Throughout the COVID-19 pandemic, the National Psoriasis Foundation (NPF) COVID-19 Task Force has been releasing and updating a series of guidelines regarding the impact of COVID-19 on the management of psoriasis (see link at the end of this blog). The guidelines are broken up into categories that each address a different question surround psoriasis and COVID-19. This blog post was written to answer any questions patients with psoriasis may have.
Risk of Acquiring COVID-19:
A recent, real-world study presented at the 2021 American Academy of Dermatology Virtual Meeting Experience indicated that patients with psoriasis are more likely to have worsened COVID-19 illness, but the reasons as to why are still being evaluated. This study and current data suggests that psoriasis patients with other co-morbid health conditions (i.e., chronic heart disease, diabetes) are more likely to have severe COVID-19 illness.
Your psoriasis may flare up if you become infected by Sars-CoV-2. If you require isolation due to Sars- CoV-2 infection or exposure, please consider following current CDC guidelines (e.g., masks, handwashing, social distancing, etc., until at least 10 days after symptoms resolve) to prevent disease spread and follow the guidance of your health care providers regarding what treatment options may be available to you.
Impact of Psoriasis Therapy on COVID-19:
We do not believe that psoriasis treatments are linked to increasing risks contracting or having more severe COVID-19 illness. Therefore, if you do not have Sars-CoV-2/COVID-19, you should continue your current therapy.
Most psoriasis patients hospitalized with COVID-19 can resume their psoriasis medications after their hospital stay and appropriate symptom free recovery time, but if you have any questions or if your symptoms were severe, please talk with your dermatologist regarding your psoriasis medications.
Vaccinations & COVID-19:
Influenza vaccination is encouraged for all psoriasis patients. If you are taking psoriasis medications, talk
with your dermatologist about what time is best to get the vaccine according to your treatment schedule.
Importantly, psoriasis medications are NOT contraindications to mMRNA-based COVID-19 vaccines (Pfizer and Moderna), nor are they contraindications to the more recent adenovirus-based COVID-19 vaccines (Johnson & Johnson). Unless you have a contraindication, you are encouraged to get the COVID-19 vaccine as soon as it is available to you. If you are planning to receive any COVID-19 vaccine, you should continue your treatment(s) as planned.
If you have questions, don’t hesitate to reach out and cal! your dermatologist.
In any case, it is HIGHLY recommended that patients with psoriasis and their dermatologists engage in shared decision making to create best “plans-of-action” for each individual patient’s situation. As healthcare providers, we understand the harsh impact the COVID-19 pandemic has had on the care of our patients.
The most important thing you can do regarding the treatment of your psoriasis during this pandemic is to continue communicating with your dermatologist, whether it be in-person or through telemedicine.
Link to NPF COVID-19 Task Force Guidelines:
Telemedicine is more important than ever. With the uncertainty the COVID-19 has bestowed on the world. We are being forced to rethink how we interact with each other, and conduct business on a daily basis. This extends to how we interact with our healthcare providers. With telemedicine in healthcare, there are ways that you can interact with your doctor and still receive the care and advice that you need without leaving your home. Dermatology is a visual field that is well suited to take advantage of the convenience and efficiency of telemedicine tools. With telemedicine, you are able to set up an appointment and use your internet enabled device to have a face-to-face appointment with you doctor. Your dermatologist will be able to see your skin, answer your questions, and give advice about what to do next in your treatment plan, without being in the same room as them. Since this technology is relatively new, people may not know much about how it works. Here are a few important concepts to know about telemedicine and how it is done:
- Synchronous versus asynchronous appointments:
There are two main types of telemedicine appointments that you can schedule with you doctor, synchronous and asynchronous. Synchronous telemedicine appointments involve both parties to be online at the same time having a live session that includes both audio and video components. Essentially, this means that you are able to video chat with your doctor in real time and discuss your concerns with them, just like you would in a face-to-face appointment.
Asynchronous telemedicine is a term used to describe store-and-forward transmission of medical images and/or data that is recorded by the patient and then sent to the physician over a secure web server, encrypted email, specially designed store and forward software or electronic health record. Once the physician receives the information, they can assess the patient’s concern and send back their diagnosis, treatment, and recommendations back electronically or fax their recommendations. This means that a patient is able to record themselves with their questions and concerns and send this to their physician and wait for their recommendations. The difference between this and synchronous telemedicine, is that asynchronous encounters do not occur in real time, as where synchronous encounters happen in real time.
- Digital platforms:
Telemedicine software is a sector of health IT that focuses on delivering clinical healthcare via secure audio and video connection. These platforms are the means in which you can interact with your doctor and discuss your concerns with them. There are numerous platforms in which you can interact with your physician via telemedicine. Mobile applications (we use Chiron and Hale at Fivenson Dermatology currently) can be downloaded onto your computer or mobile device and securely run your virtual appointment with your physician. This is similar to popular apps like Facetime, What’s App, Skype but with all the necessary security to protect our personal health information
If you are interested in doing setting up a telemedicine appointment at Fivenson Dermatology, you can request a virtual appointment here.The rise of these applications makes telemedicine easier than ever and it offers great convenience for patients. This encounter is ideal for patients who are not able to make to the office. This includes people who cannot leave their place of work, taking care of their children, or not able to leave their homes. It also allows people to get the advice of physicians that they trust while they are out of town, and still need advice about their skin. Insurance coverage is still variable but growing (temporarily it is much more widespread due to the government’s response to the COVID-19 pandemic with relaxation of the HIPAA privacy rules)
Sunscreen is a vital tool in the prevention of skin cancer, photoaging, and worsening of certain light-sensitive skin conditions. Because of this vast application, numerous formulations of sunscreens have been developed to encourage their use, including creams, lotions, gels, sprays, sticks, and powders. In this post, we highlight various formulations of sunscreen available today and discuss their recommended uses (Table).
Before discussing sunscreen formulations, it's important to highlight general sunscreen facts. When choosing a sunscreen, an SPF of 30 blocks ~97% of ultraviolet radiation and is the lowest recommended SPF. Sunscreen products with an SPF of 30 or higher that are also broad-spectrum (blocking multiples types of harmful ultraviolet radiation) and water-resistant are highly recommended.
Table - Various sunscreen formulations and their applications.
* Special note on lip protection:
The lips are especially prone to sun damage and may also develop skin cancer. Numerous dual-action lip balms exist providing both moisturization and sun-protection.
When choosing a sunscreen formulation, it's important to choose one a product that is easiest for you to use so that you will routinely use it and adhere to a sun protection regimen. Despite the importance of sunscreen in protecting yourself from the sun’s ultraviolet rays, no sunscreen formulation is able to block all of the damaging light. Avoiding prime sun-exposure time (10 A.M. to 4 P.M.), wearing sun-protective clothing, and seeking out shaded areas are vital components of sun-protection.
* Disclaimer: This discussion summarizes the look and feel of sunscreen products but does not approach the nature of the active ingredients, which will be covered in another blog post.
Many skin conditions are treated with topical medications. Instead of applying active medicine directly onto the skin, “vehicles” are combined with the chosen medication to aid in its delivery. Vehicles are inactive creams, lotions, solutions and/or ointments that change the properties of the medicine mixed into them – assisting its application.
The primary components of vehicles include powders, oils, and liquids. The inherent properties of these three ingredients is translated to the vehicle, and thus how the medicine is delivered on the skin. For example, a vehicle with a prominent liquid component can assist with the drying of wet skin lesions through evaporation, whereas oils can provide an occluding coating to the skin and enhance the penetration of the active medicine.
When vehicles are combined with active medicines, you get “formulations”. Formulations can be creams, ointments, lotions, solutions, and foams embedded with active medicine. Different formulations have different potencies (i.e. triamcinolone ointment is more potent than triamcinolone cream) and different body region applications (i.e. solutions for the scalp instead of creams). The consideration of which formulation to use is crucial, as certain formulations are easier to use, therefore promoting adherence to a treatment regimen and overall improvement of a patient’s skin condition.
Outline of formulations:
Creams are predominantly mixtures or emulsions of oils in water. Creams are usually white in color and easily rubbed in without leaving much of a residue. They are applicable to numerous body regions. For these reasons, they tend to be favored by patients and frequently prescribed by clinicians. Creams are particularly beneficial in the skin folds and offer a drying effect to help with wet or damp skin lesions. Additionally, certain creams can be “augmented”, meaning they are more potent and penetrate the skin deeper (i.e. betamethasone dipropionate vs. betamethasone dipropionate augmented). Because a cream is an oil in water emulsion, it requires added agents to keep the mixture stable. This is the same idea as the difference between oil and water salad dressings and a thicker one like ranch or thousand island.
Ointments are mainly composed of oils and greases with a small amount of water. Oils are translucent and greasy, with the latter characteristic making them cosmetically unfavorable for some patients. They provide great lubrication and can be used on dry skin lesions. Ointments are more occlusive, which allows for better penetration of medication through the skin and higher potency. Because of this effect, ointments may not always be indicated for certain regions of the skin that are naturally thinner than others (i.e. the face, armpits, groin folds, etc.). Ointments work best in smooth skin regions lacking hair and on thick and dry skin lesions.
Lotions are composed of powder and water. Lotions are easily spread but only slightly occlusive, making them the least potent topical vehicle. However, lotions are useful in the treatment of moist or exudative skin lesions, as they provide a drying effect through evaporation after application. Lotions can be useful in hairy areas of the skin, as well as large areas due to their ease of application.
Gels may appear similar to ointments, except they are composed of water, carboxymethylcellulose beads, propylene glycol, and occasionally alcohol. Gels are translucent, greaseless, and easy to apply. For comparison, think of the common surgical lubricant or K-Y Jelly. Gels dry and form a thin film, which does not stain or leave behind greasy texture. These features make gels cosmetically favorable, but they are poorly occlusive and do not provide hydration. Gels are particularly applicable for acne and hair-bearing areas, since they do not mat down the hair after drying.
Foams are composed of liquid film and gas bubbles. Foams easily spread and absorb into the skin while leaving behind little residue. Because of this, they are cosmetically appealing and more expensive formulations. Foams provide little to no hydration or occlusion. However, certain types of foams called emollient foams can provide skin hydration and build up the skin barrier - making them advantageous over traditional foams. Because of their easy application, foams are often utilized on the scalp or other hair-bearing areas.
Solutions are very thin and light. They are made from water, alcohol, and other liquids. Solutions come in a clear or hazy, thin-textured, liquid phase. As a result of this, they can be drying from evaporation, easy to spread, and messy to apply. Solutions are most useful for the scalp, as they can penetrate the skin through hair. Due to the presence of alcohols, they are more prone to stinging sensations when applied to inflamed skin.
Psoriasis is a disease that many of us have encountered in our daily lives. Chances are you know someone who has it, or you may even have it yourself. Psoriasis is a disease that causes flaking of the skin with inflammation and thick white, silvery, or red patches of the skin. The scaly patches can be anywhere on the body, but tends to effect the elbow, knees, face, hands and feet, nails, and skin folds (e.g. armpits).
So what causes psoriasis?
Psoriasis is an autoimmune skin condition that speeds up the life cycle of skin cells and causes them to build up on the surface of the skin. The patches and scales that are seen on the affected areas are from this process. There are common things that can trigger a psoriasis flare that are important to know about if you or a loved one has psoriasis.
Triggers of Psoriasis:
1. Strep infections:
Strep throat infections have been linked to causing flares of psoriasis in some people. When you get a strep throat, your immune system responds by sending many immune cells to the tonsils to fight the infection. It is believed that some of these immune cells go to the skin and can trigger a psoriasis flare up. According to a study that looked at the relationship between psoriasis and strep throat, 42% of plaque psoriasis patients reported that their psoriasis got worse when they had a sore throat. Interestingly, 48% of patients who had their tonsils out after getting psoriasis reported that their psoriasis got better.
2. Beta blockers:
Beta blockers are a very common drug class that is used for controlling arrythmias, high blood pressure, and many other conditions. This class of drugs has been reported to induce and exacerbate psoriasis in many people. The latency period between taking a beta blockers like propranolol, atenolol, and metoprolol, and a drug eruption can range from several days to 48 weeks. It was also found that eruptions were usually resistant to psoriasis medications until the Beta-blocker was discontinued.
3. Anti malarial medications:
Medications that are used to treat malaria have been shown to exacerbate psoriasis in many patients. Antimalarials are commonly used to treat psoriatic arthritis, which is an arthritis that can be caused coexist with psoriasis, but can commonly precipitate eruptions and flares of psoriasis. Because of this, some authorities say that antimalarials are contraindicated in patients with psoriasis.
Stress is commonplace in many of our lives, and it can have negative effects on many parts our life. Unfortunately, this is also the case for psoriasis and flareups. Stress is a very common trigger for psoriasis and it is important to reduce stress to lower your chances of having a psoriasis flare due to stress. Exercise and meditation have been shown to help patients reduce their stress and thus reduce the amount of psoriasis flares that can occur due to stress that compounds throughout a long period of time.
Check out the National Psoriasis Foundation website: https://www.psoriasis.org for more information about psoriasis.
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