'm using this cream,” there's no, “I forgot to bring it!”
There are other things you learn from seeing people in their environment. You see what's reasonable for them. If it's a young girl who's in an apartment with three people, she may be sharing a bedroom and it may not be reasonable for her to get a gigantic humidifier that might be loud and upset [her roommates]. And a comfortable patient is an open and receptive patient. Sometimes there's a little bit of white coat hypertension when people are outside of their normal space. But when they're in their home environment, oftentimes, they're really calm, they're really comfortable. Sometimes I find that they're even better at [recounting their medical] history because they're at home and they're comfortable. They have their notes with them and not that nervous feeling they may feel when they're in the office.
I've been doing this for a long time. Even the complex types of psoriasis I could probably diagnose via telemedicine. Once we make that diagnosis, we try [treatments] with the least side effects. For the most part — unless this person is erythrodermic, meaning they're completely covered, which is an emergency and I'd have them go to the hospital — there's a lot that we [can do via telemedicine] if someone has psoriasis.
Preparing for a Virtual Appointment
[Ahead of the appointment], we make sure that their insurance company covers telemedicine visits, which shockingly, some didn't during the pandemic, but then many did. Because we don't want to waste precious time fixing tech stuff, do a tech check at home to make sure that your internet's working, your computer's working, your phone's working. Write down a list and have any medications you've tried right next to you so you can just pull them up and show us immediately. Sometimes, because the camera quality is not as good as we'd like, I ask my patients to take photos in advance. Using your iPhone, which has really good quality, take a sharp photo. I have them email it to me so I can look at everything in better detail before seeing them. Write down all of your questions. Sometimes I even like my patients to do a disease journal. They'll say, "I was better on Monday, I was better today. These are the things that happened. It worsened. Today, I ate tacos and I felt like it was worse." Whatever it is, I like them to give me as many details as possible, so that I can make a better diagnosis.
What Happens During a Typical Telemedicine Appointment
To start the appointment, either a nurse or I will ask them all the questions we normally do in the office: What's your history? What are your symptoms? How are you feeling? Past medical history, family history, behavioral history, medications, allergies, all of those things.
[If a nurse started the appointment] I ask them all those things again when I appear on-camera, but in deeper detail. I want to learn about when they first noticed it, how quickly it's been growing, what sorts of symptoms they have, does it hurt, family history of anything similar, any other medical conditions, were they sick prior to this happening? There are certain types of psoriasis that are triggered by illnesses or new medications.
Then I ask them to put something on that is easy to disrobe so that they can reveal [the affected] areas. It’s hard for us to completely do a physical exam, but I'll have them touch [the area] and describe how thick it feels. Does it feel much thicker than the surrounding skin? Then we probe for other symptoms. Are you having joint pain? Because there's something called psoriatic arthritis, which can be really destructive to the joints. Then, if it's not clear-cut psoriasis, I think about any other conditions that might be in that differential diagnosis and I try to "tease" them out as well.
I want [my patients] to be comforted by the fact that psoriasis is exceedingly common. It's really one of the top 10 conditions that we see and train on. Any board-certified dermatologist will not be surprised by psoriasis and we'll be able to give you a good treatment plan [virtually]. If you have a complex [case], you may want to see a specialist. The National Psoriasis Foundation can help guide you to a physician who has made psoriasis a big part of their practice.
Treating the Other Effects of Psoriasis
There are things that we can do to significantly improve your comfort and your quality of life. Sometimes psoriasis can be asymptomatic in terms of not itching or hurting, so [some patients] feel like it's vanity. It is absolutely not vanity. We understand how much it affects you socially. Whether it is work or in your romantic life, having to explain to others that it is not contagious. You cannot catch it; having to explain why when you take off your jacket and there are flakes leftover…
A dermatologist can guide you on how to have those conversations in your personal life to make your life better. All of these things matter, because they affect your quality of life. There are higher levels of depression in psoriasis patients. There are higher levels of heart disease, higher levels of obesity. It can affect so many systems, so having the right diagnosis is important. It's not "just a skin thing." It is a full-systemic condition. Treating it early can prolong your life, so having your dermatologist diagnose it and making sure you have the other doctors in line to also assess and help you treat any other conditions we know that are associated with psoriasis is really important. Treating psoriasis is absolutely not vanity. We always call ourselves "skinvestigators." Your skin tells us what's going on inside your body. We need to take that information and make sure we do the best with it to keep ourselves safe and healthy. — As told to Kirbie Johnson
This story is part of Survivor's Guide, a series on navigating the impact of psoriasis through beauty and self-care.
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