Editor's Note: This story is part of a new series on HealthCentral called "Get Your Ph.D.!", which is geared toward people who've got the basics of their condition down and want to up their expertise. Who's ready to go pro?!
If psoriasis had a street name, it would be known as “Slim Shady.” Not only does the exact cause of this condition baffle even the best of scientific minds (genetics and an overactive immune system are possible culprits, as are triggers like stress, skin trauma, and weight gain), but its characteristic itchy and painful lesions can crop up anywhere from head to toe. In the world of skin conditions, psoriasis is all kinds of sly.
While there are effective treatments available to manage symptoms and stop them from getting worse—including topicals, ultraviolet light therapy, oral meds, and biologics, which target the immune system—there is yet to be a foolproof, one-size-fits-all cure. What’s more, larger implications about the relationship between psoriasis and other diseases are still a question mark. Now, thanks to groundbreaking studies from some seriously smart researchers, there is new hope for a better understanding and treatment of the condition. We talked with three of these doctors to find out what they’re working on. Caution: Majorly impressive science ahead.
Unlocking the Skin/Heart Connection
MEET THE EXPERT:
Nehal N. Mehta, M.D.
Title: Head of the Lab of Inflammation and Cardiometabolic Diseases at the National Heart, Lung, and Blood Institute (NHLBI)
Research: Exploring the link between psoriasis inflammation and heart disease
Skin health isn’t usually among the conditions a cardiologist studies, let alone treats, but for Nehal N. Mehta, M.D., psoriasis plays a starring role in his research.
It started with a single patient. “I met a 45-year-old physician who had been having recurrent heart attacks with no real risk factors, and when I examined him, I saw a patch of psoriasis on his right inner thigh that he’d had since med school,” Dr. Mehta says.
It could have been nothing, but then again, there were no other clues to go on. Dr. Mehta started wondering. On a hunch, he and his team began examining scans of people with psoriasis, and what they found was startling: The condition was not just skin deep. “When you look at these images, there’s inflammation everywhere—in the joints, in the skin, in the liver, in the spleen—this is a whole-body disease,” Dr. Mehta says.
Then they applied those findings to people who also had a heart attack. It was a eureka moment. “Even if you accounted for all the other risk factors people had for cardiovascular disease, if they had psoriasis, it increased their risk for a heart attack by 53 percent,” Dr. Mehta says.
As it turns out, the same overactive immune cells in the skin that lead to psoriasis can also be found in the heart arteries. In the arteries, however, the immune system is associated with plaque buildup—a major risk for heart attack. So if you treat the psoriasis that’s causing the immune system to be overactive, says Dr. Mehta, you can also reduce the risk of heart artery disease. “Treating remote inflammation in the body can reduce the plaque that leads heart disease and heart attack,” he says.
The treatment he uses is a biologic medication—a protein-based injectible drug created from living cells that targets the areas of the immune system associated with psoriasis. “Using a biologic treatment redistributes fat in your body in a beneficial way, so you’re not only improving the skin but also HDL, the body’s good cholesterol, as well as glucose levels which reduces the risk for diabetes.”
Why are these findings so crucial? In addition to showing that patients with psoriasis may warrant early heart disease intervention, says Dr. Mehta, it also reveals a new risk factor (and treatment) for people with heart conditions. Along with diabetes, hypertension, high cholesterol, family history, and smoking, inflammation from psoriasis is an important variable in cardiac events. “You have patients who are now learning about a sixth risk factor for heart attacks—it’s pretty wild,” he says.
Shedding Light on Skin Disease
MEET THE EXPERT:
Joel Gelfand, M.D.
Title: Director of the Psoriasis and Phototherapy Treatment Center and Professor of Dermatology at University of Pennsylvania Perelman School of Medicine
Research: Studying the benefits of at-home phototherapy treatment
Long used to help treat psoriasis, Ultraviolet B phototherapy improves symptoms by penetrating the top layer of the skin with narrowband UVB light, preventing skin cells from growing too quickly. Patients prefer it to systemic medications because it’s virtually free of side effects. But phototherapy is expensive, time consuming (it requires 12 weeks of in-office treatments), and not always covered by insurance.
Enter: Joel Gelfand, M.D., the director of the Psoriasis and Phototherapy Treatment Center and a professor of dermatology at University of Pennsylvania Perelman School of Medicine. Dr. Gelfand is studying the effects of at-home phototherapy as a lower cost, more accessible alternative to in-office treatments, so that more people can benefit from it.
Helming what’s known as the LITE Study, Gelfand and his team are conducting an ongoing randomized, controlled study of 1,050 patients to compare the effectiveness of home-based phototherapy devices to office-based treatments. The study charts the success rate and safety of 12 weeks of therapy in both environments. It also documents the outcomes for three different skin tones—light skin, olive to light brown skin, and dark brown to black skin—to measure tolerance and effectiveness.
Up until now, there hasn’t been enough data on at-home therapies, and “this has led to decisional uncertainty from patients, dermatologists, and insurers,” Dr. Gelfand says. “What we’re doing is an example of real-world pragmatic research designed to shift the practice of medicine in a way that’s more patient-centered.”
Not only does the study aim to provide important data on treatment response in patients of different skin colors, but it will ultimately help broaden the options for anyone struggling with this disease. Says Dr. Gelfand, “We’re trying to make phototherapy accessible and affordable to anyone who needs it.”
Zeroing in on Treatment Pathways
MEET THE EXPERT:
Richard Wang, M.D.
Title: Assistant Professor at the University of Texas Southwestern
Research: Slowing cell metabolism to prevent hyper-skin growth linked to psoriasis
Here’s the thing about psoriasis treatment: Because most medications broadly target the immune cells responsible for the disease in a system-wide way, they come with some serious side effects that are, in a word, uncomfortable. But, what if by simply targeting certain cell pathways the disease could be treated without side effects?
This is the question that lead Richard Wang, M.D., an assistant professor of dermatology at the University of Texas Southwestern, to start looking at glucose transport and metabolism to understand their roles in cell growth and division in conditions like psoriasis, which is characterized by skin overgrowth.
In a lab experiment, Dr. Wang and his team blocked glucose transport in the skin cells of mice using genetic and chemical inhibitors. “Glucose is critical for cell survival and cell growth,” Dr. Wang says. “To maintain normal functioning throughout the body, glucose moves through transporters in very specific pathways so that growth and division of cells is controlled.”
In people with psoriasis though, inflammation sends cells false signals that an infection is happening and those glucose transporters, which regulate the amount of glucose in cells, respond by letting more glucose in. All this extra glucose causes cells to divide, grow, and thicken—resulting in the visible scales and inflamed skin characteristic of psoriasis. “By blocking those glucose transporters in the mice, we were able to shut this process down, inhibiting the growth of skin cells and controlling inflammation without disrupting the skin’s normal functioning,” Dr. Wang says.
While Dr. Wang’s research is ongoing, the promise is clear: “There is potential for a new, more targeted chemical inhibitor topical agent to treat humans with mild-to-moderate psoriasis without the side effects of traditional treatments,” he says.
Glucose Transport and Cell Metabolism:Nature. (2018). “Differential Glucose Requirement in Skin Homeostasis and Injury Identifies a Therapeutic Target for Psoriasis.” nature.com/articles/s41591-018-0003-0