JULY 2012 Jerry Bagel, MD of Windsor Dermatology Home of the Psoriasis Treatment Center of Central New Jersey Restoring Quality of Life for Psoriatic Patients Throughout NJ and Beyond
Jerry Bagel, MD of Windsor Dermatology Home of the Psoriasis Treatment Center of Central New Jersey Restoring Quality of Life for Psoriatic Patients Throughout NJ and Beyond By Iris Goldberg To say that psoriasis is a challenge to treat is an understatement. An immunemediated disease that affects the skin, psoriasis is typically a lifelong condition. The disorder is chronic, recurring and varies in severity from minor localized patches to complete body coverage. Plaque psoriasis is the most common form, affecting 80 to 90 percent of all patients with psoriasis. In plaque psoriasis skin rapidly accumulates and typically appears as raised areas of inflamed skin covered with silvery white scales. These plaques frequently occur on the skin of the elbows and knees but can appear on any area including the scalp, palms of hands, soles of the feet and genitals. Fig. 1 Dr. Bagel Serves As: Associate Medical Editor of the Psoriasis Forum Medical Editor of Practical Dermatology Peer Review of: British Journal of Dermatology Journal of the American Academy of Dermatology Psoriasis can be associated with significant physical discomfort of itching and pain as well as some disability. Approximately 25 percent of psoriatic patients develop inflammation in their joints, known as psoriatic arthritis. Psychological distress caused by feelings of self-consciousness and embarrassment may lead to significant depression and even selfimposed social isolation. Fortunately for psoriatic patients in New Jersey and surrounding areas, Jerry Bagel, MD, who is the founder of and director of the Psoriasis Treatment Center of Central New Jersey (PTCCNJ) at Windsor Dermatology, has spent almost 25 years investigating promising treatments in a continuing mission to improve the quality of daily life for those who are afflicted with psoriasis. Honored by the National Psoriasis Foundation (NPF) as the nation s leading recruiter of psoriasis patients, Dr. Bagel has been an investigator on more than 75 clinical trials to find innovative treatments for psoriasis and other skin conditions. Additionally, he has been appointed to four three-year terms as a member of the NPF Medical Advisory Board. Dr. Bagel is renowned as an expert on psoriasis, who contributes to several prominent peer review journals (see Fig. 1) and often speaks at dermatology conferences worldwide to share current developments. Dr. Bagel examines the elbow of a patient who is a candidate for an upcoming clinical trial. photography by Michael Goldberg For every FDA-approved drug for the treatment of psoriasis ENBREL, HUMIRA, STELARA and those that came before, we have been involved, Dr. Bagel strongly states. Dr. Bagel, who is no less than passionate about finding new and more effective treatments for psoriasis, shares that the involvement of PTCCNJ is ongoing. We have more people in registries than anywhere in the country, he reports, adding that the FDA requires patients who are enrolled in trials to be followed for at least five years. Furthermore, Dr. Bagel explains that PTCCNJ s role in fighting the disease carries over to the creation and organization of support groups to help psoriatic patients cope with the many issues associated with their condition. To understand how Dr. Bagel came to choose improving psoriasis treatment as the centerpiece of his work within the field of dermatology, it is important to go back 30 years to the early 1980s, when he was a dermatology resident at Columbia University. The program required that he spend six months on an in-patient service following patients who needed hospitalization for up to a month in order to clear their psoriasis. They would be in tar baths for an hour or two a day, get moisturizing treatments every day and be exposed to increasing amounts of light because light decreases the proliferation of the epidermis. And so after about a month of this, they would go home, stay clear for eight or nine months and then would eventually have to come back to the hospital, relates Dr. Bagel. When he began his own practice, Dr. Bagel located his office just a few miles from where he was raised because he knew there was not an adequate dermatology practice or psoriasis treatment facility in the area. He acquired the necessary
Patient is receiving phototherapy. There are numerous lightboxes on-site at PTCCNJ. equipment to treat patients with moderate to severe psoriasis in his office in order to spare them a hospital stay. I wanted psoriasis treatment to be one of the mainstays of my practice. I brought in light boxes and we started doing psoriasis day care here in the office and back then people actually would stay for six hours a day, five days a week to get phototherapy, tar baths and moisturizing creams, he recalls. In 1982, Dr. Bagel did extensive research and published his findings on phototherapy, which involves exposing the skin to ultraviolet light on a regular basis under medical supervision. Phototherapy has been and continues to be an integral part of psoriasis treatment, often inducing a remission of psoriasis symptoms. Ultraviolet light A (UVA) and ultraviolet light B (UVB) are found in sunlight. UVA is relatively ineffective unless used in combination with psoralen, a light-sensitizing medication. This process, called PUVA, slows down excessive skin cell growth and can clear psoriasis symptoms for expansive periods of time. Severe plaque psoriasis and psoriasis of the palms and soles are most responsive to PUVA therapy. UVB is also an extremely effective treatment for appropriate patients and does not require light-sensitizing medication. UVB phototherapy penetrates the skin and slows the growth of affected skin cells by exposing the skin to an artificial UVB light source for specific intervals of time on a regular schedule. Narrowband UVB maximizes efficacy and safety. At PTCCNJ both PUVA and narrowband UVB phototherapy, supervised by on-site photo-therapists, are used depending upon the individual needs of each patient. Unfortunately, when Dr. Bagel first began treating psoriatic patients, the time required for effective treatment was significantly longer and many patients did not have enough time to devote to coming in on a daily basis. Also, most insurance companies were unwilling to cover the treatments. In 1990 things changed significantly when Dr. Bagel had the opportunity to collaborate with Merck Pharmaceuticals researching cyclosporine, an antirejection medication originally used in the 1980s for those undergoing kidney transplant. It was found that in kidney transplant patients who also happened to have psoriasis, taking cyclosporine caused the psoriasis to clear. It was then they realized that psoriasis was an immunologic disease, Dr. Bagel explains. For some reason, in a genetically pre-disposed individual, the white blood cells are producing chemicals that make the epidermis grow too quickly, he elaborates. After first researching cyclosporine as a medication for psoriasis, in the early1990s, Dr. Bagel became involved in clinical trials researching other biologic agents that might hopefully diminish the immune system s ability to produce the chemicals that speed up epidermis growth. Although these did not come to fruition, in 1997 he began clinical trials with a medication called AMEVIVE. This was the first of the biologic agents to show real promise in treating psoriasis. Biologics are protein-based drugs derived from living cells cultured in a laboratory. Used mostly for patients with moderate to severe psoriasis, Dr. Bagel explains that instead of impacting the entire immune system as is the case with traditional systemic drugs, biologics target specific parts of the immune system by blocking the action of immune cells called T cells or by blocking proteins in the immune system, such as tumor necrosis factor-alpha (TNF-alpha) or interleukins 12, 17 and 23. It is these cells and proteins that are majorly involved in the development of psoriasis and psoriatic arthritis. Dr. Bagel is pleased to report that as a result of clinical trials with pharmaceutical companies over the years, there are now medications that can significantly improve the quality of life for psoriatic patients. For example, he points to STELARA by Janssen Pharmaceuticals. With one injection every three months - that s only four times a year 75 percent of psoriasis patients can walk around almost clear, he happily states. This is a real breakthrough compared to what was available ten years ago, Dr. Bagel adds. At PTCCNJ trials to investigate promising immunosuppressant medications are continuously ongoing to determine their effectiveness on manipulating the immune system. Dr. Bagel discusses the significant benefits derived by appropriate patients who participate in Here a patient uses special light boxes designed to treat psoriasis of the palms of the hands and soles of the feet.
The dramatic results that can be achieved with biologic agents is evident in before and after photos of a patient who has undergone treatment at the Psoriasis Treatment Center of Central New Jersey. clinical trials. In some cases, they get five years of medical care and medication for free. They don t have to deal with their insurance companies to get drugs approved. They don t have to deal with copays, Dr. Bagel points out. Now we re developing newer IL-17 (interleukin 17) drugs where we ve seen people with a significant percent of their bodies covered with psoriasis become clear in a few weeks. So the scientific research and the impetus from pharmaceutical companies and clinical trial development for psoriasis over the last ten years have been phenomenal and the improvement in the quality of life has been significant, relates Dr. Bagel. For Dr. Bagel it s all about bringing a better quality of life to those who suffer the physical and psychological trauma Dr. Bagel uses an excimer laser to treat the elbow of a psoriatic patient. of living with psoriasis. He offers a hypothetical scenario involving a young girl with psoriasis: Imagine being a 16 year old girl with psoriasis on your elbows and forehead on a beautiful summer day. You re meeting your best friend at a public pool. You both approach the water and you re told you cannot go in because you might have something contagious. You cry and you go home. Now imagine how this affects your self-esteem and increases your depression, Dr. Bagel asks. In fact, as Dr. Bagel states, psoriatics have a significantly higher incidence of depression compared to the normal population and use anti-anxiety medications with significantly more frequency. So you have depression, which is severe, increased frequency of suicidal ideation and in fact, there is an increased frequency of suicide, he informs. In addition to the overwhelming psychological problems that detract from their quality of life, psoriatic patients suffer much physical discomfort. Psoriasis is very itchy and patients lose sleep at night, Dr. Bagel reports. There s also pain and bleeding from the excessive scratching. So there s itching and pain and times when psoriatics have go to work tired from lack of sleep, he states. Dr. Bagel goes on to share the results of a Harvard study which he collaborated on, that was reported this month at the American Academy of Dermatology meeting, held in New York City. It revealed that when asked, the average psoriatic patient would agree to relinquish five years of his or her life to have normal skin. Ironically, as Dr. Bagel further reports, the average psoriatic actually lives five years less than the normal lifespan because of underlying risk factors associated with psoriasis. It has been found out over the past six or seven years that psoriasis is not just a disease of the skin, reveals Dr. Bagel. First of all, 25 percent of all people with psoriasis also have psoriatic arthritis. The same inflammation that appears on the skin is present within the joints. When left untreated, that destruction of the joints becomes irreversible, he explains. Since the initial presentation of psoriasis usually precedes the development of psoriatic arthritis by ten years, Dr. Bagel emphasizes the importance of early diagnosis and intervention by the dermatologist. Besides the risk of developing psoriatic
arthritis, as Dr. Bagel discusses in great detail, recent studies have confirmed that young people with psoriasis have increased risk for developing a heart attack or stroke. This is primarily due to the fact that people with psoriasis tend to have a greater incidence of those conditions that put one at increased risk. People with psoriasis have an increased frequency of obesity, have an increased frequency of diabetes, have an increased frequency of metabolic syndrome and in addition, have an increased frequency of depression, Dr. Bagel specifies. I think we have to look at psoriasis much like we look at diabetes. When an ophthalmologist looks at the retina of the eye and discovers vasculopathy, he or she tells the patient to see an endocrinologist to be evaluated for diabetes, he states. When you, as a dermatologist, see a patient with psoriasis, you need to tell that person to consult with a cardiologist or at the very least, an internist to be evaluated for lipids and possible cardiovascular problems, Dr. Bagel strongly advises. On the brighter side, Dr. Bagel reports on some preliminary data which suggests that when psoriatics are treated with the newer biologic agents, especially TNF inhibitors, the incidence of heart attacks and strokes decreases. Not only does the psoriasis go away but you re decreasing the entire inflammatory load, explains Dr. Bagel. By decreasing the body s inflammation, you re decreasing the amount of psoriasis, you re decreasing the amount of atherosclerosis in the blood vessels and you re decreasing the incidence of heart attacks and stroke, he reiterates. Dr. Bagel makes a point of emphasizing that for patients with mild psoriasis affecting less than 10 percent of the body, going to a traditional dermatology office and receiving a prescription for a topical ointment is probably sufficient most of the time. However for those patients with moderate to severe cases of psoriasis, the resources of a dedicated psoriasis treatment center are crucial for the ability to provide the most optimal level of care in each case. If you re not involved with all the bells and whistles of a psoriasis treatment center, it s hard to make a go of psoriasis if you re just writing prescriptions for biologic agents or topicals, asserts Dr. Bagel. You need to be doing other things like phototherapy 25% of people with psoriasis also have psoriatic arthritis as can be seen on the hand of this patient. This patient is a participant in a clinical trial investigating one of the newer biologic agents. His psoriasis has cleared significantly after only a few weeks of treatment. Dr. Bagel and the clinical trials team at PTCCNJ meet regularly to discuss each patient s progress. and clinical trials in order to have that infrastructure which allows you to really provide optimal care to psoriatic patients, he strongly believes. Without the success of Windsor Dermatology, Dr. Bagel acknowledges that the Psoriasis Treatment Center of Central New Jersey would not have been able to thrive and evolve into the haven for psoriatics that it is today. He built Windsor Dermatology on the foundation of providing the highest level of care for a myriad of medical skin conditions in addition to psoriasis, including skin cancer. Today, Windsor Dermatology also offers the most innovative cosmetic and laser procedures. Here is an overview of the medical and cosmetic treatment services available:
MEDICAL DERMATOLOGY Annual skin cancer check-up Eczema Hair loss Hives Hyperhidrosis (excessive sweating) Moles Molluscum Port wine stains Rosacea Skin allergy/contact dermatitis Skin cancer/mohs surgery Skin tags Sun-damaged skin Warts Besides Dr. Bagel, five board-certified dermatologists comprise Windsor Dermatology s staff of expertly-trained physicians (see below). Most recently, Windsor Dermatology has added a licensed and accredited aesthetician to recommend personal skincare treatment customized for each patient s needs. The Physicians of Windsor Dermatology Jerry Bagel, MD Judit Stenn, MD David Nieves, MD Wendy Meyers, MD Brian Keegan, MD, PhD Matthew Halpern, MD Theresa Zwada, Windsor Dermatology s aesthetician, performs a facial treatment.. COSMETIC and LASER Botox and Juvederm for wrinkle correction Skin rejuvenation lasers to treat skin laxity, blotchiness, sun spots, scars and superficial blood vessels Hair removal laser to treat unwanted hair Sclerotherapy to eliminate unsightly leg veins Skin tag removal Dr. Bagel makes a point of mentioning the priority placed on making sure that patients treated at Windsor Dermatology have a positive experience. First and foremost, he cites the impressive qualifications of the physicians. We really try to maintain a high level of expertise, says Dr. Bagel. We have smart people who went to excellent schools. Additionally, patient surveys are undertaken often to identify problems and correct them. We ve gotten to the point where we are very patient-friendly and service-oriented, Dr. Bagel shares. It s taken some time but this is something we have really tried to develop with no nonsense, he emphasizes. Certainly, for anyone within New Jersey or surrounding areas who is suffering with moderate to severe psoriasis, Dr. Bagel and the staff at the Psoriasis Treatment Center of Central New Jersey offer real hope for a dramatically improved quality of life. For other medical and/or cosmetic dermatology patients treated at Windsor Dermatology, the results will be no less exceptional. Dr. Bagel wouldn t have it any other way. Windsor Dermatology and the Psoriasis Treatment Center of Central New Jersey are located at 59 One Mile Road Ext, Suite G. For more information or to schedule an appointment, please call (609) 443-4500 or visit www.windsordermatology.com