Dr. Robert Kalb talks with Beth Fildes, a nurse in his Buffalo Medical Group office. (Harry Scull Jr./Buffalo News)
By Scott Scanlon – Refresh Editor
Those who have been hospitalized in recent months and unable to get a dermatologist to come to their bedside, and others who suffer from psoriasis, can take heart from new developments in the Western New York medical community.
The University at Buffalo School of Medicine dermatology residency program has been reaccredited, and a doctor who is key to psoriasis treatment in the region is in line for more federal funding for his ongoing research on the skin condition.
The UB dermatology program lost is accreditation after four dermatologists left the region and the teaching of dermatology residents suffered as a result.
UB has since improved the program, which learned in February it would regain its lost status. It expects to staff one hospital in the region again come July.
“In the hospital where they’re going to open a clinic – I don’t know which one that’s going to be – they’ll see hospital patients,” said Dr. Robert Kalb, a Williamsville dermatologist and clinical professor with UB medical school.
Kalb is subject of today’s “In the Field” feature in WNY Refresh.
Our interview covered his medical training in New York City, the reaccreditation and the clinical trail work in his office. Below are excerpts I didn’t have room to include in Refresh.
Why don’t dermatologists ever go to a hospital in Buffalo?
In general, a lot of it has to do with the lack of the university dermatology program. Before, there was a doctor at Roswell, Womens & Childrens and Buffalo General Hospital. Then there was the shortage of dermatologists.
We’re going to see a couple again by summer but the real issue is UB is going to have to build up the dermatology program again.
How does the dermatology shortage play itself out here?
The difficulty getting appointments. Some physicians are closed to new patients and in many cases, the wait is significant, six months if you call a new doctor. We do our best. This is a challenge across the country, but in the bigger cities not as much. Try to work through your regular doctor for an appointment. Usually, your primary doctor has a connection.
You got your medical degree from Downstate Health Science Center in Brooklyn and did your residency at the College of Physicians and Surgeons at Columbia University in Manhattan. Why dermatology?
Where I lived in New York City, in Brooklyn, there was a faculty member who had a dermatology practice close to where I lived. As a summer elective, I worked there because I could walk. This was my second year of medical school. It was fascinating. I pursued it from there. The chairman of the department at Downstate (Dr. Alan Shality) was a nationally known figure in the field and that helped me to get a residency spot.
Why the intense focus, including clinical trials, on psoriasis?
At Columbia, there was a psoriasis center. At the time, there were only two medicines used for psoriasis. One’s called phototherapy, and people would come to the hospital and stay for two or three weeks as inpatients and put on this crude coal tar – it’s like black tar – on their skin every day. Tar is a known treatment for psoriasis. If your run tar on your skin and get sunlight, it can help. The treatment would give you a suntan as well, so people would joke, ‘What happened to you, you’ve been gone two or three weeks,’ and they would say, ‘I went to Columbia.’ People would think Columbia, South America, not Columbia Presbyterian.
The other treatment was methotrexate, a pill you take once a week for psoriasis.
When I left Columbia, I was kind of a psoriasis expert. ... I worked in New York and then I came to Buffalo and started working with the university full-time. I started getting referrals from other doctors, other dermatologists, of patients with psoriasis. From there, we started doing clinical trials and it kind of snowballed.
Are there any sort of triggers you suspect? Are food insensitivities involved?
In psoriasis, they’ve looked at that, and with very few exceptions food does not play a role. There are patients who notice a correlation with stress, patients who notice a correlation with infections in general – if you get a bad cold or bad flu – but with a vast majority of patients, it tends to be a more chronic disease. They just have it and it stays. There’s a small minority who have the disease and it goes up and down, they’re fine and then it flares.
Some of the treatments have been likened to diabetes, where you have to take an insulin shot every day. With psoriasis, it’s a control, not a cure, so whatever the medicine is, you have to stay on it (whether it’s a pill or newer injection medication). A lot of people choose to go off the medication and, predictably, it comes back. It’s not a total cure for many patients ... but they’re controlled for the most part.
What are the most common symptoms and concerns?
Some people have it in a tiny, little spot, so it’s not a big deal. Some people have it much more widespread. A lot depends on how much of the body surface is involved. It’s a big spectrum. Generally symptoms include scaling of the skin. You can have significant itching with the lesions on the skin, open areas and slightly raw areas, so it can be tender, uncomfortable. People who have psoriasis on their hands and feet, it may be hard for them to grasp things, it may be somewhat painful to walk. Some may have it fairly significantly in the genital area, so interpersonal relations become an issue.
How does onset work?
There’s two groups of patients. The first age of onset is usually in the late teens or early 20s, then there is a second group that their psoriasis usually comes at about 45, 50, but it can occur at any age.
In terms of some of the concerns?
Patients with psoriasis have a higher incidence of other conditions – inflammatory bowel disease – but the main issue is arthritis. About one-third of patients with severe psoriasis have arthritis. Then, there’s the possible connection with heart disease, so the systemic inflammation can lead to arthritis, heart disease.
So what you see on the skin is only part of the story?
Correct. Psoriasis is not a skin disease, it’s a total systemic disease.
How does inflammation figure into it?
With heart disease, it used to be thought that blood vessels were like pipe and you blocked the pipe. It’s not true. Heart disease, systemic inflammation, leads to the buildup of these plaques. Block the inflammation and in many cases you can improve the tendency toward prevention of heart disease. We know that psoriasis is a risk factor. The question is, if you treat the skin, do you reduce the chance of heart disease? That’s one of the questions we’re trying to answer right now.
Can you talk about those trials? How do they work and what have so far been your findings?
The latest research in psoriasis is on medications called ‘biologics.’ A biologic medicine is made in a living cell and in general has to be injected. In general, the biologic medicines will block a specific chemical, a cytokine (that causes symptoms). In general, the patients for the first 12 weeks will get a biologic medicine or a placebo injection. After the 12 weeks, the people who are on the placebo will get the real medicine. So everyone in the trial has the medicine eventually.
In some of the trials there may be a third arm, where there’s another medicine researchers are comparing to the first medicine, because they want to know what happens after the first 12 weeks.
Everyone stays on medicine and then we measure them for the long run, so a lot of these trials last over five years. It’s not only to measure how the medicine works but any potential side-effects. There are different trials with different medicines that block.
Some of the medicines block Tumor Necrosis Factor (TNF). That’s one of the cytokines, so we’ve done trials with some of the TNF-blocking agents. Now there’s other ones that block – Interleukin 17, Interleukin 23 – so there’s different chemicals that block. With the Interluken 17 drug, the efficacy has been dramatic. There’s people who just totally clear right up. We’re starting a new trial with an Interleukin 23 blocking agent. We have another trial where we’re comparing one of these blocking medications to the phototherapy, which historically has been a good treatment, to see if it blocks the inflammation and helps in terms of heart disease. There’s a special PET scan, which people have before treatment and after treatment. If this PET scan improves, it’s an indirect measure of their heart disease risk.
In that trial, we don’t have the results yet.
Do you find that in that 12-week window these medications work quickly?
Yes, very quickly. Sometimes, in a matter of four weeks, patients can be totally clear. Not everyone.
So not everyone sees the same results?
Absolutely. If you get the same treatment, for some patients, it doesn’t work at all and then the next treatment looks great. The issue is can you identify ahead of time which treatment works best? Should you use conventional treatments first and, if they don’t work, move on to some of these biologic medicines.
What does this tell you about the disease?
It’s probably different genetically, that they have different chemicals that stimulate their immune system. One theory is if one medicine that say, blocks the TNF, and doesn’t work, switch to something different to see if that works.
When we do this research, I’m one site. There’s other sites, so there may be 1,000 patients. It’s not just psoriasis, but genetically, they’re probably different. If we can identify those specific genes, you’d probably be able to treat them better.
Do you use one drug at a time?
Generally yes. We will use a combination of drugs for the tougher cases.
What are you using here?
Phototherapy, which is a standard treatment. We use methotrexate, which is a pill once a week. We use Cyclosporine, which is the drug that revolutionized kidney transplants. That’s very effective in psoriasis. Then we use the biologic agents: Enbrel, Humira, Remicade, Stelara.
How many people do you need for your research and how many have already gone through the clinical trials?
With any given trial, there may be five, 10, 15 patients, but these are multi-center trials, so there’s different centers across the country, but in general these trials are trying to enroll 500 to 1,000 patients.
What tends to be the compensation for patients in these trials?
Free care, free laboratory tests any X-rays, cardiograms, anything involved in the trial. In some of the trials, there’s also compensation for the patients. It’s not a lot. They may get $25 or $50 a visit, depending on what study.
What about lotions or ointments? Which tend to work best?
For patients with limited disease, in general we use topical medicine and it’s very effective. The disadvantage is patients have to keep using it or the psoriasis will come back, so people get frustrated. If it’s just a few spots, it’s not a big deal, but if it’s more than a few spots, it’s difficult to put cream on all the time. We have a trial coming up for different topical treatment.
For normal trials, patients generally have to have psoriasis on 10 percent or more body surface area. For the topical trial, you just need a few patches.
(Kalb said he has about a half-dozen trials going on at any given time “and each one’s a little different.” There are different inclusion criteria. Folks are screened. If someone is interested, call 630-1457.)
Dr. Robert Kalb of Williamsville is doing clinical trials on those suffering with various levels of psoriasis.