She’s been mortified by these flares since childhood. “As a kid, I’d go to day camp wearing jeans and long-sleeved shirts — and I never, ever wore a bathing suit,” she recalls.
What Knee and Elbow Psoriasis Looks Like
The knees and elbows are the most common location for psoriasis flare-ups. “Those are the textbook cases,” says Elisabeth Richard, MD, an assistant professor of dermatology at the Johns Hopkins University School of Medicine in Baltimore. Psoriasis on these body parts tends to have a distinctive appearance: “You’ll usually see a well-circumscribed plaque, bigger than a centimeter, with thickened skin and overlying white scales,” Dr. Richard explains. Plaques may appear red or salmon pink on white skin and purple or brown on Black or brown skin. Psoriasis most often appears on the front of the knees and the elbows, known as extensor surfaces, says Jeffrey Cohen, MD, an assistant professor of dermatology and director of the psoriasis treatment program at Yale Medical School in New Haven, Connecticut. The prevalence of psoriasis in these areas is likely no accident. “We lean on our knees and elbows frequently, or they are apt to rub against clothing. That can result in a process called Koebnerization, in which micro-traumas like rubbing or banging skin potentially lead to flare-ups,” Dr. Cohen explains. With knee psoriasis, there is some evidence that the condition can harm not just the skin but also the joint. In a 2021 study published in the journal Frontiers in Medicine of more than 10,000 people with psoriasis, women with psoriasis, in particular, were significantly more likely to end up having total knee replacement surgery than people of the same age without psoriasis. Flare-ups on the knees and elbows can also cause emotional pain. “I see a lot of patients who don’t feel comfortable wearing shorts or short sleeves, even in summer, because they’re embarrassed,” Cohen says. Pace says that even as a successful psychotherapist, she feels the same self-consciousness about her skin that she did as an insecure 11-year-old. “I still won’t wear a bathing suit — and even though I had a pool built, I won’t go in, because I don’t want anyone to see my flares,” she says. Knowing that other people in her family have also dealt with psoriasis — the condition has a strong genetic link — hasn’t eased her distress. “I have it worse than my other relatives, and at times, I’ve thought, ‘Why me?’ It has definitely played a psychological game with me.”
Psoriasis Treatments Can Help the Knees and Elbows
The good news is that people with psoriasis on the knees and elbows have numerous treatment options that can make a significant difference. Most dermatologists will typically start out by prescribing topical steroids. Non-steroidal topical treatments are another, relatively new alternative since the U.S. Food and Drug Administration (FDA) approved tapinarof (Vtama) and roflumilast (Zoryve) creams. There is also a new non-steroidal oral treatment (in pill form) called deucravacitinib (Sotyktu), for people with moderate to severe psoriasis. Cohen explains that it helps minimize inflammation by blocking certain molecules that affect immune system signaling. Other treatments include light therapy (also called phototherapy), which can be a good option when psoriasis is localized as opposed to all over the body. Pace purchased her own light box and used it for 10 years. “It helped,” she says, “but I eventually stopped because I was worried about developing skin cancer.” (Light therapy utilizes ultraviolet B — UVB — rays rather than the UVA kind to minimize skin cancer risk.) Richard says that one alternative method for delivering phototherapy is the excimer laser. “You can use a handpiece to deliver the treatment in a very focused way,” she says. Two more options for people with moderate to severe psoriasis are methotrexate, a chemotherapy drug also used to treat psoriasis and psoriatic arthritis, as well as a class of drugs known as biologics, which are administered via IV or injection. These medications target underlying inflammation by suppressing the body’s immune response but can cause side effects. Pace has tried a number of biologics. “They worked wonderfully,” she says. Yet eventually, side effects got in her way. “It happened like clockwork — after taking them for three months, I’d start to experience joint pain and nausea,” she says. Cohen and Richard emphasize that physicians and patients often need to explore a number of therapies before finding the one that works best at a given point in time.
Sunlight and Moisturizers Can Also Help With Psoriasis
For now, Pace is not using medication for her psoriasis, but she is spending more time at her home in Florida. “The one thing that really helps me is the sun,” she says. Keeping her knees, elbows, and other affected areas well moisturized helps, too. “Aquaphor is my friend,” she quips. Richard agrees: “It’s really important to stay ahead of the dryness with moisturization, and hypoallergenic ointments are best.” The most important thing to do, says Cohen, is to keep working with your dermatologist. “The main thing I want to impress on people who feel disheartened is that we have a lot of good treatments out there, and the options are expanding all the time.”
