Peter Amento avoided shorts and short sleeves for most of his life, no matter how warm the weather. When he did wear them, “People would comment: ‘What have you got? Poison ivy?’ That’s how bad my psoriasis would look,” says the 61-year-old husband and father of three from Hamden.
The skin disorder appeared when Amento was 15, and over the years he tried everything to make it go away. “I started with sunlamps, which was the way to go back then,” he says. “It didn’t do much.” He moved on to ointments, slathering them on the red patches on his arms, legs and torso, then covering the areas with plastic wrap to help the medication seep in. “They’d go away for a couple of weeks, then you’d have to repeat the whole process.”
Later, he would fly to Florida and sunbathe on the beach until his skin was crisp. “The sunburn killed me for a couple of days, but it got rid of the psoriasis for a month,” he says.
Amento assumed he would struggle with the condition for the rest of his life. Then his local dermatologist referred him to Yale Medicine, where physicians had a new approach.
A painful overgrowth
Psoriasis is an autoimmune disease that affects 2 percent to 3 percent of the population. Dermatologists can make the diagnosis just by looking at a patient. “It likes certain parts of the body, and the patches are pink to red, well demarcated and also have a silver scale,” says Keith Choate, MD, PhD, a dermatologist at Yale Medicine.
The patches on the skin can be unsightly, often leading to comments and questions from strangers. And the scaling can be itchy, uncomfortable and annoying. “Patients talk about carrying Dustbusters around with them, and wives who wake up in a sea of flakes,” says Dr. Choate. Symptoms may wax and wane, but few people have long remissions.
People who have psoriasis have skin cells that grow up to 10 times faster than normal. Recently researchers discovered the reason for that. “Psoriasis requires both genetic susceptibility and an environmental trigger,” such as a strep infection, Dr. Choate says. When these co-occur, “The immune system is inappropriately activated, leading to inflammation in the skin but also, potentially, in the joints and blood vessels,” he says.
Scientists have identified many of the genes associated with psoriasis and have made remarkable progress in understanding how the inflammation occurs. This has led to new biologic treatments—protein-based drugs derived from living cells cultured in a laboratory. The first, Remicade (infliximab), was approved for the treatment of psoriasis in 2006.
Researchers had figured out that excess production of a molecule called tumor necrosis factor-alpha (TNF-alpha) was driving psoriasis. They looked for ways to either remove it from circulation or inhibit its action. The first group of biologics was composed of TNF-alpha inhibitors. Subsequent medications blocked the production of the molecule. Patients with psoriasis now have seven or eight biologic treatment options that can complement approaches that still work for milder cases, such as light therapy and creams.
Finding a fix
After the biologics came onto the market, Amento’s local dermatologist referred him to Yale Medicine, where dermatologists had experience helping patients with the toughest conditions. “People with the worst psoriasis end up in our care, so we might use the different therapies more creatively,” says Brett King, MD, a dermatologist at Yale Medicine.
Amento sat down with Dr. Choate to discuss his history with psoriasis and the treatments he had tried. “Peter had widespread psoriasis, and he was very frustrated by it,” Dr. Choate says.
“Dr. Choate made me feel comfortable right off the bat,” Amento says. “He explained how there were different medicines out there, and which ones we should try.” They agreed to start with Humira (adalimumab), another TNF-alpha inhibitor that was approved for psoriasis in 2008. After eight months of treatment, in which Amento would inject the drug at home every other week, 60 percent of Amento’s psoriasis had cleared up.
But Dr. Choate thought they could get an even better response. “He explained that Humira wasn’t for everyone,” Amento says. “He recommended switching over to Stelara (ustekinumab).”
The treatment works
It worked. “I only have about 5 percent of the psoriasis remaining, mostly on the bottom of my right leg, and with little spots here and there,” Amento says. “I’m the only one who knows they’re there.”
The three-month schedule is convenient, too. “When I was doing light treatments, I’d have to go first thing in the morning or leave work early to get there in the afternoon,” he says. “It was a bit of a hassle.”
Amento and Dr. Choate have developed a friendly relationship, and Amento’s quarterly appointment has become a chance for the two to catch up. “We’ve worked together to find the best treatment for his condition,” Dr. Choate says. “It’s a great partnership.”
Amento recently retired from his job at AT&T and started working with a friend on a landscaping business. He dons shorts and T-shirts every day without giving it a second thought.
“It’s why I chose medical dermatology,” Dr. Choate says. “People can make a lot more money doing cosmetics. But at the end of the day, I wanted to make a difference in patients’ lives.”