The Challenge of Skin Diseases: “Everything’s on the Surface”

Dr. Challgren


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An Affiliate of Anne Arundel Dermatology

Gregory J. Wilmoth, MD
Eric D. Challgren, MD
Margaret B. Boyse, MD
Laura D. Briley, MD
Tracey Cloninger, PA-C
Stephanie S. Pascale, MSN, FNP-C

4201 Lake Boone Trail, Suite 200
Raleigh, NC 27607
Telephone: (919) 782-2152

4201 Lake Boone Trail, Suite 207
Raleigh, NC 27607
Telephone: (919) 863-0073

“The unique challenge we confront as dermatologists,” observes Dr. Eric Challgren of Southern Dermatology and Skin Cancer Center in Raleigh, “is that, for most skin diseases, everything’s on the surface. The majority of the common conditions we treat—such as eczema, psoriasis, and acne—are visible, often in painfully embarrassing ways.

“The important thing,” he adds, “is not that we see these conditions—but that these are the problems that patients also see. And if they’re on the face, or hands, or arms, they’re not only visible, they’re often life altering.”

The Challenge of Visible Diseases

“Because of their visibility, there’s a huge psychological component to skin diseases such as acne, atopic dermatitis, and psoriasis,” notes Dr. Challgren. “These aren’t dangerous conditions with a long-term impact on mortality, but they can have a huge impact on quality of life and mental well-being. Psychologically, it’s easy to ignore your high blood pressure—but it’s not easy to ignore your psoriasis or acne or atopic dermatitis, which is right there in front of you every day.

“Eczema is a good example. It can be flagrantly bad all over your face and arms. You’re itchy and miserable and have trouble sleeping. But, on top of that, your skin is weeping and crusting, and you think ‘Man, I don’t want to go out public looking like this!’ It’s depressing and embarrassing.

“This is also true of psoriasis and acne,” he says. “Severe plaque psoriasis, for example, is an auto-immune disease that presents as scaly skin lesions that may cover as much as 90 percent of the body. And it can have a profound psychological effect as well as a physical one. Patients often limit activities to avoid being seen. And studies have found that people with psoriasis tend to have lowered self-confidence and experience higher rates of anxiety and depression.”

Another example many can relate to is acne, notes Dr. Challgren. “Studies have shown that adolescents with acne endure more bullying and teasing from peers, and experience higher instances of social challenges during high school than those with clear skin.”

Highly visible diseases aren’t simply annoying and embarrassing,” explains Dr. Challgren. “Their visibility has physical consequences. We see this mind-body connection in particular with diseases such as psoriasis and eczema—diseases that are exacerbated by stress. And their visibility is a source of stress; it’s a vicious cycle.”

Breakthroughs in Treatment

For a long time, notes Dr. Challgren, one of the greatest challenges in treating diseases such as psoriasis and eczema were the limited options available in medications. “Happily, in the last 20 years or so, that has changed dramatically.

“The development of biologic medications,” he explains, “has been revolutionary. Twenty years ago, we had a handful of therapeutic interventions for these autoimmune diseases, many of them toxic or inconvenient. Now, rather than treating a condition systemically, new biologic medications target specific parts of the immune system, significantly reducing adverse side effects.

“New biologic drugs continue to come out every year, giving even more opportunity for patient-specific treatment,” he adds. “There are unique classes of them, depending on what pathway they suppress, and we can target the medication to the specific patient in a way that was simply not possible with the older meds.”

The results of these advances, he says, “are remarkable. For example, the medications that were available previously for psoriasis were likely to result in, at best, 50-75 percent skin clearance. With the new biologic medications, we can expect 90-100 percent skin clearance. And that gets back to the emotional connection. The emotional state of the psoriasis patients I’m treating today is quite different from the emotional state of my patients 10 and 20 years ago, because these medications allow them to look better and feel better about themselves.”

The Challenge of Compliance

“I’m sure everyone in medicine would agree that compliance with a treatment regimen is always an underlying issue,” observes Dr. Challgren. “For dermatology, it can be especially problematic. Simply put, it’s easier to take a pill than to apply a cream. That’s understandable; treatment regimens for skin diseases can often be complex—with a cream in the morning, a cream at night, and a pill in the morning. It’s annoying and can be time consuming.

“Acne treatment,” he notes, “is a classic example of when we run into compliance problems, because you’re dealing with a lot of teenagers who aren’t known for being particularly compliant. Using acne as an example, the challenge we face is to determine why a treatment is not working. It’s usually one of three reasons: one is when the patient is fully compliance, but the medicine doesn’t work; a second reason is because the patient can’t tolerate the medicines; and the third reason is the compliance problem—the patient is just not using the medicines as directed.

“As a rule, I would say that we have compliance problems with about 25 to 50 percent of acne patients—a number that’s greater with teenage boys than with teenage girls. It’s part of the challenge.”


When talking about challenges in providing health care, says Dr. Challgren, “we can’t ignore the cumbersome, bureaucratic nature of America’s health care system. We are blessed with many treatment options; awesome new medications; and better and better understanding of how to treat chronic skin diseases. These give us wonderful flexibility to find the solution for an individual patient’s problem. But too often we’re caught up short—unable to use a particular medication because it’s not covered by insurance, or approval is slow and cumbersome. And newer (often better) medications are much more expensive. So, the challenges are many; and the frustration can be enormous.

“We run into these bureaucratic problems every day with these new drugs—especially since new biologics are developed every year. These advances allow us more and more options for patient-specific treatment, which is wonderful. But they’re not free, they’re not cheap, and insurance companies push back on some of these. So, you have to learn to navigate the bureaucratic side of medicine—what I call the ‘not-fun’ part of medicine.

“This has been particularly frustrating with respect to the biologic medications for psoriasis and atopic dermatitis—the visible diseases that are so stressful. Unfortunately, the complexity of the insurance system can mean that we can’t get these medications for all patients. I would say that, for one out of ten patients that we want to put on a specific targeted drug, it’s not an option. For another four out of ten, the process is difficult and we spend a lot of time and effort negotiating with insurance companies in order to get authorization. We’re successful, but it’s frustrating. In these cases, you’re not really practicing medicine, you’re practicing bureaucracy, “But, despite the frustration, it’s worth it,” he says. “If you get approval and the psoriasis patient goes from 80 percent body coverage to less than 1 percent body coverage, and their joints feel better, it’s a big win. But it’s challenging.”