Thing is, Nana L's in the UK. I don't think a UK derm would go for biologics on the basis of psoriatic nails and I doubt they'd prescribe DMARDs either, though I might be wrong. And I don't think the protocols would allow a dermatologist to prescribe treatment for PsA either, even if they strongly suspect it. I think they'd just refer on to rheumatology.
Hardly anyone gets straight onto biologics in this country. There again ... I do agree that asking GP for a referral to all relevant specialists may be a good idea - it probably won't slow things down, it might just speed them up and it could prepare the ground for communication between the two specialisms.
tntlamb said:
Dermies a back door to getting the good meds more quickly. As the treatment is very similar for P and PsA, It doesn't matter. In the US, there are far fewer hoops to jump through to get the biologics for Psoriasis than PsA. You best bet is to have the two speak to each other. Believe it or not most rheumies LIKE havin the Derms manage the biologics. saves them lots of letter writing....................
So I think you’ve formulated a good plan, NanaL. See the rheumatologist, and be very sure that he is aware of your past history of severe psoriasis. If that isn’t enough to tick the psoriasis box on his list, he can send you to a dermatologist to get an opionion on your nails. (I’m guessing that your history will be quite enough for him. But if not, he can probably get you in to a dermatology colleague faster than your GP can.) Going to your podiatrist in the meanwhile is a good idea, because a podiatrist can give you practical help with the pain.
So that’s the plan. Now look after yourself as best you can until you can get to the rheumatologist! I have a feeling that you are going into this consultation better organized and more assertive than you’ve been before. That can only be a good thing!
Nana L, tntlamb is right. I went to a dermatologist because my daughter is her nurse and my daughter kept trying to convince me to go on a biologic. She'd say they would put people with a lot less psoriasis than I had on biologics. And, with my history of seeing a rheumy for about 8 years and having a dx of PsA for 6 years, the dermy contacted my rheumy to get things done. And, dermys can get you on a double dose of the biologic for the first 3 months.
Nana L, you've mentioned you have mild psoriasis--your knees, elbows, a few random spots and scalp? That combined with all of your PsA symptoms is really eligibility for biologics. Well, good luck! I'm falling asleep!
A lot of the time our experiences on both side of the pond are very similar, mainly because we all have this stupid disease. But your discussion has prompted me to check out a few differences in the way UK healthcare works.
I took a look at the guidelines for treating psoriasis as set out by NICE (the National Institute for Health and Clinical Excellence).
It doesn’t look as if we can get straight onto biologic therapy for psoriasis in the UK, in fact it looks like they always start with topical treatment if at all possible.
However, according to the NICE guidelines, dermatologists should keep a look out for PsA in all psoriasis patients. Even so, the guidance is to refer patients with suspected PsA to a rheumatologist. It does not look as if dermatologists can make a PsA diagnosis or treat psoriasis more aggressively because they suspect PsA.
I’ve just started seeing a dermatologist myself and the quality of care has been amazing. Looking at the guidelines it looks as if that’s not just down to luck – it seems that NICE recommends keeping quite a close eye on us people with psoriasis: taking our emotional state into account, advising on lifestyle, checking for co-morbidities ….. all the things that rheumatologists do but more so.
I think if your psoriasis, including your nails, is bothering you at all it would definitely be worth asking for a referral to dermatology. It really looks like they are meant to take a very thoughtful approach. And if for some reason there’s an unacceptably long wait to see your rheumatologist they might help bump you up his list.
NICE mentions PASI which dermatologists use to measure the severity of psoriasis. Have you heard of it? I found this tool for checking our PASI score:
Could be useful as I think we sometimes underestimate how bad things are. A score of 10, for example, means psoriasis patients qualify for biologics as long as they fulfil some other conditions.
Personal places eh? Me too. This thing has no respect!
Nana L said:
Thank you so much for doing that for me Sybil. I think I will mention seeing a dermatologist to my doctor with the reason that I haven't been for years and do have some patches in personal places too that know one will be getting a look at. So that could be a good reason to go. The patches elsewhere are doing well with my exorex then E45 on top. I also think It's just luck too that it's not aggressive. But again thank you so much
Ooops, I was half asleep when I wrote my last comment. It sounded like I was saying the dermies in the U.S. go right to biologics when psoriasis starts. That is way wrong, at least in my case.
I treated stubborn psoriasis all my adult life. It started out severe and then went to moderate for almost 40 years now. (Actually, now with Enbrel it's very mild.) But, I wish I would have kept track of all the tubes of cortisone cream I've used over the years--it must be in the thousands! And I went through light therapy for several months 2 years ago without any significant improvement. So, in my case, I had a lifetime of treatment for psoriasis which had got worse and was actually getting out of control by the time I went to that particular dermy.
I'm almost sure the dermatology patients who get a biologic go through the standard treatments/creams/light therapy, etc., first. My daughter just used to tell me that a lot of their psoriasis patients got a biologic with less psoriasis than I had and no PsA. But, she really didn't go into detail about how much other treatment they had first.
Biologics are on TV ads here all the time. I think that's how I first heard of them. But, really scary because they have so many potential side effects and health risks (although supposedly those are rare--but they need to be disclosed). So, for years I said I'd rather suffer from the disease than worry about SEs, etc., by taking a biologic. I've had no SEs from Enbrel, but now my white blood cell count is below the normal range. My rheumy is going to check it again in September and if it's lower yet, he said he'll take me off the Enbrel! That's not something I look forward to. But, there are people who've been on Enbrel for 10 years and still going strong, so I'm hoping of course that can be me, too!
When you qualify for a biologic your doctor and this website can answer all your questions....actually, I'd trust this website more because we all have our own unique experiences with them.
I’ve had psoriasis in my fingernails for more than 20 years. I can remember when I was much younger (10- 12 yo) my pre-psoriatic nails peeled in layers and my cuticles were always a mess. I’ve never had normal nails. I was 22 before I went to see a dermatologist and by this time my nails had been horrible for about 3 years. Your nails look like mine did in my early days.
Ha, ha that is NOTHING compared to the razor blades and hot coals that I'm walking on .... although I have just sliced a lemon and that got in one of those thumb cracks and a few choice words slipped past my lips while I hot footed it as fast as I could to the cold tap ;)
As long as we’re showing off ugly fingernails, I’ll share some of mine. I realized how bad they still look, even though they’re much improved since I’ve been on enbrel! I still have some of the pitting - dimpling - as you can see on the one photo. My left thumbnail is still rippled, but it’s a lot better than it was a year ago. Amazing that I’m not afraid to show you guys here, but among everyone else I keep my fingers hidden as much as possible. :-(. Oops, I don’t think they’ll upload.
As long as we're showing off ugly fingernails, I'll share some of mine. I realized how bad they still look, even though they're much improved since I've been on enbrel! I still have some of the pitting - dimpling - as you can see on the one photo. My left thumbnail is still rippled, but it's a lot better than it was a year ago. Amazing that I'm not afraid to show you guys here, but among everyone else I keep my fingers hidden as much as possible. :-(. Oops, I don't think they'll upload.
Jules, ugh I had those feet! What are you doing for them? Also, omg you reminded me about the cracked fingertips. That is the most painful little cut imaginable!!! I only got them in the winter before I went on enbrel. Wow, they could make me nearly cry! I found that putting some cortisone cream in them helped a little.
Jules G said:
Ha, ha that is NOTHING compared to the razor blades and hot coals that I’m walking on … although I have just sliced a lemon and that got in one of those thumb cracks and a few choice words slipped past my lips while I hot footed it as fast as I could to the cold tap
