Ep 233 – Psoriasis: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

0:00:01.2 Ruth Werner: Hey, I Have a Client Who listeners. Did you know I have a growing library of NCB approved one-hour online self-paced continuing education courses that you can do any time, anywhere? Well, now you know. Current classes include; What's Next: COVID-19 Updates From Massage Therapists, and A Massage Therapist's Introduction to Pharmacology Part One, and brand new, A Massage Therapist's Introduction to Pharmacology Part Two. Classes are $20 each, and they confer one hour of continuing education credit. Wanna know more? Visit my website at ruthwerner.com and check it out. Be sure to sign up for my mailing list so you'll never miss a new class.

0:00:48.0 Speaker 2: Anatomy Trains is delighted to invite you to our in-person fascial dissection workshop, May 30th through June 3rd, 2022. We're excited to be back in the lab with Anatomy Trains author Tom Myers, and master dissector Todd Garcia in Todd's laboratory of anatomical enlightenment in Boulder, Colorado. Join students from around the world and from all types of manual movement and fitness professions to explore the real human form, not the images you get from books. Visit anatomytrains.com for details.

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0:01:30.8 RW: Hi, and welcome to I Have a Client Who pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes as we have all learned, that is harder than it looks.

0:02:17.9 RW: In today's episode, I will try to answer some very general questions that I've gotten about a very common, often mild, sometimes extremely severe condition, psoriasis. These questions are only loosely based on, I Have a Client Who stories, because they didn't really come to me with a story attached, but clearly some massage therapists wanna know more about this condition and how they might be helpful and this is right up my alley. Psoriasis, with a silent P. It comes from a Greek root, Psora, which means itch. Essentially, this means itchy condition, which is frankly a little odd to me because there are tons of conditions that are itchier than psoriasis, poison ivy, for instance, or scabies or any number of other kinds of rashes or bug bites, but... Okay, no one asked me, and psoriasis means itchy condition. That's fine. In the years I've been teaching about diseases and conditions, this is one of the situations where our understanding has changed some over time. In the olden days, that is say, 25 years ago or so, psoriasis was discussed as a general skin condition, often lumped in with eczema, but as we have learned more about immune system function, we have come to realize that, while eczema is a type of hypersensitivity reaction, psoriasis fits more snugly in the category of auto-immune diseases.

0:03:41.9 RW: Remember, these are situations where for unknown reasons, the immune system attacks some cells or tissues as though they're trying to kill us. Psoriasis fits the pattern of many autoimmune diseases, it's often present with certain other members of this disease family. Regular listeners might remember that it came up in the context of our recent episode on Ankylosing spondylitis. Psoriasis runs in cycles of flare and remission, it responds to treatment with immune suppressant drugs at least for a while, and about 30% of people with psoriasis are eventually diagnosed with another form of arthritis, psoriatic arthritis, that looks a lot like rheumatoid arthritis, one of the earliest known autoimmune diseases. We've had, an I Have a Client Who story on psoriatic arthritis, so I will include that in our show notes. But what is really going on here and what is the role, if there is one for a massage? According to the National Psoriasis Foundation, about 8 million people in the United States are living with this condition and it affects about 125 million people worldwide, that's about 2.2% of the worldwide population, so roughly two out of every 100 people has psoriasis. It's diagnosed in light-skinned people about twice as often as in dark-skinned people. That might be an issue of genetics, but it may also be an issue of unrecognized differences in clinical presentation.

0:05:14.2 RW: This is frequently a problem in identifying skin symptoms in people of color, and for interested listeners, I wrote a blog on this issue that I will put in the show notes. As a pathology educator who must focus on skin issues, this is something I pay close attention to. I think we should all be aware of this problem in healthcare disparities, but back to psoriasis. This condition can occur at any age, but there are two age groups where it is most common in people 20 to 30, and in people 50 to 60, these immune system anomalies plus genetic predisposition, plus environmental exposures, all combine to lead to excess growth of keratinocytes in the epidermis and the cell turnover rate in these areas accelerates, and this usually happens in isolated patches. You might remember that normal skin cells are constantly being replaced, newly keratinized cells from the dermis are pushed up toward the surface by the cells coming up from underneath, all dead cells are sloughed off to become a major component in household dust. I used to tell my beginning anatomy students to test this by stripping off their beds and hitting the mattress hard with a baseball bat, and the dust cloud that arises is mostly skin cells.

0:06:33.3 RW: Cool, right? Anyway, the normal rate of replication of skin cells is roughly every 28 days. I still marvel at this. 28 days. Can you think of anything else that runs on a 28-day cycle, and don't you love repeating patterns in nature, but at the sight of psoriasis lesions, that turnover rate is more like every four to six days or even faster, so we get these pile ups of hard keratinized cells and eventually, they can form a light colored scaly appearance over the top. On light-skinned people, these are often pink with a white scale. On dark skin patients, it looks a little different. I found a gallery of photos of psoriasis as it presents in dark-skinned people, and it shows that the lesions are more purple or brown sometimes with a gray scale. I will provide a link in the show notes. Just a word of warning, these pictures are of very severe cases, maybe because these people were not diagnosed in early stages, and they might be pretty intense for someone whose job is not looking at pictures of people with diseases and conditions, in fact, they're pretty intense for me too. Well, what we've been describing so far is the most common version of this condition, which is called plaque psoriasis, and you've probably seen it, it's often fairly mild with limited areas, usually on the elbows or knees or other joints, but sometimes plaque psoriasis can be very severe and extreme.

0:08:06.9 RW: As I prepared this podcast, I ran across a statement that I really appreciate. It said basically that sometimes psoriasis is rated as a mild, moderate or severe depending on what percentage of the skin is affected, but what is much more relevant is whether the condition has a mild, moderate or severe impact on the person's quality of life. That makes a lot of sense to me, and I appreciate that fine-tuning. Plaque psoriasis is often on the joints of the extremities, but it can certainly occur on the trunk and on the scalp and the neck and all over the arms and legs, it runs in cycles of flare and remission as we've said, but if the lesions are deep and long-standing, this will cause scarring that is visible regardless of whether the lesions are currently inflamed. Psoriasis can be a disfiguring disease that causes deep embarrassment and negative body image, it can prevent people from seeking massage, which is heartbreaking to me, and I'll get back to that in a minute. Before we move on to talk about treatment options and where massage fits, and it does emphatically fit, I want to be sure to tell you that plaque psoriasis is not the only form of this disease, there are several other presentations that I won't go into deeply, but here's a short list. Guttate psoriasis looks like round drops on the trunk or extremities.

0:09:29.7 RW: Guttate comes from the Latin for drop, like rain drop, it isn't common, but when it appears it often comes after a bout with strep throat. Pustular psoriasis usually involves blisters on the palms of the hands and the soles of the feet, and it can involve, as the name implies, pustules. These aren't typically filled with infectious material. Pustular psoriasis can be a really difficult condition and it has some serious complications. Nail psoriasis involves lesions under the nails of the hands or the feet, the nails can be damaged or destroyed. Nail psoriasis can occur all on its own or along with some other form, and it may predict psoriatic arthritis, which we have spoken about before. And there are a couple of other types too, they're fairly rare and pretty severe. I know a good pathology book where you can get more information if you need it, or here's an idea, you can send me an I Have A Client Who story about inverse psoriasis or Erythrodermic psoriasis. The treatment options for psoriasis are based on how severe the situation is, and they range from soothing lotions, there's a hint about massage by the way, to injections of steroids into the scarred up lesions to combining a medication called Psoralen with exposure to UVA radiation.

0:10:47.0 RW: And now we have some biologic drugs, these are designed to alter immune system function that have been developed for psoriasis too, but currently we don't have a treatment option that works for all patients, and many patients find that the treatment option that works for a while eventually doesn't work anymore, and they have to find something new. What do you think about massage therapy with someone with psoriasis? Is psoriasis catching? It is not. You will not catch psoriasis by working with a client who has it. Does psoriasis spread? Well, yes, but not through surface contact, it gets worse and spreads as a function of the immune system, but not like a spreading rash. Can massage make psoriasis worse? Maybe. What would that look like? And for this, I will refer you back to the meaning of the word psoriasis, the itch or itchy condition. There are really only a handful of worst case scenarios for massage in this context. Number one, the massage therapist can make itching worse, number two, the massage therapist can go over an area where the skin is damaged and vulnerable to secondary infection, or number three, the massage therapist can say something or behave in some way that makes the client self-conscious or embarrassed about their situation, and I bet that every person listening to this can figure out a way to avoid those pitfalls.

0:12:13.2 RW: But what can we do to make things better? Well, that will depend on the individual and this is where working as a team can yield best results. Do you wanna avoid making itching worse? Consult with your client. Do they have a lotion they love, use it. One massage therapist suggests draping clients with warm wet towels and massaging through that, which sounds awesome to me, regardless of psoriasis. Is your client uncomfortable with skin to skin contact? Maybe working through the sheet is a better choice. There's no one-size-fits-all solution for how to make our clients with psoriasis as comfortable as possible, that's up to you to work out with them, but with our unconditional positive regard, with our ability to help clients reconnect with their bodies in a wonderful way, the gentle influence of massage can be a powerfully positive part of living with this very challenging condition.

0:13:13.5 RW: Hey everybody, thanks for listening to I Have A Client Who pathology conversations with Ruth Werner. Remember you can send me your I Have A Client Who stories to ihaveaclientwho@abmp.com, that's ihaveaclientwho, all one word, all lowercase, @abmp.com. I can't wait to see what you send me and I'll see you next time.

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