salt lake city more than skin deep presentation may 17, 2014

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 find a cure for psoriasis and psoriatic arthritis and to eliminate their devastating effects through

research, advocacy and education.

Our mission: Connection

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

Our mission: Connection

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• Donate• Help find a cure

HOPEACTIONCONNECTION

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

Kristina Callis Duffin, M.D., M.S.

Co-Director, Utah Psoriasis InitiativeAssistant Professor

Department of Dermatology, University of UtahSalt Lake City, Utah

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

Wound:•Injury to skin•entry of bacteria

Body: •Stop the bleeding•Send Inflammatory cells•to kill pathogens•Activate tissue repair

•INFLAMMATION

Mechanisms of Disease Psoriasis Nestle et al. N Eng J Med 361;5 July 30, 2009

Mechanisms of Disease Psoriasis Nestle et al. N Eng J Med 361;5 July 30, 2009

Inflammation in Psoriasisstressed

T cells mature and propogate

Skin cells stressed, signals released

Dendritic cells activated, secrete cytokines

Other cells (neutrophils) get recruited

More cytokines

Charge!

The Role of T-cells in Psoriasis

T cells become activated (without identifiable cause)

Activated T cells (“Th1” and “Th17”) release cytokines (biological signals) 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

How Inflammation Shows Up In Psoriasis

The most common form of

psoriasis. Characterized by raised patches

called lesions or plaques which are covered by

silvery white scale.

Sudden onset, raindrop lesions, often preceded

by a sore throat

Found in skin folds: armpits, groin, under the breast. May lack

scale.

Lesions with sterile pus. May require hospitalization.

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

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% for coronary heart disease• 30% for development of psoriatic arthritis• 43% for having a stroke• 46% for the development of Type 2 diabetes• 58% for having a major cardiac event• 85% for developing peripheral vascular disease

Other Serious Health ConditionsAssociated with Psoriasis and Psoriatic Arthritis

• Sleep apnea• Crohn’s Disease• Cancer/lymphoma• Fatty liver disease• Chronic obstructive pulmonary disease (COPD)

• emphysema, chronic bronchitis

• Shorter lifespan by ~5 years

Why increased risk?

• Environmental factors (smoking, stress, obesity, alcohol)

• Genetic factors associated with psoriasis, cardiovascular disease and diabetes

• 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 can: • Improve your physical and emotional well being

• Help reduce joint pain, swelling and potential joint destruction

• Help reduce inflammation and potential risks associated with serious health conditions

Treatment Options for Psoriasis

Oral Systemics

AcitretinMethotrexateCyclosporinePhototherapy

NarrowbandPUVA

Excimer Laser

Biologics

Etanercept (Enbrel)Adalimumab (Humira) Ustekinumab (Stelara)Infliximab (Remicade)

TopicalsCorticosteroids

Vitamin D analogsTazarotene

TarAnthralin

Emollients

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?

x x

x

x x

Anti-TNF agentsEtanercept (Enbrel)Adalimumab (Humira)Infliximab (Remicade)Golimumab (Simponi)Certolizumab pegol (Cimzia)

x

x

Interleukin-12

Anti-IL-12/23 agentUstekinumab (Stelara)

New Treatment Option

Apremilast (Otezla)

Oral drug - Phosphodiesterase-4 inhibitor (Celgene®)

Anti-inflammatory

Results may be limited by nausea, diarrhea, and effectiveness

Available April 2nd 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

x

Interleukin-12

Upcoming Treatments

Anti IL-23(MK 3222 Tildrakizumab (Merck),

Guselkumab (Janssen)

Monoclonal antibody blocks IL-23 Phase II Pathway is also blocked by Stelara®

x

Interleukin-12

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• Try to maintain a positive attitude

If you need help, look for resources to help support your efforts.

Eat a Well Balanced Diet Eating healthy foods overall help reduce your risk of serious health conditions. Key tips include:

• Eat plenty of fruits and vegetables (more than five a day)

• Avoid most saturated and trans fats. Eat more low fat food choices (monounsaturated fatty acids or polyunsaturated fats (avocado, olive oil, nuts)

• Limit refined grains, choose whole

grains and eat more fiber.

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

• Consult a health care provider before beginning an exercise program

• Start slow! – 10 minute increments and work up

• 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

10:45 – 11:00 a.m. Break

The Emotional Impact of Psoriasis and Psoriatic

Arthritis

Lee Olsen, L.C.S.W.Clinical PsychotherapistSolution Focused Therapy

Salt Lake City, Utah

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

Large Group Discussionand Q & A

in Five Minutes No

Questions for Dr. Callis Duffin

& Lee Olsen

Large Group Discussion(12:05 – 12:25 p.m.)

Please Complete Your Evaluation Form

Our thanks to: Dr. Kristina Callis Duffin & Lee Olsen, L.C.S.W. To all of you for attending Our sponsors: AbbVie, Amgen, Janssen Biotech and Novartis

Please Complete Your Evaluation Form