wa dc more than skin deep slide set june 21, 2014
DESCRIPTION
Through More Than Skin Deep, Outsmart Psoriasis and Psoriatic Arthritis, learn how you can lower risks for developing other serious conditions like heart disease, diabetes and depression. You will be armed with the information you need to live well with psoriasis and psoriatic arthritis.TRANSCRIPT
WELCOME TOMORE THAN SKIN DEEP
Outsmart psoriasis and psoriatic arthritis from the inside out
Thanks to our sponsors
The National Psoriasis Foundation is solely responsible for all content and development of this program.
Reminders
• Cell phones• Restrooms• Questions• Evaluation form
Our mission
National Psoriasis Foundation mission isto drive efforts to cure psoriatic disease and
improve the lives of those affected.
Our mission: Education
Outreach programs and activities focus on individuals and health care providers to best manage psoriasis and psoriatic arthritis and improve overall health. Such education programs include:
www.psoriasis.org
• Psoriasis One to One Program• More Than Skin Deep education events• Free education webcasts• TalkPsoriasis.org• Health educator• Free E-newsletters• PsoMe.org for children and parents
Our mission: Education
Education programs for medical professionals designed to enhance the quality of health care received by psoriasis and psoriatic arthritis patients. Such programs include:
• Annual Dermatology Resident’s Meeting• Physician Assistant’s Summit• Nurse Practitioner’s Psoriasis
Symposium• Psoriasis Forum journal • Research Symposium
Our mission: Action
The Foundation’s advocacy priorities include:
• Growing and supporting federal funding for psoriasis and psoriatic arthritis research.
• Advancing the psoriasis and psoriatic arthritis public health efforts at the Centers for Disease Control and Prevention.
• Reducing out-of-pocket treatment expenses.
• Ensuring affordable access to new treatments.
Our mission: Action
TAKE ACTION!
Have you enrolled in the Marketplace? Share the good and the bad of your experience at www.puttingpatientsfirst.net
Urge Congress to help lower out-of-pocket costs for medication by passing the Patients’ Access to Treatments Act (PATA).
www.psoriasis.org/toolbox
Our mission: Hope
In 2013, the National Psoriasis Foundation invested
$2 MILLIONin psoriatic disease research
Our mission: Hope
The Foundation’s research priorities include:
• Fund Discovery and Translational Grants.
• Increase the number of scientists doing
psoriatic disease research through the
Medical Research Fellowship Program.
• Provide scientists with DNA samples
through the Victor Henschel BioBank.
• Work with federal policymakers to
increase government investment in
psoriatic disease research.
• Promote patient involvement in research studies and clinical trials.
Our mission: Join us. Be involved.
• Become an advocate• Volunteer• Participate in Walk to
Cure Psoriasis• Help find a cure
Help find a cure - please join us
1K & 5K Walk RoutesLincoln Memorial Reflecting Pool
Saturday, September 20, 2014
Why I walk
Walk to Cure Psoriasis
has raised over $8 million
towards improving the lives of people with
psoriatic diseases and accelerating a cure.
It’s Fun and Easy
• Easy 1K or 5K routes• Family Friendly• Form a team• Be creative • Entertainment & food
Registration begins at 8:00 a.m.Walk begins at 9:00 a.m.
Psoriasis and Psoriatic Arthritis Health Fair
Don’t miss the opportunity:
• Get treatment information• Learn more about disease
management• Explore wellness tips• Try product samples
How can you start?
Saturday, September 20, 2014
Lincoln MemorialReflecting Pool
To register, visit www.psoriasis.org/walk/wdc
What You Will Learn Today
• The relationship between psoriasis, psoriatic arthritis and inflammation.
• Risks associated with psoriatic diseases and other serious health conditions such as heart disease, diabetes and depression.
• How to lower risks, reduce pain and other symptoms while taking a holistic approach to care.
The Role and Impact of Inflammation
Rishi R. Patel, M.D., F.A.A.D., F.A.S.D.P.
Dermatologist and DermatopathologistDermAssociates, P.C.
Silver Spring, MD
Psoriasis isa noncontagious, chronic, inflammatory disease
of the immune system that affects the skin and/or joints
PsoriasisGenetic
Predisposition
TriggersTrauma, infection,
drugs, stress
Skin cell proliferationInflammation
Itch
Immune Dysregulation
What is Inflammation?
Inflammation is a natural part of the body’s immune process which is
designed to protect the body from infection, bacteria and viruses.
Acute vs. Chronic Inflammation
• Normal T-cell (white blood cell) response to injury or infection
• Characterized by: redness, heat, swelling and pain
• Duration self-limited short-term damage
• Body recovers
Acute Inflammation Chronic Inflammation
• Immune cells overact inside the body
• Is persistent
• Duration NOT self-limited Damage does not repair
• Can contribute to development of serious health conditions
Acute Inflammation
The Role of T-cells in Psoriasis
T cells can become activated in the absence of an identifiable antigen
Activated T cells (“Th1” and “Th17”) release cytokines (biological chemicals) prompting inflammation and recruitment of other inflammatory cells (neutrophils)
Such inflammation leads to the overproduction of
skin cells
Overproduced skin cells do not mature and build up forming red plaques with piles of white scales
Psoriasis Inflammation Cycle
How Inflammation Shows Up In Psoriasis
Plaque Psoriasis Guttate Psoriasis
Inverse Psoriasis Pustular Psoriasis
About Psoriatic Arthritis
Psoriatic Arthritis and Inflammation
• Psoriatic arthritis is caused by abnormal activity of the body’s immune system
• Persistent warmth and swelling (inflammation) around a joint can lead to damage if not treated
Relationship Between Skin and Joint Inflammation (Psoriasis and Psoriatic Arthritis)
Nograles KE et al. (2009) New insights into the pathogenesis and genetics of psoriatic arthritis Nat Clin Pract Rheumatol doi:10.1038/ncprheum0987
Psoriatic Arthritis and Inflammation
Psoriatic Arthritis and Inflammation
• Pain and stiffness• 50% have morning stiffness greater than
30 minutes, improved with activity• Neck pain, back pain, heel (Achilles) pain• Needs to be distinguished from
osteoarthritis, gout, rheumatoid arthritis (see a rheumatologist)
Psoriasis is More Than Skin Deep
Results in:
• Chronic inflammation of the skin and sometimes joints (psoriatic arthritis)
• May cause inflammation elsewhere in the body leading to serious health conditions such as heart disease, diabetes, Crohn’s disease, depression
Psoriasis and InflammationThe image at left shows increased inflammation: (A) in the patient's right knee joint and surrounding muscle and in the ankle;
(B) throughout the liver;
(C) in the wall of the aorta and arteries in both thighs that lead to the aorta; and
(D) on the skin in the lower parts of the legs, consistent with inflammation of psoriasis plaques.
Severity of Psoriasis
Definite link between the
severity of psoriasis and the
odds of developing other
serious health conditions
Potential Impact of Psoriasis and Inflammation
Having moderate to severe psoriasis increases risks by up to:
• 28 percent for coronary heart disease• 30 percent for development of psoriatic arthritis• 43 percent for having a stroke• 46 percent for the development of Type 2 diabetes• 58 percent for having a major cardiac event• 85 percent for developing peripheral vascular
disease
Other Serious Health ConditionsAssociated with Psoriasis and Psoriatic Arthritis
• Sleep apnea• Crohn’s Disease• Cancer/lymphoma• Nonalcoholic steatohepatitis (NASH)• Chronic obstructive pulmonary disease
(COPD)• Increased mortality
Why increased risk?
• Environmental factors (smoking, stress, obesity, alcohol)
• Genetic factors associated with psoriasis, cardiovascular disease and diabetes
(PSORS 2,3,4; CDKAL 1; ApoE4; TNF-AIP 3, Il-17, IL-18)
• Degree of inflammation (external & internal)
• Treatment choices
• Psychological impact
Psoriasis vs Atherosclerosis:Common inflammatory pathways
Atherosclerosis
Shared pathway: Diabetes
TH-1 cytokines are molecules in the immune system known to promote inflammation and insulin resistance.
Shared pathway: Crohn’s Disease
IL–12 and IL-23 are cytokines believed to
be responsible for overstimulating the
immune system and causing at least two
autoimmune diseases – psoriasis and
Crohn’s Disease
Psychological Impact
• Depression is 2.7 times more likely in those who have psoriasis
• More than 50% of those who have psoriasis have anxiety which may increase risk of a flare
Creates a cascade of physiological changes that increase risk of other diseases
It’s complicated
Psoriasis and/or
Psoriatic Arthritis
Autoimmune
Disease
Psoriasis
InflammationPain
Chronic Disease
Fatigue Depression Stress
Painful Joints
Joint Damage
Treatments
Risk Factors / co-morbid conditions
I want a cure
How to OutsmartPsoriasis and Psoriatic Arthritis
from the Inside Out
Treat Your Psoriasis and Psoriatic Arthritis
Treating your psoriasis and psoriatic arthritis will: • Improve your physical and emotional well being
• Help reduce inflammation and potential risks associated with serious health conditions
• Help reduce symptoms associated with pain, swelling and potential joint destruction
Treatment Options for Psoriasis
Systemics
AcitretinMethotrexateCyclosporine
RetinoidsPhototherapy
UVBNarrowband
PUVAExcimer Laser
Biologics
Etanercept (Enbrel)Adalimumab (Humira) Ustekinumab (Stelara)Infliximab (Remicade)Topicals
CorticosteroidsVitamin D analogs
TazaroteneTar
AnthralinEmollients
Monotherapy
CombinationTherapy
RotationalTherapy
SequentialTherapy
Treatment Options for Psoriatic Arthritis
Oral Systemics
MethotrexateLeflunomide (Arava)
Sulfasalazine Hydroxychloroquine (Plaquenil)
Apremilast (Otezla)Corticosteroids
BiologicsEtanercept (Enbrel)
Adalimumab (Humira)Infliximab (Remicade)Golimumab (Simponi)
Certolizumab pegol (Cimzia) Ustekinumab (Stelara)
NSAIDs
Non-prescriptionand
PrescriptionAdjunct TherapyHot/cold packs
Physical therapyAcupunctureVitamin D?
Fish Oil?
The “Autoimmune” System: block TNF:
Naïve helper T-cell, TH0
TH-1 CD4 cell
Activ-ated LHC
TH-17 Cell
Keratinocyte(Normal)
Keratinocyte(Psoriasis)
LHC
IL-23
IL-12
IL-17 TNF-α
TNF-α
INF-γ
IL-23
TNF-α
Adalimumab (Humira)Etanercept (Enbrel)Infliximab (Remicade)Golimumab (Simponi)Certolizumab (Cimzia)
New Treatment OptionApremilast (Otezla)
Oral drug - Phosphodiesterase-4 inhibitor (Celgene®) for psoriatic arthritis
Anti-inflammatory
Results may be limited by nausea, diarrhea, and effectiveness
Now available through specialty or mail order pharmacies
Upcoming Treatments
Anti IL-17/IL-17RSecukinumab (Novartis),
Ixekizumab (Eli Lilly), Brodalumab (Amgen)
Monoclonal antibody blocks IL-17 (AIN457, LY2439821 or IL-17 receptor (AMG 827)Phase III for psoriasisPhase II for psoriatic arthritis
The “Autoimmune” System: block IL-17 (coming soon)
Naïve helper T-cell, TH0
TH-1 CD4 cell
Activ-ated LHC
TH-17 Cell
Keratinocyte(Normal)
Keratinocyte(Psoriasis)
LHC
IL-23
IL-12
IL-17 TNF-α
TNF-α
INF-γ
IL-23
TNF-α
Key: IL = interleukinINF = interferonLHC = Langerhans cellTNF = Tumor necrosis factorTH = T-helperCD = cluster of differentiation
Upcoming Treatments
Anti IL-23(MK 3222 Tildrakizumab (Merck),
Guselkumab (Janssen)
Monoclonal antibody blocks IL-23 Phase II Pathway is also blocked by Stelara®
The “Autoimmune” System: block IL-12/23 (ustekinumab)
Naïve helper T-cell, TH0
TH-1 CD4 cell
Activ-ated LHC
TH-17 Cell
Keratinocyte(Normal)
Keratinocyte(Psoriasis)
LHC
IL-23
IL-12
IL-17 TNF-α
TNF-α
INF-γ
IL-23
TNF-α
Key: IL = interleukinINF = interferonLHC = Langerhans cellTNF = Tumor necrosis factorTH = T-helperCD = cluster of differentiation
Learn What Triggers Your Psoriasis
Known triggers for a psoriasis flare include:
• Stress• Smoking, alcohol and
drug use• Injury to the skin
(Koebner Phenomenon)• Strep infection• Medications• For some – diet, weather
Get Screenedfor other health conditions
Visit your primary care provider regularly to check:
• Blood pressure (at every visit pending frequency of visits and other health conditions)
• Blood sugar (> age 45, every three years)• Cholesterol (at annual physical)
If you already have other health conditions, see a specialist for treatment and care.
Screening Guidelines
Other Health Condition Screening Criteria
High blood pressure* ≥ 120/80 mm Hg
Pre-diabetes**(at increased risk for diabetes)
FPG 100 – 125 mg/dl
Diabetes** FPG ≥126 mg/dl
Cholesterol*(pending risk for heart disease from low to very high risk)
Total cholesterol: < 200 mg/dlHDL: Women 50 mg/dl or higher Men 40 mg/dl or higherLDL: < 160 mg/dl to < 70 mg/dlTriglycerides: < 150 mg/dl
BMI (Body Mass Index) < 25 kg/m
Smoking and alcohol use If you smoke, stop. Reduce or eliminate alcohol use.
*American Heart Association Screening Guidelines 2011**American Diabetes Association Clinical Practice Guidelines 2013
Lifestyle Choices: What You Can Do
Lifestyle choices you can make to help reduce your risk factors include:
• Maintain a well-balanced diet and a healthy weight• Increase activity levels• Get plenty of rest• Stop smoking and limit alcohol intake• Address stress issues• Maintain a positive attitude
If you need help, look for resources to help support your efforts.
Foods That May Promote Inflammation
• Processed foods (snacks)• Sugary foods• White flour, white rice• Omega-6 fatty acid (found in various meats, cow’s milk)• Processed meats (corn/grain fed)• Vegetable shortening (high Omega-6)• Alcohol
Foods That May Reduce Inflammation• Omega 3 fatty acids: cold water fish (salmon, mackerel, sardines, herring), walnuts• Seeds (flax, pumpkin, sunflower)• Foods rich in monounsaturated fatty acids (avocado, olive oil, nuts)• Leafy greens and colorful vegetables (Squash, spinach, kale, broccoli, carrots)• Fresh fruit (strawberries, blueberries mangoes, figs)
Tips to Help Improve Your Eating Habits
• Use the “Plate Method”, a 9” plate consisting of:
- Half vegetables
- Quarter protein
- Quarter starch
• Free resources to help with weight loss include:
-SparkPeople
-My Fitness Pal
-Choose My Plate
-Mobile apps: MealSnap.com
Fooducate.com
General Exercise Recommendations
• Start slow with 10 minute increments and work up• Consult a health care provider before beginning an
exercise program • Work up to 30 to 60 minutes of moderate to intense
exercise, 5 days a week into your daily routine• Try yoga, swimming, walking, bicycling• Seek help and support when needed• Find a friend or family member to join you
Work with Your Health Care Team
• Communicate with your health care providers about your health care needs
• Be prepared for your provider visits – identify your question before your visit
• Be informed about risks and benefits for treatment options
• Take medication as prescribed
• Seek help and support when needed
To Help Outsmart Psoriasis and Psoriatic Arthritis
• Be aware of risks associated with inflammation• Treat your psoriasis and/or psoriatic arthritis and
learn what your treatment options are• Seek to identify your triggers• Be screened for other health conditions• Make lifestyle changes if appropriate• Communicate with your health care team
11:00 – 11:15 a.m. Break
The Emotional Impact of Psoriasis and Psoriatic
Arthritis
Ralph W. Wilson, N.D., M.S.Licensed Naturopathic Physician,
Counseling, Coaching and BiofeedbackWashington, D.C.
Psychosocial Impact of Psoriasis
Key findings from the National Psoriasis Foundation:
• 28% have another chronic inflammatory disease• 59% experience physical pain with their psoriasis• 63% said psoriasis negatively impacts their overall
well being• 71% said they feel helpless• 73% feel angry or frustrated
Results based on 6 years of summarized data from nearly 5,000 survey participants
with psoriasis and/or psoriatic arthritis.
Common Feelings
• Stress• Anxiety• Low self-esteem• Anger• Rejection• Embarrassment• Alone or isolated• Low mood or
depression
Stress and Psoriatic Diseases
• Creates a cascade of physiological changes that increase risk of disease
• Thoughts become more negative
• Causes psoriasis to flare
• Psoriasis causes stress
• Relieving stress doesn’t always stop a flare
• Stress increases unhealthy behaviors
Stress and Psoriatic DiseasesCan Impact Family Members
• Can be hard to deal with a person who is physically uncomfortable, emotionally down or irritable
• Financial impact if a spouse is unable to work
• Financial impact of medical bills
• Parental stress if a child is having issues coping or being bullied
• Other stressors (i.e. aging parents, lack of employment)
Anxiety and Psoriatic Diseases
Feeling anxious or tension results in:
• Physical reactions (heart racing, palpitations, stomach churning, muscle
tension, dry mouth)
• Feeling frightened or panic, need to escape• Change in behavior• Negative thoughts
Low Self-Esteem and Negative Thoughts
Common negative thought patterns include:
• Over-generalization• It’s “catastrophic”• It’s all personal• Ignoring the positive
Depression
Depression is a “whole body” illness, involving the body, mood and thoughts. It can
affect how you eat and sleep,how you feel about yourself
and how you think.
Signs of Depression
There are many signs related to depression. They include feelings of:
• Fatigue• Persistent sadness, anxious, or empty mood• Hopeless and pessimistic• Guilt, worthlessness and/or helplessness
Other Signs of Depression• Sleep problems (either inability to sleep or sleep
too much)• Change in eating habits (under or overeating)• Persistent physical symptoms that don’t respond to
treatment• Loss of interest in activities previously enjoyed• Restlessness and irritability• Difficult concentrating• Diminished self-esteem• Thoughts of suicide
Does everyone with psoriasis and psoriatic arthritis
feel this way?
No
Take Charge of Your Life
Coping and Stress Relaxation Tips
• Exercise (walking, swimming, bicycling, etc.)• Stop negative thoughts midway• Talk with friends, family or a mentor for support• Self-care
(change lifestyle habits: improve eating, obtain
adequate sleep, etc.)• Try relaxation exercises
(Ex. meditation, guided imagery, progressive
muscle relaxation, breathing exercises)
No
Guided Meditation Exercises
No
Stress Relaxation Tips: Try Yoga
• Improves muscle tone, joint mobility, sleep and mood• Choose a gentle yoga class if you have psoriatic arthritis• Check with a health care provider or physical therapist
before beginning any exercise program• To find a yoga instructor near you: International Association
of Yoga Therapists at www.iayt.org
Strategies to Address Negative Thoughts
Challenge your negative thought patterns by asking yourself:
• What is the evidence that this thought is true?• Am I predicting the future negatively?• Are there alternative interpretations which are
more realistic?• Am I making things worse than they are?• Does this thought help me succeed?• Does it really matter?
What to Do if People Stareor Say Something Rude
• Nod or smile at the person to indicate you are aware of them
• If staring persists, frown to indicate your displeasure
• If not effective, say a comment such as “I have psoriasis. Don’t worry it isn’t contagious.”
• Quick effective comments works best.
Emotional Impact of Psoriatic Diseases
If you are experiencing feelings of sadness, depression, anger,
frustration, hopelessness, etc. because of your psoriasis and/or
psoriatic arthritis, talk with a health care provider and consider seeking
psychological help.
Where to Obtain Help(Anxiety, depression, negative thoughts)
• Ask your health care provider for a referral -PHQ-9 (Patient Health Questionnaire)
• Look for mental health providers in your area
-American Psychological Association
www.apa.org/helpcenter/
Find a psychologist feature
-www.psychologytoday.com
Find a psychiatrist (physician or nurse)
Other Resources to Help You
• National Psoriasis Foundation www.psoriasis.org / www.TalkPsoriasis.org
• UCLA Free Guided Meditation Exercises
www.marc.ucla.edu/body.cfm?id=22
• Nutrition Resource: SparkPeople www.sparkpeople.com
• MyFitnessPal www.myfitnessPal.com
Resources to Help You:One to One Mentor Program
Improve your health with a support system
Voice concerns and get answers to your questions about psoriasis
and psoriatic arthritis
To request a mentor visitwww.psoriasis.org/one-to-one
Resources to Help You: Webcasts
What are Your Issues About Psoriasis and/or
Psoriatic Arthritis?
Small Group Discussion20 Minutes
(11:45 a.m. to 12:05 p.m.)
No
• Identify treatment issues that impact your
psoriasis and/or psoriatic arthritis.
• What are your group’s most prevalent
feelings about having psoriasis and/or
psoriatic arthritis?
• What barriers, issues or fears are contributing factors?
Within your group discuss:
Large Group Discussionand Q & A
in Five Minutes No
Questions for Dr. Patel & Dr. Wilson
Large Group Discussion(12:05 – 12:25 p.m.)
Please Complete Your Evaluation Form
Saturday, September 6, 201410:30 a.m. – 1:00 p.m.
Washington Marriott at Metro Center
For more information call800.723.9166 ext. 362
Our thanks to: Dr. Rishi Patel and Dr. Ralph Wilson To all of you for attending Our sponsors: AbbVie, Amgen, Janssen Biotech, Novartis
Please Complete Your Evaluation Form
Help find a cure - please join us
Lincoln Memorial Reflecting PoolSaturday, September 20, 2014
1 and 5K routes