Nilanjana Bose, MD, to Susan Bernstein
I’m an adult rheumatologist, so I see patients 18 and older, with a variety of rheumatic conditions. Every patient I see is different. In a typical psoriasis patient, skin psoriasis symptoms usually precede arthritis symptoms. For some, the two conditions may even be years apart. But this is not absolute. You may develop arthritis, or joint pain and swelling, first and then psoriasis.
Patients often come to us first with swollen joints. Typically, psoriatic arthritis causes swelling in the peripheral joints. They can make your fingers and toes swell and look similar to rheumatoid arthritis (RA). We do an initial check and check their skin. If they have psoriasis, including nail pits or psoriatic plaques, or if they have a family history of psoriasis or psoriatic arthritis, this could be a sign that they may have psoriatic arthritis.
COVID: Hello Telehealth
Our clinic had to go into retreat mode for the first few months after the pandemic hit last year. We really had to scramble to adapt. We quickly began using telehealth to treat our patients. We didn’t have some telehealth technologies, but once we learned that there were resources out there, like telehealth portals and online platforms that we could use, we started adopting them.
I think our patients have adapted very quickly to telemedicine as well. Older adults face some challenges. Some people don’t have access to the internet, or find it harder to navigate the logistics of telemedicine. But for those patients, we’re also able to do regular phone interviews.
Telemedicine brings its own challenges. We have to learn how to “check in” patients via the Internet. It’s not easy, and it’s not the best option for joint or skin conditions. However, a telehealth visit is better than a patient missing an appointment entirely and not being able to get care.
For follow-up visits, telemedicine is simple and works well. You can check in with patients to find out about their current medications. Some of my patients really prefer telemedicine for convenience. Again, this is not optimal. We still encourage our psoriasis patients to come to the office. It’s hard to see everything with a camera.
Overall, telemedicine has been a fun experience, but if a patient needs to be checked in person, I’ll ask them to come in. We are all wearing masks, maintaining social distance and taking every precaution. We are very committed to the whole aspect of infection control for patients.
I’ve even seen new patients using telehealth, especially during the worst stages of the COVID pandemic. If they are referred to me by another doctor because they have psoriasis, I can do the initial consultation remotely, but I still try to get them in. Just coming in and seeing a rheumatologist to start treating psoriasis is ultimately the most important step. You can build a rapport with your doctor and get the information you need.
Biologics: A Game Changer for Psoriasis
Biologics have completely changed the way we manage this disease. Once you’ve been diagnosed with psoriatic arthritis, there are excellent treatment options. In the past, we had steroids, DMARDs (disease-modifying antirheumatic drugs), and TNF inhibitors, but now, we have IL-17 and IL-23 inhibitors, and JAK inhibitors.
Initially, we evaluate our new patients with lab tests and joint imaging, and check them for all symptoms. Some people have mild psoriasis symptoms, while others have more severe systemic symptoms. With younger patients, we might try to manage their disease more aggressively because they are at greater risk of joint damage.
When we discuss treatment options, it’s actually a two-way, fluid discussion. I discuss all risks and benefits of each treatment with my patients. If my patient improves after a few months, we discuss and possibly reevaluate the treatment plan.
It is now rare to see chronic joint deformities in people with psoriatic arthritis. This can happen if someone was diagnosed a long time ago, before better treatment options became available, or if they couldn’t get care before they came to us. These improvements are largely due to advances in drug therapy, but also to increased awareness of rheumatic diseases. They google it. They just have more awareness about rheumatology and they need to see a rheumatologist.
We screen every patient. Some of them had true inflammatory psoriasis, while others did not. They may have osteoarthritis or fibromyalgia that cause joint pain. Every patient deserves a thorough, comprehensive examination. We want to diagnose these patients early enough to initiate treatment to manage their disease and prevent damage.
COVID and Other Infections: Take Extra Precautions
We had this exact discussion with patients before COVID as well.They are at higher risk for serious infections – Not just COVID, but other types of pneumonia and other infections. We have been encouraging these patients to wash their hands frequently, take common-sense precautions, avoid close contact with sick people, and get all vaccinations.
As soon as the COVID vaccine became available, I told them, “Please get vaccinated and keep wearing your mask.” People who use biologics for psoriasis are more cautious by default. For new patients who are just starting biologics, I advise them on how to take precautions to prevent infection. We tell many psoriasis patients, “Stay home as much as possible right now and avoid close contact with others.” Patients do heed this advice because they trust us to be their physicians.
Making people with psoriasis feel safer
Always have a backup plan for telehealth technology! Additionally, I encourage all of my patients to sign up for our online patient portal so we can stay in touch. They can message me, I can renew their prescriptions, we can share test results with them.
Technology is a beautiful thing. We need to take full advantage of it in modern healthcare. Technology can make it easier to stay in touch with people with psoriasis who need ongoing care. But some patients may not be used to telemedicine, so they may feel a little frustrated at first. Be patient, take the time to learn to use these tools, and help your patients adapt. If something goes wrong at first, don’t give up.
When you’re working with someone with psoriatic arthritis, face-to-face interaction is still very important. It can be difficult to create new doctor-patient relationships without any face-to-face component.
Some patients continued to visit me virtually after being diagnosed. It seems that we can really get to know each other very well. Telemedicine provides a safe and secure environment for patients. They’re at home or in the office, or even in the car. Sometimes when I’m discussing telehealth with psoriasis patients, I see them taking notes. That’s very good! Some people find they feel less anxious when they have a telehealth appointment rather than when they are in a doctor’s office.
