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Psoriasis (transcript)
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(ANNOUNCER)

Major funding for Second Opinion is provided by The Blue Cross and Blue Shield Association.  An association of independent, locally operated and community based Blue Cross and Blue Shield companies supporting solutions that make safe, quality, affordable healthcare available to all Americans.

 

Second Opinion is produced in association with the University of Rochester Medical Center, Rochester, NY.

 

(MUSIC)

 

(Dr. Peter Salgo)

Welcome to Second Opinion where you get to see first hand how some of the countries leading healthcare professionals tackle health issues important to you.  Well each week our studio guests are put on the spot with medical cases based on real life experiences and by the end of the program you’re going to learn the outcome of this week’s case.  And by the way, you’ll be better able to take charge of your own healthcare too.  I’m your host, Dr. Peter Salgo, and today our panel includes our Second Opinion primary care physician Dr. Lou Papa from the University of Rochester Medical Center, clinical psychologist Dr. Vickie Dowling, Dr. Christopher Ritchlin from the University of Rochester Medical Center and Dr. Alexa Kimball from Harvard Medical School.

All right folks, let’s get right to work.  I want to tell you about our case today, it begins in the pediatrician’s office Lou with Sarah, she’s 15 years old, a cheerleader and the chart says she’s also a soccer player and an honor student.  At the age of 8 Sarah was diagnosed with guttate psoriasis.  Okay, what’s psoriasis?

 

(Dr. Lou Papa)

Psoriasis is an autoimmune skin condition where the skin excessively grows, it can crack, it can bleed, it scales.  It comes in various different forms.

 

(Dr. Peter Salgo)

And guttate is one of them?

 

(Dr. Lou Papa)

One of those forms, yep.

 

(Dr. Peter Salgo)

Why does psoriasis look the way it does?

 

(Dr. Alexa Kimball)

A number of different reasons, the first is that the skin cells are turning over very, very quickly, overgrowing and so you get a lot of scale on the surface because, and thickness, because the skin can’t shed it in time.

 

(Dr. Peter Salgo)

A piling up from below?

 

(Dr. Alexa Kimball)

The other interesting thing is that you do get more blood vessels that grow to support all of that growth and that gives it the very red, ugly look that people really don’t like.

 

(Dr. Peter Salgo)

Well, Sarah was diagnosed with psoriasis at the age of 8.  Isn’t that unusual Vickie?

 

(Dr. Vickie Dowling)

Many children have been diagnosed as youngsters.  I myself actually was diagnosed as a youngster but it went into remission and didn’t come back again until much later.

 

(Dr. Peter Salgo)

So you have psoriasis?

 

(Dr. Vickie Dowling)

I do have psoriasis.

 

(Dr. Peter Salgo)

And how old were you when it first started?

 

(Dr. Vickie Dowling)

I was first diagnosed when I was 10.  I suspect it was earlier than that because I had “allergies”.

 

(Dr. Peter Salgo)

That brings up the obvious question, if it was first diagnosed when you were 10, how do you make the diagnosis?

 

(Dr. Christopher Ritchlin)

So the diagnosis is made by visual inspection and in this case the guttate is very interesting because that means drop like, so these are drop like individual lesions that occur on the skin and are often seen in the setting of a streptococcal infection.

 

(Dr. Peter Salgo)

Just how common is this disease?

 

(Dr. Alexa Kimball)

Well it effects about somewhere between 2 to 3% of the population and a good proportion are diagnosed as children although I will say misdiagnosis as eczema which is often very common in children as well is pretty usual so it may take a little bit of time to get to the right diagnosis and the right person to make that call.

 

(Dr. Peter Salgo)

How do you make that distinction?

 

(Dr. Alexa Kimball)

For people who see a lot of psoriasis most of the time it’s a pretty classic presentation in that it’s pretty clear when you look at it but there are cases that are less clear.  This guttate presentation of lots of little dots really doesn’t happen with anything else.

 

(Dr. Peter Salgo)

Sarah’s chart indicates that her mother, two aunts and her uncle all have psoriasis.  So is this a genetic disease and if you don’t have any relatives who have it are you safe?

 

(Dr. Lou Papa)

It is a genetic disease, in fact it’s in my family.  I have a brother, two nephews, my mother and a sister who have it.

 

(Dr. Peter Salgo)

So there’s a genetic predisposition but just because your family has psoriasis, does that mean you’re going to get it?

 

(Dr. Christopher Ritchlin)

This is a classic example of a disease in which there is a genetic predisposition but there is environmental factors that can lead to the development of psoriasis individuals.  Some of these factors include infection perhaps in the case here, trauma, medications and a variety of other insults and we still don’t fully understand that can lead to the development in a patient who may have the genetics for the disease.

 

(Dr. Peter Salgo)

Where does it typically appear on the body?

 

(Dr. Alexa Kimball)

The most common places especially in adolescents and adults will be the scalp, the arm, elbows and the knees.  And one of the reasons we think it occurs there is those are areas of trauma so there often, you put your elbows on the counter, your knees rub up against things and that sort of trauma to the skin tends to make it come out.  And again eczema in contrast tends to be in the reverse places, insides of the arms, backs of the knees, so again that can be used to help distinguish it as well.

 

(Dr. Peter Salgo)

That’s interesting, that’s one way you can make the differential.

 

(Dr. Alexa Kimball)

It helps.

 

(Dr. Peter Salgo)

Between psoriasis and some other skin condition.  And again we mention Sarah has guttate psoriasis, what are the other types?

 

(Dr. Alexa Kimball)

Well plaque is by far and away the most common and people when we talk about plaque may have small ones or they could have huge ones and then two other forms that are less common fortunately include what’s called pustular psoriasis, where you get actually little pockets of puss particularly on the palms and soles and that also can spread throughout the body.  And then something called erythroderma, which means just red skin.  So it’s red skin everywhere essentially.

 

(Dr. Peter Salgo)

So what are we seeing here?  This is guttate?

 

(Dr. Alexa Kimball)

This would be guttate.  Again sort of the concept of little tiny dots, sort of like rain drops scattered all over the skin.  And this would be more classic, more of a moderate to severe case.  Classic plaque psoriasis with larger areas and a few small ones too.  And again, you can see all the scale and kind of the redness and the thickness of those.

 

(Dr. Peter Salgo)

And that’s on the arm?

 

(Dr. Alexa Kimball)

That’s on the arm, hmmhmm.

 

(Dr. Peter Salgo)

And there it is on the hand?

 

(Dr. Alexa Kimball)

And there it is on the hands right.  Again I think what’s interesting here is you can see a lot on the knuckles right, so again an area with frequent rubbing and as we talk about the impact psoriasis has, obviously this is something that is very hard to masquerade or hide.

 

(Dr. Peter Salgo)

All right, well I’ll tell you Sarah’s pediatrician takes a look at her and sees that her psoriasis looks a lot worse than it did since the last time she was in the office so the pediatrician cultures Sarah’s throat and finds that Sarah tests positive for streptococcus or strep throat.  Why did this pediatrician test for strep?

 

(Dr. Lou Papa)

That’s actually a pretty common exacerbant for psoriasis even in the adults we look for that as well. 

 

(Dr. Peter Salgo)

Is that right?

 

(Dr. Lou Papa)

Yup.

 

(Dr. Alexa Kimball)

The way we’ve thought about it although we haven’t completely proven it yet is that you get a strep infection, your body’s immune system revs up to deal with that.  There are parts of the skin that look like strep that aren’t strep possibly.  And so your body starts to react to them as well.  So you get sort of a misprogramming that results in your skin, there’s no strep infecting your skin per say.  It’s actually the part in your throat that’s the problem.

 

(Dr. Peter Salgo)

So again to close the loop here, you started off by saying it’s autoimmune, your immune system triggered by strep and confused by strep, then becomes immune to itself in the skin?

 

(Dr. Alexa Kimball)

Correct.

 

(Dr. Peter Salgo)

Well that’s not great.

 

(Dr. Alexa Kimball)

No and that’s why you have it forever because once that’s triggered, unprogramming that immune system to not react is pretty much impossible to do.

 

(Dr. Peter Salgo)

Again I want to move on a little bit about Sarah.  The pediatrician finds that her rash has spread to her scalp, her legs, her trunk and her breasts.  And she’s a teenager and she’s wearing this disease on her skin, what’s she going through emotionally Vicky?

 

(Dr. Vickie Dowling)

She’s probably having a lot of mixed feelings, a lot of shame and stigma, humiliation because of the visibility and because she’s at such a tender age, being a teenager your looks are really important.

 

(Dr. Peter Salgo)

Well you went through this, what was it like for you?

 

(Dr. Vickie Dowling)

I was pulled out of school when I was 10 years old for months so I didn’t really have to go through that embarrassment and shame when I was younger but my next flare wasn’t until I was a freshman in college and I was very stigmatized.  I lost boyfriends and friends, I came back from sophomore year I was completely 100% covered and was very stigmatized feeling.  People were shunning me, they didn’t know what to do because I had full body coverage, I mean literally head-to-toe and had other complications with edema which is a swelling of course as you know.  People thought I was a third degree burn victim.  I was 19 years old and I lost my hair so people thought I had cancer at that point afterwards as my skin started improving.  So it was very stigmatizing and it in fact has led me to where I am hoping to make a difference in people as a role model.

 

(Dr. Peter Salgo)

You use words like stigmatizing, it was difficult, people looked at me differently.  But I’m not getting the flavor of what it felt like to be you.

 

(Dr. Vickie Dowling)

Very lonely, very depressed.  Very, very, very isolated.  And those are things that I think a lot of people don’t talk about, I cover it up, I didn’t want to be seen by anybody and when I was a sophomore and was completely covered, I couldn’t function.  I couldn’t feed or dress myself because I had psoriatic arthritis as well and because the psoriasis was so bad and enflamed I couldn’t hold things or touch things, there was too much pain.

 

(Dr. Peter Salgo)

What were you thinking?  What thoughts went through your head?

 

(Dr. Vickie Dowling)

I wasn’t sure if I would ever be normal again.  And I didn’t know if I’d have friends again because I also moved across the country so I lost my support network which is what I think is one of the most important things for people.

 

(Dr. Peter Salgo)

So Sarah must be going through a really tough time?

 

(Dr. Vickie Dowling)

Absolutely.

 

(Dr. Peter Salgo)

And that’s the cosmetic aspect of the disease but there’s more here right?

 

(Dr. Christopher Ritchlin)

There’s a lot more, so as already mentioned, there’s Vickie the emotional component which is powerful, but these patients can also have other problems, they have a higher amount of diabetes, high blood pressure and even heart disease.  Now this girls young but these are the kinds of concerns we would have as she gets older.

 

(Dr. Peter Salgo)

What about Crohn’s disease?  Part of the picture?

 

(Dr. Alexa Kimball)

Higher rates of really every autoimmune disease related.  But just to emphasize something Vickie was bringing up, it’s not just that it looks scary and people think it’s contagious but it hurts and it bleeds and it cracks and it itches.  And so there’s a level of profound discomfort, I mean think about you burn your little finger tip and how painful that can be, think about if 10% of your body scattered in 50 spots has that kind of distress then think about if your whole body is covered that way, and so I think we have underestimated to some extent in the past the physical discomfort associated.

 

(Dr. Lou Papa)

And it’s interesting because for my patients and family, especially my brother, that was the biggest issue.  He’s actually a funeral director so the cosmetic issue is a big deal but the cracking and bleeding, the pain that came from that because he has large plaque psoriasis was and still is the most frustrating thing for him.

 

(Dr. Peter Salgo)

And Vickie mentioned something which is psoriatic arthritis.  What’s that?

 

(Dr. Christopher Ritchlin)

So about a quarter of patients with psoriasis develop an inflammatory arthritis which is different from osteoarthritis which is a disease we see in aging, it can involve any of the joints but unlike rheumatoid arthritis it can also involve the spine, it can involve the digits, it can get swollen, the tendons and ligaments and it’s seen in up to 600,000 patients in the United States and it can be very debilitating and cause chronic problems for patients over time.  You take the joint problems and combine that with the skin issues we just addressed and these patients really go through a lot of pain and suffering in their every day lives so it’s more than just skin deep.

 

(Dr. Peter Salgo)

All right, what I want to do is just take a moment and sum up what we have been talking about so far cause we are talking about psoriasis which is a chronic, autoimmune disease for many beginning in childhood with strong genetic pre-dispositions.  An outbreak though is often triggered by injury to the skin or stress or medication and even though psoriasis is not contagious, patients often feel stigmatized by the disease.  And of course we are talking about Sarah who happens to have psoriasis, she is 15 years old, she’s been living with psoriasis for the past 7 years and also sharing her story with us is Vickie.  And we’re thrilled you’re here Vickie by the way.  Thank you.  Sarah’s pediatrician decides that, remember Sarah had strep throat, she’s going to go ahead and give her some antibiotics and then have her follow up with a dermatologist.  Does it make sense for her to have her pediatrician manage her care?

 

(Dr. Christopher Ritchlin)

Certainly I think it’s essential for the primary care dermatologist team to be leading the charge and taking care of these patients but if they have joint problems obviously you’re going to have a rheumatologist involved, if they have Crohn’s disease as you mentioned they may have gastroenterology.  So I think the most important point is you have to take a comprehensive view to treating these patients which depends on the manifestations.  And very important are the psychologic and psychiatric issue often overlooked in this patient population.

 

(Dr. Alexa Kimball)

Absolutely

 

(Dr. Peter Salgo)

I was going to say, in an era when we’re sending people to the dermatologist for this and the rheumatologist for this, the psychosocial aspects can get lost in the shuffle can’t they?

 

(Dr. Vickie Dowling)

And they are absolutely essential.  Like I said, I lost my social support network and especially a teenagers age as Sarah is, she’s very vulnerable.

 

(Dr. Peter Salgo)

Well I can tell you that over the past 10 years, Sarah’s dermatologist has treated her with coal tar, more about that because I want to talk about coal tar.  Topical steroids, steroids you put on the skin, umm calcipotriol, and short courses of narrow band phototherapy.  You were mouthing that along with me, it’s like responsive reading isn’t it?  You want to break all this down for me?  What’s going on here?

 

(Dr. Alexa Kimball)

Coal tar goes back to the Egyptians and it was one of the very first therapy’s obviously tried in psoriasis and frankly we have no idea why it works and it is smelly and it is yucky and…

 

(Dr. Peter Salgo)

It’s a petroleum byproduct right?

 

(Dr. Alexa Kimball)

And many people have tried to figure out what’s the secret sauce in the coal tar that we can pull out to fix this and make it more elegant and no one has done it.  Once calcipotriene came out on the market which is a vitamin D analog, derivative in a cream, coal tar has really faded in terms of how much it’s used.

 

(Dr. Peter Salgo)

We did talk about or mention phototherapy, so what’s that?

 

(Dr. Alexa Kimball)

Well so as a dermatologist in general we tell you to stay out of the sun right with the exceptions of a few skin diseases that are incredibly responsive to light.  What we do is essentially have a light box and for someone who is 15 years old, this is a very nice strategy at this point in her time.  She has tons and tons of little dots, impractical completely to spot all of those dots with a cream or a lotion or a potion.  So doing something that kind of gets her whole skin at once is what is important.  And because it is not, it doesn’t have any effect on her inside unlike some of the other therapy’s we may talk about, the safety profile should be really quite good.

 

(Dr. Peter Salgo)

Well we put skin cancer aside now?

 

(Dr. Alexa Kimball)

Well what’s interesting in the psoriasis patients, so is because their immune system is so active in their skin, we don’t see nearly as much skin cancer as you’d expect.  It’s just a very strange phenomenon.  The other thing is we give this very specific dosed light, narrow band UVB so that way you kind of get the maximum benefit without the deficit.  Tanning beds….

 

(Dr. Peter Salgo)

I was gonna say…

 

(Dr. Alexa Kimball)

Cause that’s important to note, tanning beds are primarily UVA and that is the one we are most concerned about from a skin cancer, particularly a melanoma standpoint, so while you get a smidge of UVB in those that are from bulk contamination, you would not get the same therapeutic effect and you’re really increasing the skin cancer risk.

 

(Dr. Peter Salgo)

Well it’s been about a year now Sarah is back in her pediatrician’s office with her mother.  Sarah is frustrated.  The topicals, the phototherapy, they are no longer working.  Is this typical?  Lou, do you see this?

 

(Dr. Lou Papa)

Oh yeah, I have seen patients, I’ve seen it in my family, they’ll respond for a while, they’ll do the topicals which are impractical because if you’re working you will smell, it will destroy clothes.  So that becomes impractical after a while, it will stop working and very often they will go through treatment and treatment that will stop working.

 

(Dr. Peter Salgo)

What’s the goal?  Is the goal here to be completely lesion free?  I mean what are you shooting for, what do you tell patients?

 

(Dr. Lou Papa)

For my patients with any chronic condition, that’s probably an important thing to set ahead of time because you very often when you’re treating a chronic condition you are trading one disease for another, the side effects or the bother of the treatments versus the disease.  So I think it’s a good idea beforehand to set what the goal is to see how aggressive you can get.

 

(Dr. Peter Salgo)

What was your goal?

 

(Dr. Vickie Dowling)

I didn’t really have a goal when I was so young.  In knowing how and where I wanted to go except that I didn’t want it.  Period.  And as an adult, I mean I have evolved in my thinking about it and I’m happy having minimal psoriasis.  I mean I have pretty beautiful skin and as I tell people, I have free chemical peels periodically because a lot of people I know have very nice skin if they go into remission.  Some people don’t go into remission ever but I think it’s coming to terms with your disease and being comfortable with it and that’s why it’s so important to have the social connections and meeting other people who have the illness.

 

(Dr. Peter Salgo)

Well I’ll tell you why Sarah now is at the doctor’s office.  Her knees and toes have begun to bother her, Sarah thinks it’s cause of soccer but her mom is terrified it might be something else.  So what’s her mother afraid of, I think we’ve touched on this.

 

(Dr. Christopher Ritchlin)

Yeah so her mother’s afraid that she’s got some new musculoskeletal condition or arthritis and in a young girl this age there’s a wide variety of problems that can look like this ranging from lupus to juvenile rheumatoid arthritis to psoriatic arthritis and those will all be considerations depending on what the exam shows and the history.

 

(Dr. Peter Salgo)

Psoriatic arthritis.

 

(Dr. Christopher Ritchlin)

Yes.

 

(Dr. Peter Salgo)

It’s an arthritis associated with psoriasis.

 

(Dr. Christopher Ritchlin)

Yes.

 

(Dr. Peter Salgo)

Is it bad, mild, good?

 

(Dr. Christopher Ritchlin)

Well one of the remarkable features of psoriatic arthritis is that its very diverse in its presentation and in its course.  Having said that studies are indicating that about 50% of patients have significant x-ray damage within two years of the disease.

 

(Dr. Peter Salgo)

That’s of patients who get it?

 

(Dr. Christopher Ritchlin)

Patients, new onset within two years have damage on their x-rays.

 

(Dr. Peter Salgo)

Okay so Sarah is now referred to a rheumatologist and the rheumatologist indicates that she has widespread plaque psoriasis and juvenile psoriatic arthritis.  Just what her mom was afraid of.

 

(Dr. Christopher Ritchlin)

Yes.

 

(Dr. Peter Salgo)

All right, now what?

 

(Dr. Christopher Ritchlin)

Um, the arthritis is a feature that can be seen in children although it’s less common, it’s more common in adults but this is a major problem when children have arthritis or adolescents it adds to the sense of isolation and now you’re having functional problems carrying out her daily school activities and as a cheerleader so this becomes a major problem.

 

(Dr. Peter Salgo)

You mentioned that you can get irreversible damage in the first two years which raises the obvious question, can I do anything about it?  If I catch it will therapy prevent that damage?

 

(Dr. Christopher Ritchlin)

Yeah so this is the big emphasis now is to try and diagnose these patients early, working very closely with dermatologist because they are generally the doctors and primary care doctors that see these patients first and yes there are medications we can use to retard or even prevent progression over time.

 

(Dr. Peter Salgo)

What can Sarah do now, not medication but lifestyle choices for example to make the progression of her disease and the progression of her arthritis less severe?

 

(Dr. Christopher Ritchlin)

Well lifestyle choices are difficult, you really have to treat the inflammation, she has to be treated and then the lifestyle choices really depend on how well her joints respond and then you adjust to that but not to avoid exercise that’s still very important but to do the right kinds of exercises depending on how severe the arthritis is, physical therapy and trying to maintain an exercise and proper diet are all very important.

 

(Dr. Alexa Kimball)

I would say again, for her, we haven’t mentioned whether her weight is normal or not but we actually know from some of our pediatric studies that a high proportion of kids with psoriasis are already substantially overweight or obese and that’s a very hard behavior modification and that will certainly make her arthritis worse as well.  So that would be an important part of the discussion.

 

(Dr. Peter Salgo)

The rheumatologist put her on a drug called adalimumab, what is this drug and what does it do?

 

(Dr. Christopher Ritchlin)

This is a class of drugs called anti tumor necrosis factor therapies, tumor necrosis factor is a small cytokine molecule that drives inflammation and this is a targeted therapy that blocks that molecule and interestingly enough is very very effective for not only the skin but also the joint disease so this is really a very interesting therapy because of it’s comprehensive nature.

 

(Dr. Peter Salgo)

Kind of a two-fer.

 

(Dr. Christopher Ritchlin)

A two-fer exactly.  The downside for some people is that you have to give yourself an injection because it’s given subcutaneously but it’s effectiveness is quite impressive in many people.

 

(Dr. Peter Salgo)

Well in young patients like Sarah, what role does age play in determining how aggressively you go after this disease?  Do you more aggressively in young people, less aggressively? What?

 

(Dr. Christopher Ritchlin)

Well when it comes to joint disease you go aggressive in everybody.  Because these agents are particularly effective at preventing disease progression in the joints and bones so no matter what your age you want to try and interrupt that process and I wouldn’t treat a child necessarily differently than an adult with that goal in mind.

 

(Dr. Lou Papa)

One of the things that sits very important because the joint disease is so destructive but it’s very important, this is where I get back to you trade one disease for another, these immunomodulating agents are going to increase your risk for getting infection, you need to make sure you don’t have or exposed to TB at some point and there’s a question of an increased risk for malignancies, although it may be small, it’s there over time.

 

(Dr. Alexa Kimball)

One of the remarkable things though is that over the past 10 years we do have this whole wrath of new therapies that really broke us out of the coal tar era and for the first time we really do have the ability to start to treat people the same way for a decade if we need to, it really has been really liberating for some folks.  And some of these things are quite manageable, in fact the psoriasis patients have a better safety experience with these medications than perhaps the rheumatoid arthritis patients so I don’t want to leave people with hesitancy about making that leap because I think for some people it really is the right choice.

 

(Dr. Lou Papa)

I think as always informing the patient is critical.

 

(Dr. Alexa Kimball)

Absolutely

 

(Dr. Lou Papa)

Because like with any other disease when things go bad and there’s a complication, they come back to the primary care doctor and say “why didn’t I know about this”.

 

(Dr. Peter Salgo)

What is on the horizon, what’s coming up?

 

(Dr. Alexa Kimball)

Psoriasis has moved from a research standpoint to really a first disease that people are looking at because it’s reasonably easy to test and see.  You do a joint study, you need to do specific examinations, you need to do x-rays, you need to do all sorts of things.  The end point may be a year.  Psoriasis patients they may clear dramatic disease in 12 weeks.

 

(Dr. Peter Salgo)

Okay, I just want to sum up just for a minute here, we have really good news here and it’s worth just stopping and making that very clear.  Effective treatment for psoriasis can be challenging, skin can become resistant to treatment over time and more powerful medications have serious side effects sometimes.  Treatment for the individual may change throughout lifetime, it’s important to talk to your doctor about your options but the bottom line is there are great treatments now and more on the way.  Fair enough?

 

(Dr. Christopher Ritchlin)

Fair enough.

 

(Dr. Peter Salgo)

That’s great.  Now Vickie, fair to say complicated disease that effects you physically, emotionally, socially, you seem so positive, how’d you do that?

 

(Dr. Vickie Dowling)

It took social support to start with and an education.  Educating yourselves about psoriasis and psoriatic arthritis, what it is and what the treatments are and again, networking and being supportive.  I’m supported because I’m a volunteer, I have a huge network of friends that are very dear friends who have psoriasis and psoriatic arthritis and their quality of life has sky rocketed because of the new medications.

 

(Dr. Peter Salgo)

And you know, it’s because you give them hope too though isn’t it?

 

(Dr. Vickie Dowling)

Exactly.  And I try to be a role model for others to give hope, educate people because people are scared.  They are afraid of contagion, kind of sum it up in a nutshell, give them an idea of what psoriasis is, learn enough so you can say, “hey my skin is faster acting than yours” something quick and short and sweet.

 

(Dr. Peter Salgo)

You know something, you said something earlier in the broadcast, you said your skin is beautiful.  Now speaking as a clinician, I’d like to vote yes it is.  We all agree on that?

 

(Group)

Yes

 

(Dr. Peter Salgo)

It’s remarkable, it’s remarkable.

 

(Dr. Lou Papa)

Especially after the story you told.

 

(Dr. Peter Salgo)

I want to thank you by the way for coming on the show.  It’s tough to talk about a problem that you’ve got.  Especially one that can be so socially stigmatizing.  It was brave of you to do that and thank you so much for helping us out.  After three months of treatment I can tell you that Sarah’s skin has improved significantly, also but we’re out of time.  I want to thank all of you for being here, it’s been a great discussion and it’s not often you get a serious disease that has such remarkable progress and such an explosion of good research so good news today, thank you all again.  But unfortunately we are out of time, you can continue this conversation on our website, Second Opinion-tv.org where you will find transcripts, videos, more about psoriasis and other health care topics.  In the meantime, thank you for watching and thank you all for being here, this was a great discussion.  I’m (Dr. Peter Salgo), we’re going to see you next time for another Second Opinion