Living with psoriasis or psoriatic arthritis is tough. The U.S. healthcare system is complex. Learning about your treatment options can feel overwhelming. These two conditions are related, and they affect millions of Americans. Finding the right treatment plan for you will take time and planning.

These conditions don't always start the same way. Most people notice skin patches first. This signals psoriasis. But some people get joint pain and stiffness before any skin problems show up. This makes it hard for doctors to diagnose. Getting the best treatment often means working with both skin doctors and joint doctors.

How Skin and Joints Connect

About 7.5 million Americans have psoriasis. This condition causes red, scaly, inflamed patches on the skin. Many people don't know that about 30% of people with psoriasis will develop psoriatic arthritis later. This type of arthritis affects joints, tendons, and ligaments. It causes painful swelling when the immune system becomes overactive.

The immune system is at the heart of both diseases. In psoriasis, immune cells in the skin work too fast to make new skin cells. This creates the thick, silvery scaling you see. In psoriatic arthritis, the same faulty immune response attacks healthy joint tissue. This makes joints painful, swollen, and permanently damaged if not treated.

Dr. Sarah Martinez works at Johns Hopkins as a joint doctor. She says: "We're not dealing with two different diseases. They share the same inflammatory pathways. Many of our best treatments work on both skin and joint symptoms at the same time."

Treatment Options Today

How we treat psoriasis and psoriatic arthritis has changed a lot in the past 20 years. Patients no longer have to choose between treating their skin or their joints. Today's approach treats the inflammation that drives both conditions.

Topical Treatments: Your First Line of Defense

For many Americans with mild to moderate psoriasis, topical treatments are where we start. These medications have improved a lot from the basic coal tar preparations used in the past. Modern versions work better and are easier to use.

Steroid creams and ointments remain the main treatment for psoriasis. But doctors now recommend using them smarter, not all the time. Dr. Michael Chen is a skin doctor in California. He says, "We've learned that rotating different topical treatments stops the skin from becoming resistant to any one treatment. This also helps reduce side effects."

Vitamin D-like treatments have become popular because you can use them long-term without the skin thinning that steroids can cause. Most patients like combination products that include both a steroid and a vitamin D treatment. These offer both treatments in one package, making them easier to use.

Newer topical treatments include medicines that work well for psoriasis in sensitive areas like the face and skin folds where regular steroids might be too strong. They quiet local immune activity without causing skin thinning.

Phototherapy: Light Treatment

Ultraviolet light therapy remains one of the most important treatments for moderate psoriasis in the United States. This builds on the fact that sunlight often helps psoriasis symptoms. But medical light therapy is much more advanced than just spending time in the sun.

Narrowband UVB is the gold standard for light treatment. This specific wavelength of ultraviolet light can slow down the rapid skin cell production that causes psoriasis. It avoids the skin damage that broad-spectrum UV exposure can cause. Most patients get treatment two to three times a week for several months. This happens either at a skin doctor's office or a special light therapy center. Many insurance plans cover light therapy because it's safe and effective compared to some whole-body medications.

PUVA therapy is used for severe cases that don't respond to other treatments. However, it carries a higher risk for skin cancer with long-term use. Still, it's an effective option for patients who don't respond to other treatments.

Home light therapy units are becoming more popular. They make treatment much easier for people with busy schedules or who don't live near a treatment facility. These can be helpful, but the doctor prescribing the treatment needs to watch how it's used to ensure safety.

Systemic Treatments: Treating from the Inside

When topical therapies aren't enough, or when someone has psoriatic arthritis, whole-body medications are needed. These treat psoriasis from the inside out. All whole-body treatments decrease the immune system response that causes these conditions.

Older whole-body treatments include medications like methotrexate. Methotrexate has been used to treat psoriasis and psoriatic arthritis for years. Patients typically do quite well with this medication when they get regular blood tests. Cyclosporine may also be used. It works when someone needs rapid disease control, but treatment is usually limited to a few months or less because of effects on the kidneys and blood pressure.

New oral medicines have greatly expanded treatment options. For instance, apremilast is approved for psoriasis and psoriatic arthritis. It works by blocking a specific enzyme. Many patients appreciate not having to get regular blood tests while on this medication. The side effects are generally mild.

The Biologic Revolution: Precision Medicine

No single treatment development has changed the psoriasis and psoriatic arthritis treatment landscape more than biologics. Biologics have had the greatest overall impact. Biologics are advanced medications that target specific immune system parts that play a role in inflammation and tissue damage in these conditions. These medications are very effective and usually lead to improvement that wasn't seen before.

All biologics approved for psoriasis and psoriatic arthritis originally were TNF-alpha inhibitors. This includes medicines with names like etanercept, adalimumab, and infliximab. This was a major advance in treatment. They gave patients dramatic improvement in both skin and joint symptoms. When these were first introduced, there were questions about their effectiveness and safety, especially regarding infection risk.

The next generation of biologics are IL-17 inhibitors. These include medicines with names like secukinumab, ixekizumab, and brodalumab. With these medications, patients can see significant improvement in their skin symptoms. In many cases, they can even achieve "clear" skin.

The newest generation of biologics are IL-23 inhibitors. These medicines work very well for long-term control of both psoriasis and psoriatic arthritis. Some patients, once their disease is stable, can inject every few months to stay controlled.

Doctors must consider many factors when choosing between biologics. These include how severe the skin and joint symptoms are, how often patients want to inject, other medical conditions, insurance approvals, and how different patients respond to different medications. Dr. Jennifer Rodriguez is a joint doctor in Texas. She puts it well: "We're lucky to have so many great options. But we also need to consider each patient's individual situation for their best treatment."

Oral JAK Inhibitors

JAK inhibitors are a promising treatment for psoriatic arthritis. These oral medications also target most inflammatory pathways like biologics. The benefit is they are given as pills instead of injections.

Although they are mainly indicated for psoriatic arthritis (and not psoriasis on its own), they are an option for someone who has psoriatic arthritis but wants oral medications or who hasn't responded well enough to other whole-body options. Recent safety data showing increased heart and cancer risks in some populations has limited the options for some patients.

Insurance Issues

Insurance and coverage issues are the most challenging, frustrating, and sometimes disheartening issues American patients must face. Insurance coverage varies a lot depending on having private insurance, Medicare, Medicaid, or being uninsured.

Most insurances require patients to use and fail less expensive therapies before a biologic or newer medication can be approved. This is called step therapy. While frustrating, step therapy should be seen as a way to control healthcare spending and a strategy for the right care at the right time for a patient.

Prior authorizations can delay care and access to medications. Patient assistance programs from drug companies can help fill the gaps. All biologic makers have co-pay assistance programs to reduce out-of-pocket costs for patients to sometimes as low as $5 per month depending on the plan design and type of insurance.

Getting prescription oral medications through Medicare Part D is usually fairly straightforward. Access to medications covered under Medicare Part B may be different. A patient approaching Medicare coverage should consider discussing this either with their healthcare provider or a knowledgeable patient advocate.

State Medicaid programs vary widely in their coverage for psoriasis and psoriatic arthritis treatments. Some states provide excellent coverage for biologics, while others have barriers. Medicaid expansion under the Affordable Care Act has improved access to treatment for many previously uninsured people.

Building Your Care Team

Effective treatment of both psoriasis and psoriatic arthritis usually involves several coordinated providers. The classic model of seeing a skin doctor for skin disease and joint doctor for joint disease is being replaced with a more coordinated approach.

Most of all, the diagnosis is made by primary care doctors. They are typically the first medical professional who notices the basic signs of psoriatic arthritis in patients with existing psoriasis or recognizes psoriasis in patients complaining only about joint symptoms.

The skin doctor has specific expertise managing the multiple psoriatic skin disease presentations from basic classic plaques to more unusual issues like inverse psoriasis or pustular psoriasis. They will perform procedures like steroid injections for chronic plaques and help assess the psychological effects of a visible skin illness.

The joint doctor's job is to preserve joint function to limit long-term damage. Joint doctors would qualify and monitor for treatment complications.

Some clinics are beginning to offer skin and joint doctor combined services for psoriasis and psoriatic arthritis. In this type of specialized clinic, the providers work together in a cooperative manner. When asked, patients can see both the skin doctor and joint doctor at the same appointment. By seeing both doctors together for new and current skin or joint symptoms, it becomes easier for either provider to discuss the important areas of treatment where consideration should also be applied to the other area. Unfortunately, in practice it is not clear whether this process helps streamline the medications and other treatments while maximizing overall improvement.

Mental health practitioners are also becoming increasingly aware of the mental health impact of these chronic illnesses. Research shows there is an increase in depression and anxiety in patients with psoriasis and psoriatic arthritis when compared with the general population. Thus, mental health aspects of care are also very important.

Lifestyle Changes: Non-Drug Interventions

For patients, drugs are often the main treatment strategy, but lifestyle changes can be important in managing their disease and maximizing the opportunity for improving their quality of life. The American way of managing disease in psoriasis and psoriatic arthritis is increasingly considering non-drug resources or alternatives.

Regarding diet recommendations, dietary studies on the impact of diet on psoriasis and psoriatic arthritis have received a good deal of attention. However, advice and recommendations are still scattered and generally not specific. While generally healthy eating can apply to all patients who have psoriasis or psoriatic arthritis, many patients identify improvement related to an anti-inflammatory diet. An anti-inflammatory diet includes higher omega-3 fatty acids, fruits and vegetables, while reducing highly processed food and sugars. The Mediterranean diet appears to offer some hope based on small studies. Further studies are needed.

Weight management is particularly important because obesity increases the risk of both psoriasis and psoriatic arthritis and reduces the effectiveness of some treatments. Even modest weight loss can provide significant improvements in symptoms and treatment response.

Exercise can be challenging for patients with psoriatic arthritis. Joint and back stiffness and pain make physical therapy or exercise harder, but staying active is very important for mobility and overall health. Low-impact activities, such as swimming, cycling, or yoga, appeal to many patients. Patients have many different preferences and limitations, so it is essential to be aware of these patient-specific items when helping patients with exercise.

Stress management is important to note, as most patients will report symptom worsening when they become stressed. Meditation and mindfulness strategies are very effective.

Smoking cessation is very important, especially because smoking has been connected to worsening conditions and less effective treatments in both conditions. Most healthcare systems now include smoking cessation programs in their psoriasis treatment protocols.

Future Treatments

There continues to be a large pipeline of potential treatments for psoriasis and psoriatic arthritis. This gives hope to patients who haven't been successful with conventional treatments. Multiple promising new developments are being tested in clinical trials.

Many new biologics are targeting various inflammatory pathways, sometimes multiple ones at once. These may be more effective or convenient than current single-target therapies.

Topical JAK inhibitors are exciting for localized treatment approaches. Instead of using a whole-body JAK inhibitor that affects the entire body, these would mainly affect only the skin.

Gene therapies are also being considered for treating the genetic components of these diseases, though they're still years away from clinical use.

Personalized medicine is becoming more sophisticated as researchers try to use genetic and biomarker profiles to predict treatment response. Ideally, this will help doctors make appropriate treatment decisions early and avoid the "trial and error" approach.

Access to Care Differences

There's huge variation in access to specialized psoriasis and psoriatic arthritis care across the United States. In city areas, the availability and options of treatment and treating specialists are typically greater than what's available in rural areas. Available care can be quite poorer in quality or harder to obtain in rural areas.

The arrival of telemedicine has created opportunities to address these geographic differences and limitations, especially during the pandemic. Many patients who used to be seen in-person visits are now able to follow up through video consultation. In many cases, several treatments require a face-to-face initial visit, but patients seem to prefer the possibility of being able to consult more frequently with their providers.

Academic medical centers offer opportunities for clinical trials access and their newest treatment methods. However, as a general rule, they also tend to have the longest waits for specialty providers. In many situations, community specialists provide better care access while also providing reasonable quality of care.

Several states have implemented innovative programs to address access to psoriasis care. An example of this access to specialization with skin doctors in rural areas is included in ECHO projects, which are used to help serve patients in rural underserved areas and provide some degree of specialty care that is available beyond large academic medical centers.

Special Populations and Factors

Treatment plans sometimes need to be modified for some special populations such as pregnant women, elderly, and patients with other significant medical issues.

Pregnancy complicates choice of medications because of the risk factors of some of the more effective medications used to treat disease when the patient is carrying a baby.

Elderly patients may or may not be included in clinical trials and may also feel much more complicated as patients based on the differing risk/benefit opinions of physicians when prescribing immune-suppressing medications and various degrees of infections. Risk of treatment becomes a larger issue in an elderly patient and may include more than just consideration of kidney and heart function, but may also include interactions with other prescribed drug treatments.

In dealing with childhood psoriasis and juvenile psoriatic arthritis, there should be significant differences in care and education from that of adult patients since treatment in adults was not sufficiently reviewed in childhood psoriasis and juvenile psoriatic arthritis. In addition, the psychological impact of being a visible skin diseased patient is taken to an entirely different level during those developmental years.

Treatment Goals and Quality Measures

The American healthcare system increasingly emphasizes quality metrics and measurable outcomes in psoriasis and psoriatic arthritis care. Treatment goals are being better defined and set higher with new treatment options.

In psoriasis, many patients can now achieve clear or almost clear skin. Clear skin is defined as a 90% reduction in disease severity. This is a major change from years ago when modest improvement was considered success.

Treatment strategies for psoriatic arthritis aim for either clinical remission or low disease activity, usually measured with various standardized assessment tools. Alongside this, physicians implement something called "treat to target," which is elevated to standard practice. The targets will be relied on to modify therapy until disease activity is consistent with the target level.

Reliable measurement of the patient's reported outcomes is increasingly affecting treatment decisions. Assessment tools that include measurements of itching, fatigue, and functional status can be used to help inform the clinician about a course of treatment and potential monitoring. Clinical measures may not relate well to quality of life indicators and are limited in how they can be used to make clinical decision-making about treatment selection.

Patient Education and Advocacy

Patient advocacy groups provide helpful service to individuals with psoriasis and psoriatic arthritis in the United States. The National Psoriasis Foundation is one example of an advocacy group that aims to support patient interests by providing educational resources, advocating for research funding, supporting navigation to treatment, and developing databases of available clinical trials, which sometimes offer access to investigational therapies for patients when traditional treatment has not been effective.

Advocacy organizations also provide peer support and practical solutions to everyday problems. It's becoming more common for health systems to offer formal educational programs in psoriasis and psoriatic arthritis. These programs help patients improve their knowledge of their disease, treatment choices, and self-management approaches.

Costs and Value-Based Care

Costs for psoriasis and psoriatic arthritis care can be significant for patients, families, and the healthcare system. This has led to a slow shift toward value-based care. These models aim to optimize outcomes while managing costs through coordinated care and performance-based payment incentives.

Biosimilars will likely have a significant impact on treatment costs as less expensive versions of biologic drugs. While biosimilar adoption in the U.S. has been slower than in Europe, better access should eventually expand treatment availability.

Some healthcare models are now also offering outcome-based contracts, among other solutions, tying payment to treatment usefulness. These modern models can be helpful in preserving value for expensive therapies.

Research and Clinical Trials

The US is at the forefront of research into both psoriasis and psoriatic arthritis, with continuous clinical trials in the works to evaluate new methods and treatments. Drug companies, the government, and large academic medical centers are important entities in our understanding of these developments and the testing of new treatments.

Clinical trials can open doors for patients with regards to treatment. To enter a clinical trial has many pros and cons, that will take time and effort to evaluate. Advocacy organizations keep track of available clinical trials, allowing you to search for trials that can expand your options. Healthcare providers can also assist in evaluating potential trial participation for the patient, depending on their situation.

Patient Stories: Real Patients

Maria Santos - Teacher from Phoenix, Arizona

Meet Maria Santos, 34 years old, a teacher from Phoenix, Arizona. Maria first noticed some small patches on her elbows and scalp during college. "When I went to the skin doctor, he just handed me some steroid cream, and good luck! Unfortunately, for the next 15 years, I was cycling through different topical creams and thought I was dealing with my symptoms rather than the real problem. I guess it was better than nothing."

Maria was finally awakened when she started developing morning stiffness in her hands, and it became impossible for her to grade her students' papers. After struggling with this, her primary care doctor asked about her joint pains and skin condition. When the doctor made the connection, Maria was referred to a joint doctor, who confirmed her diagnosis of psoriatic arthritis.

"After starting a TNF inhibitor, within 6 months, I felt like a new person. My skin had cleared up about 85% and I could actually grip a pen and write without pain."

Unfortunately, Maria's insurance experience was riddled with obstacles. "The prior authorization took three months. Three months of watching my joints get worse as insurance companies argued over whether I 'really needed' the medication." Eventually, patient assistance programs filled the void, but this highlighted the system issues faced by many Americans.

James Miller - Rural Montana

The story of James Miller from rural Montana presents a different set of challenges. At the age of 28, when James was diagnosed with moderate plaque psoriasis, he struggled to access specialists as there was a four-hour drive to the closest skin doctor, so light therapy was impossible.

"I tried everything over the counter and I spent thousands of dollars on 'natural' remedies that offered miraculous cures," he said. "Nothing worked and I was desperate."

James eventually managed a telemedicine appointment and connected with a skin doctor in Seattle who prescribed apremilast after reviewing photographs of James' skin. "Just to have someone who actually understood what I was going through, even through a computer screen, was amazing. The medication isn't perfect - I still have a few patches - but at least it is tolerable."

The Economics of Treatment: Beyond Insurance

While insurance coverage will get most of the attention, the economic effects of these conditions go far beyond the cost of medication. Lost productivity, lost workdays and lost quality of life have effects that spread throughout families and communities.

Dr. Amanda Foster, a health economist at the University of Pennsylvania, states, "We are looking at diseases that rob people of their most productive earning years. Typically, the indirect costs - lost wages, lost work hours, care-giving - are more than the direct medical costs."

Take Robert Chen, a construction foreman, for example, whose psoriatic arthritis caused him to move from physically demanding work to desk work. "My wife says the biologic medication saved my career - but I gave up a $20,000 annual salary when I moved from hands-on to desk work," Robert explains. "And without the medication, I might not have been able to work at all."

The economics become more complicated when you add in whole families. One single mom of two kids in Atlanta, Sarah Williams spent months delaying starting biologic therapy because of cost. "I had insurance - and even with insurance, the co-pays were going to be $200 per month. That's grocery money for two weeks," Sarah explains. However, I was aware that it was impacting my kids to see me struggle due to pain and exhaustion where it should have been the least of their worries.

Eventually, patient assistance programs reduced the out-of-pocket costs of Sarah's treatment - but the emotional burden of financial stress contributed to the physical symptoms. "I really wish doctors had brought up the financial implications earlier. It's uncomfortable to discuss that you can't afford the second line of treatment they are recommending."

Geographic Differences in Healthcare

Patients' access to care for psoriasis and psoriatic arthritis varies by region of the United States. This creates unequal access, often categorized by socioeconomic status. New England and Mid-Atlantic states typically can provide a good supply of specialists for care, while some rural areas of the South and Mountain West are very limited.

Dr. Michael Torres works primarily in Boston, MA and in rural areas of Vermont where he sees patients with very different access. "In Boston, I can refer patients to three different psoriasis specialty clinics in less than twenty miles. In rural Vermont, I have patients that drive two hours each way to see me," said Torres.

Geographic differences impact not just access to specialists. Research subjects often wait very long amounts of time to enter a clinical trial. Sometimes, drug manufacturers struggle to obtain necessary data from different populations.

State Medicaid programs also create complexity. In Texas (where there was no Medicaid expansion), a lot of low-income people earn too much to qualify for regular Medicaid and too little to qualify for marketplace subsidies. Other states like New York and California have large safety net programs that allow for access to biologics and other costlier treatments.

The Covid-19 pandemic interrupted some of these disparities through pandemic-funded telemedicine legalizations, but many of them expired. Patricia Rodriguez, a patient advocate in New Mexico said, "We actually had patients receiving improved care during the pandemic than they ever had received prior. Now we are fighting to create permanent access to those telemedicine services."

Mental Health and Chronic Illness

It is hard to measure the psychological toll on patients with chronic pain and visible skin disease. Dr. Lisa Thompson, a clinical psychologist with specialization in medical conditions has said, "these are not just physical diseases. They change who patients are and how they think other people see them."

The numbers support this. Research shows that people with psoriasis have about twice the rate of depression as the general population, and suicidal thoughts are much more common. Adding psoriatic arthritis brings chronic pain and physical limitations plus additional psychological burden.

Tom Bradley, a 42-year-old accountant from Denver, spoke about his darkest times: "At my worst, psoriasis covered about 40% of my body. I stopped going to the gym, avoided social situations, and even changed to a job with less face-to-face contact. Looking back, I was obviously depressed, but nobody, not even my doctors, mentioned it."

Tom's outlook changed through effective medical treatment and psychological support. "The biologic cleared most of my skin, but I needed therapy to rebuild my confidence and social skills. You can't get that back just because your skin improves."

Fortunately, several healthcare systems now routinely screen for depression and anxiety in psoriasis care, directly acknowledging the connection between physical and mental health. Some insurance plans are beginning to cover psychological support for specific medical conditions, though this coverage isn't universal.

Employment Issues and Legal Protections

While the Americans with Disabilities Act offers some protection for people with psoriasis and psoriatic arthritis, many patients don't know they may be eligible for accommodations. Disabilities in the workplace can include obvious struggles such as physical limitations, as well as more subtle experiences of discrimination based on physical appearance.

Jennifer Park, an employment attorney who lives with psoriatic arthritis explains, "In general, law protects workers who can perform essential functions with reasonable accommodations. For many, that could be someone who has psoriatic arthritis, flexible scheduling for doctor appointments, ergonomic equipment, or limited and modified activities when in flare mode."

However, seeking accommodation in the workplace wasn't always that straightforward. Mark Thompson, a retail store manager, experienced a variety of responses once he disclosed the debilitating disease: "My employer was great at accommodations like sitting instead of standing for long periods of time. They changed my office away from the loading dock because the cold air triggered my flares. My employees were different. They definitely treated me differently, once they understood my arthritis."

When employers attempt to enforce various appearance standards and have direct contact with customers, examples of accommodation are less frequently considered. As an example of this type of accommodation, Rebecca Moore, a flight attendant states: "Most jobs have grooming standards, and when I had a flare, I didn't always have the option of makeup to cover up patches of my skin. I had to explain to HR that skin patches did not reflect personal hygiene; skin issues were considered a skin condition."

Challenges with Pediatric Care

The challenges of childhood-onset psoriasis are compounded by the complexities and limitations of the American healthcare system. The challenges and care requirements are not limited to the physical care of the child. Children have challenges in relation to their education, social skills, and family care. Approximately 1% of children are affected by psoriasis and juvenile psoriatic arthritis is even less common and more difficult to treat, specifically related to issues around growth and development.

"When we treat a child, we treat the whole child, rather than just the disease," comments Dr. Rachel Martinez, a pediatric joint doctor at Children's Hospital of Philadelphia. "We're involved in their whole development. There is always the psychological burden of having visible skin disease as a child or adolescent."

Many choices are more limited for children than adults because treatments are not fully studied in children or pediatric populations. Furthermore, families are faced with the additional burden of weighing benefits against unknown risks for the future. Although the FDA has endorsed a larger number of biologics specifically for pediatric psoriasis and pediatric psoriatic arthritis, often, the level of uncertainty in the decision making for parents may be less than optimal.

For children, school and educational accommodations are of major importance. For example: Children with psoriatic arthritis may need adaptations in physical education, breaks between classes, or assistance with activities involving fine motor work. The Individuals with Disabilities Education Act (IDEA) can provide helpful supports but parents usually need to advocate for services.

"What was hardest was not the medication or the joints, it was what other kids thought," says Alex Chen, a 15-year-old from California. "Some people thought it was contagious, some people just stared. I owe it to my school counselor to help me prepare conversations about what to say to friends."

Families make drastic changes during the time when their child is diagnosed with a chronic illness that involves extensive medical and ongoing treatment. They must coordinate many necessary factors including changing jobs and organizing care among several specialists, while also considering the emotional needs of siblings who may feel neglected.

Cultural and Community Differences

The experience of psoriasis or psoriatic arthritis will differ significantly across diverse cultural communities and perspectives across the United States. Cultural practices may involve traditional healing approaches and varying views about illness and medical interventions.

Some Latino communities may apply traditional remedies (such as aloe vera, turmeric, or dietary regimens) preferentially prior to or along with receiving medical treatment. Maria Gonzalez, a community health worker in San Antonio, explained that "Families want the best of both worlds, they want to acknowledge traditions but still want to take advantage of modern medicine. Doctors are the key to this; they need to show that there are no conflicts between the two approaches and respect both."

African American patients have additional barriers. Diagnosing psoriasis on darker skin types can be very difficult. A delay in treatment can result from the clinical view of psoriatic skin patches that appear "purple" or "brown" instead of the listed "red" patches in the medical literature as it describes clinical diagnosis. Dr. Valerie Jackson, a skin doctor in Detroit explains that "this is a new focus for education in medical school. We are just now getting started with discussing that there is minimal representation of the way that these conditions appear on different skin types."

Religious communities rely heavily on treatments that may affect immune function. Some patients may worry about interfering with divine will. Others take effective treatments as blessings. Patients often rely on their pastor and community members extensively in these decisions.

Digital Health and Technology

The digital health revolution is now changing how Americans with psoriasis and psoriatic arthritis will engage with and manage their conditions through new knowledge of monitoring symptoms, accessing care, and connecting to patients digitally. There are several smartphone applications created for psoriasis that allow patients to take pictures of their symptoms over time. These photo logs are helpful for providers.

Dr. Steven Park, a skin doctor based in Seattle, who uses digital tools collaboratively with patients describes, "Patients come in with photo logs to show me exactly how their skin lesions had changed from visit to visit. This has changed the way we assess treatment outcomes and adjust medication, using both technology and what the patients document."

Wearables will allow for an even larger data set, particularly for psoriatic arthritis patients. Activity trackers can capture sleep patterns, levels of physical activity and some inflammatory markers. Digital health technologies give us some objective data that is valuable for understanding the impact a disease has on day-to-day functioning and quality of life.

Online communities are valuable resources for support and information for patients. Free online forums sponsored by the National Psoriasis Foundation connect thousands of patients in order to share experiences and information. Smaller social media groups share helpful updates and allow for story sharing between patients.

Digital connectivity has downsides; misinformation can spread quickly through social media or online forums. Jennifer Walsh, a patient from Oregon, shares how the online community helped with her insurance issue: "When my insurance denied coverage for a biologic, patients on the forum provided templates for my appeal letter. They connected me to patient advocacy resources and I got approved for my medication less than a month after submitting a new application guided by their advice."

Complementary and Alternative Approaches

Conventional medications are the primary basis of treatment for most U.S. patients with psoriasis or psoriatic arthritis but many patients seek out other complementary therapies, either standalone or in combination with prescribed treatments. Some complementary medicines are evidence based (omega-3 supplements), and some are less evidence based and controversial.

Some patients and healthcare providers are accepting providers of complementary therapy such as acupuncturists. A limited number of small studies suggest the potential for some benefit in psoriatic arthritis pain management with acupuncture therapy. Some insurance companies now cover acupuncture therapy in certain chronic pain conditions.

Diet is another intervention area for patient interest, and the quality of the evidence is lacking. Anti-inflammatory diets targeting omega-3, while restricting processed foods and sugars, have some small studies identifying benefits.

Some patients show remarkable improvements following elimination diets, but results aren't consistent and vary between individuals. There's more evidence for meditation and mindfulness for overall stress and pain reduction. Some medical centers now offer mindfulness-based stress reduction programs for people with chronic diseases.

Dr. Patricia Williams, an integrative medicine doctor in Arizona, offers a conservative perspective: "I encourage patients to consider complementary therapies that fit their preferences, but in addition to, not instead of, effective medical therapies. Most importantly, as a healthcare provider, I need to know everything they are trying."

The risk associated with unregulated alternatives can have negative consequences. Online "miracle cures" can be financially costly to already suffering families, leaving them with nothing, at a stage where traditional and effective therapies may be delayed. Some herbals can also interact negatively with traditional prescriptions or cause flares in individuals who are more sensitive.

Nutrition: Beyond Fad Diets

No diet has shown strong evidence of curing psoriasis or psoriatic arthritis, but with the amount of recent nutrition research, it seems data is indicating that nutrition has a bigger role in disease management than we previously thought. The impact of diet is likely through a variety of different mechanisms including inflammation, gut microbiome, weight control and so on.

Dr. Emily Rodriguez explained this well when she said, "There is substantial evidence that dietary patterns alter inflammatory processes. It's not specific foods, but notable dietary patterns that are associated with altered immune responses."

The Mediterranean diet is the most focused upon, and several individuals have improved their psoriasis severity by following this eating model, which emphasizes olive oil, fish, fruits, vegetables, and whole grains—all foods that are not only considered to be anti-inflammatory, but also are devoid of processed foods which can initiate inflammatory processes.

Weight loss has been shown, on a whole, to also correlate with better outcomes in both psoriasis and psoriatic arthritis, regardless of what dietary pattern the individual uses to lose the weight. Some individuals see improvements when they lose a very modest amount of weight (10-15 pounds) at the same time as beginning an anti-inflammatory treatment.

Some individuals see improvements when they remove specific foods that trigger flares with gluten and dairy being most commonly reported. This said we contend that true food intolerances probably only affect a small proportion of individuals. An elimination diet should never be done on your own, but rather coordinated with the team that provides your care.

The gut microbiome has become an exciting area of research, with studies indicating the microbial communities in our gut may be related to inflammatory pathways. Probiotic supplements and fermented foods may be helpful, but we need more data to know if any certain strains, or doses, are more effective.

Gender Considerations

The experience of living with psoriasis and psoriatic arthritis is different for men and women in ways that extend beyond biology. Differences in hormonal cycles, pregnancy considerations, and beliefs about appearance and societal norms, can all affect treatment and the quality of life impact.

For example, many women report that their disease flares with different phases of their menstrual cycles. Some women improve in their psoriasis during pregnancy, only to flare postpartum. With increasing interest on these hormonal relationships in dermatology, research into hormone-based therapies has just started, but we are still in early data gathering stages.

When planning pregnancy, there are many considerations for women in managing their medications for psoriasis and psoriatic arthritis, as many of the effective treatments may have adverse effects on fetal development. Dr. Susan Chen, a maternal-fetal medicine physician who collaborates with skin doctors and joint doctors, explains, "It is nice to have some biologics that are studied for safety in pregnancy, but the risk-benefit consideration is different for each woman."

When considering the psychological burdens of having visible skin disease, women are more often impacted than men due to social norms, beliefs about appearance, and media distortions. While we do not know if these phenomena and impacts are the same as views regarding mind or body, there is some research that shows women with psoriasis have reported more social anxiety and difficulties concerning relationships when compared to men with similar severity of disease.

Men might also be less willing to obtain timely medical assistance and stick to treatment plans, resulting in more advanced stages of disease when treatment is sought. Cultural ideas about "toughing it out" may delay diagnosis and initiation of treatment.

Economic Innovations and Value-Based Care Models

Biologic treatments are expensive, and due to the high expense of medications, the healthcare system needs innovative payment models. Several systems are working to implement outcome contracts and shared savings programs; focusing on paying for what works, rather than simply the cost of medication, any of which may be ineffective.

Several large health systems also created "psoriasis medical homes" where primary care providers, skin doctors, and joint doctors together focus on all quality measures. Early data suggest these medical homes will increase patient satisfaction and clinical outcomes while managing costs.

Biosimilars are poorly utilized in the US, but are beginning to improve treatment access, noting that Europe has adopted their use at a much faster pace. Biosimilars are less expensive medications, and given that many original biologic drugs are soon losing patent protection, the savings available could be significant, and continue to provide equivalent patient outcomes and safety profile.

Pharmacy benefit managers (PBMs) face increased scrutiny with respect to patient access, as they often prioritize drug cost over patient, overall outcomes. Several states have passed legislation designed to create greater transparency in PBM decision-making and ensure better patient cost-sharing than impractical list price costs.

The Next Decade: Future Treatments

There is a whole pipeline of research and clinical trials assessing new treatments for psoriasis and psoriatic arthritis. There are orally administered medications coming along that impact the same biochemical pathways as injectable biologics, allowing more convenience while providing comparably effective treatments.

There are topical JAK inhibitors that look exciting for localized treatment and may provide biologic level of effectiveness for limited skin involvement with minimal whole-body absorption. Early trial data also indicate that topical JAK inhibitors may have some additional advantage when treating facial psoriasis or other sensitive areas.

The emergence of increasingly sophisticated personalized medicine models that will accurately characterize genetic and biomarker profiles that predict treatment response are an exciting development, which means it may be possible to identify the best treatment option first versus best supposition after treatment has failed multiple different options.

We have seen the emergence of artificial intelligence to assist in treatment decision-making, which may ultimately enhance treatment outcome and reduce healthcare costs. Artificial intelligence (AI) algorithms are capable of analyzing photographs of psoriasis lesions, and incorporating their entire medical records from prior and ongoing treatments to document their treatment response data; algorithms will start to match the most effective therapy combinations, and may even be able to identify flares prior to their occurrence.

Although gene therapy and cellular reprogramming as acceptable treatment options may be years away, they could materialize in the next decade as technology advances rapidly, but they will have to pass regulatory safety and enforceable standards for safe and effective practice before being acceptable to use in the real world beyond only the most severe cases.

It is our greatest hope having clear skin and pain-free joints yields quality of life and allows people to pursue fulfillment in their personal and professional aspirations. The tools we have are exceptional, and there is more hope than ever before for the millions of Americans living with these increasingly manageable, yet challenging conditions.

Conclusion: A Hopeful Future

The future of treatment for psoriasis and psoriatic arthritis in America is more optimistic than at any previous time. Patients now have access to medications and biologics that would have been unimaginable 20 years ago, and novel treatment methods and drug options continue to flood the pipeline with strong momentum from research.

Optimal care is much more than the person accessing the most effective medication. Optimal care is obtaining coordinated healthcare delivery systems, a health insurance plan that does not place unnecessary barriers to healthcare access, and being the best-informed choice in treatment, i.e., that patients educated stakeholders in the care they choose.

The replicability of personalized medicine offers exponentially more optimism that treatment outcomes are attainable. The more we can understand the genetic and molecular drivers that cause these diseases, the more chance we have to identify a feasible treatment plan at the first contact point of the care continuum.

The most significant change during this time is better public awareness of the conditions causing people to be more aware, that are coinciding, even with better and effective treatment options available. All of a sudden we are seeing a culture change, and recent advances in therapies also provide real hope to millions of Americans transforming them from unsustainable patients with psoriasis and psoriatic arthritis, where they will still have to navigate following the ups and downs of a chronic health condition.

Yet, patients have every reason to be hopeful about their future. If patients can access appropriate medical treatment, identify lifestyle changes quickly, and are diligent in their consultation in finding their preferred treatment pathway, generally a person will be able to improve their symptoms and quality of life once the impacts of their decision-making fatigue have been worked through.

What matters is to be aware of what options are available to them, be informed agents in discussions with their healthcare providers as they identify barriers to the best option, and maintain hope when mechanisms must overcome challenges during difficult times.