2020 Psoriasis Treatment Update: How a Work Leave Might Impact My Skin

Prayer Chapel, Redwood Christian Park, Boulder Creek, California

Lori and I joined a Christian conference for graduate students in the beautiful Santa Cruz mountains. We found this prayer chapel during one of our walks. The trip marked our first weekend on leave from the church.

Happy New Year! I know it is almost mid-February, but it’s my first PsoHoward entry of the year. I’ve been quite busy preparing for a personal leave that started this month. Now that I will be on four-month break I hope to come back to writing regularly.

Today I’ll start with treatment updates.

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Skyrizi Week 16: The Verdict?

The Chang family trip this summer included a trip to Crater Lake, Oregon. I especially enjoyed the trip with improved psoriasis.


This week marks the sixteenth week since I started taking Skyrizi to treat my stubborn psoriasis. I took my first dose of two 75mg injections on May 31st. My second dose came four weeks later on June 28th and anxiously awaited results. Now I’m on every twelve-week dosing with the third dose this week. 

A couple weeks ago I called the Accredo specialty pharmacy to see if they could deliver Skyrizi last Friday in anticipation of taking it this week. With travel to take my daughter to college scheduled at the end of the week I wanted to take it a few days early. My dermatologist agreed. I took the third dose on Monday.

With the third dose injected, and sixteen weeks into the new Skyrizi therapy, what’s the verdict?

I’ll use the same categories to evaluate Skyrizi that I used with Tremfya. Here’s my evaluation:

How well is Skyrizi working for me?

The Verdict: Not as good as hoped, but better than others. 

I did start taking Skyrizi with super high expectations. The dermatologists I talked to recommended it to me. I read about how the effectiveness of Skyrizi topped other biologic medications. No question I wanted to try Skyrizi next with the hope that my psoriasis would magically clear.

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Skyrizi Week 6: Anxiously Awaiting Results

I’ve experienced a steady anxiety about Skyrizi the last few weeks. My expectations changed after I injected the second dose at week 4. With the next injection at 16 weeks, I figured the medication already in me must do the work.

A graph from the Skyrizi website show the percentage of those taking the medication reaching ninety percent improvement tapering off by week 16. For once I want to be part of that three out of four who get fantastic results from a psoriasis medication.

I Want It Gone Now

In my head I know I need to practice patience when it comes to psoriasis. Few medications work as quickly and effectively as I want. I want something like a Tylenol or Benadryl that starts working within the hour. What I typically get with these drugs is more waiting with less than stellar results at the end of months of waiting.

I don’t easily admit my impatience. I see myself as a veteran of these psoriasis wars—I’ve seen it all, and nothing surprises me. Expect little. Set the bar low to the ground. Manage expectations. All these platitudes mean well, but do little to curb the appetite that’s grown for something, anything, to truly knock down my psoriasis. The fact remains I’m no different than anybody with a severe chronic condition—I want it gone now.

Alas, it just doesn’t work that way (if it works at all). I want the rabbit, but many treatments act more like the turtle. Slow and steady wins the race, Aesop’s fable declares. But what if the turtle never makes it to the finish line?

Here are some photos comparing when I started Skyrizi and about six weeks later:

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Starting Skyrizi for Psoriasis: Week 0

It happened faster than I could mentally prepare myself—I’ve stopped Tremfya (Guselkumab) and started Skyrizi (Risankizumab) on Friday. 

The conversation about starting Skyrizi began with a message to Dr. Christie Carroll on the day the FDA approved Skyrizi for moderate to severe plaque psoriasis in April. She told me that the prescription request might run into problems with gaining insurance approval for a brand new medication. Also the pharmacy probably did not yet have it in stock and ready to ship. She offered Taltz (Ixekizumab) as an alternative.

I told her about the discussions I’ve had with other doctors and their thoughts on which biologic I could take. Even though they don’t know my personal situation as well as Dr. Carroll, they thought very highly of Skyrizi. With the data from clinical trials looking amazing (the Skyrizi website claims that “3 out of 4 people achieved 90% clearer skin”) I told her I could take Taltz first, but if it failed, I wanted to try Skyrizi eventually.

I started taking Tremfya on August 21, 2017 and Skyrizi on May 31, 2019. I didn’t quite make it to two years, but it did keep me moderately under control for almost 650 days (and 56 million seconds)!

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Read about my two year journey with Tremfya

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Skyrizi Week 0

At my next dermatologist appoint on May 17th Dr. Carroll told me that with the passing of a few weeks, and a new staff member to file prior authorizations, we could give Skyrizi a try. I would first need to get blood tests, especially and updated TB test before starting the new biologic.

Just over a week later I received a cryptic email from the specialty pharmacy, Accredo, that my prescription request was being filled. The next day I received a letter from my insurance provider stating they approved the prior authorization for me take Skyrizi. I immediately signed up for Skyrizi Complete, a service by AbbVie that would provide support such as copay assistance while taking Skyrizi.

A quick call to Accredo ended with scheduling a next day delivery of my first dose. The Nurse Ambassador, Adele, from Abbvie also agreed to call me in the late afternoon to assist me with the first dose the next day.

Two weeks after Dr. Carroll submitted the prior authorization request for Skyrizi I found myself injecting my first dose–one syringe on the left side of my abdomen and another on the right side. Hopefully in the future the dose will be one pen or syringe, but I didn’t mind the two injections this time around.

May 31, 2019 Photos to record my psoriasis at the start of Skyrizi treatment. (Above) Back and upper arms. (Below) My leg (left) and arm (right) showing psoriasis lesions broken out.

First Reactions and Impressions

Less than a week into treatment I’ve experienced a myriad of emotions including hope, anxiety, excitement, and fear. I wouldn’t try a new biologic unless I felt hopeful and excited it might clear my psoriasis–even if for a season. The anxiety and fear of what side effects I might feel, and what it might be doing to my body besides cleaning my psoriasis is just as real.

Physically, I experienced some headache, lightheadedness, and fatigue after the first dose. It’s only been about five days so I’m not going to make too much of it. No doubt someone from the manufacturer will want to talk to me about my experience (they tweeted as much!) Not to worry, I will talk to my Nurse Ambassador soon about my experience so it can benefit others.

My psoriasis is about the same. Every time I’ve checked it the last few days it’s about the same. So nothing to report there yet, although I wish I could say it worked so quickly.

Prayers Welcome

Finally, if you are praying person, I covet your prayers. I didn’t expect to start Skyrizi so quickly, and I’m still trying to figure out how I feel about trying my 6th (!) biologic for psoriasis since 2003. But whatever happens I know I’ve been through the lowest of lows with this disease and made it through with the strength of God.

85 Weeks with Tremfya: Finally a New Dosing Schedule

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The view from my office during a heavy thunderstorm. A fitting picture of how I’ve felt the last couple weeks with worsening skin conditions.

My how time passes. Almost six hundred days in fact since I started using Tremfya (guselkumab) to treat recalcitrant psoriasis. The twelfth injection three weeks ago held special significance as the first dose at the new every six-week dose schedule. With two extra syringes from my dermatologist I can try out every six-week dosing for about a year.

I figured since Week 24 that if I could take Tremfya more frequently I could avoid the inevitable flare that comes at the last two weeks before I get my last dose. Now with two extra boxes in my refrigerator I could try it out.

Thanks to my Doctor

First of all, I want to give credit where credit is due. My dermatologist, Dr. Christie Carroll, offered two sample injections to me late last year after my insurance provider denied our request for every six-week dosing.

She took the initiative to sign them out to me and wrote a note with my name on them. She mentioned, unfortunately, that she might not be able to give me more samples in the future as she faced pressure to give up samples. I don’t understand all the ins and outs of why she might not be able to get Tremfya for me in the future. But I’m glad that she looked out for me to find a way to try it.


Follow my Tremfya journey!

Tremfya (Guselkumab) Week One  

3 Weeks with Tremfya: The Waiting Game

8 Weeks with Tremfya: It’s Working!

16 Weeks with Tremfya: The Verdict?

24 Weeks with Tremfya: A Pattern Emerges

38 Weeks with Tremfya: The Q&A Edition

42 Weeks with Tremfya: Coping with a Skin Flare

Tremfya is much, much harder to get than I imagined

One Year with Tremfya: Can’t Get Enough!


Is My Skin Better with More Frequent Dosing?

The quick answer is not really.

Almost four weeks into the new dosing schedule I cannot say that I notice as much improvement than I expected. I hoped to side step that flare, but it came anyhow. Along with the psoriasis dotting my trunk, legs, and arms, my eczema flared badly as well. I’ve lost sleep, concentration and productivity due to the constant itchiness and irritation.

I can think of a few problems with making any conclusions about the effectiveness of this dosing. Continue reading →

One Year with Tremfya: Can’t Get Enough!

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I love visiting my parents in Orange County, California, especially going to the beach. But this last time around my psoriasis flared during the trip and is only slowly calming down.

The anniversary of my first injection of Tremfya (Guselkumab) came and went in late August. In a way it’s a good sign that the time went by quickly, for as the saying goes, I had more freedom and fun while it knocked down skin inflammation. In fact, I can’t get enough of Tremfya.

Why Can’t I Get More?

Soon after starting Tremfya I recognized a pattern that continues to this day: about six weeks into the eight-week injection cycle the psoriasis begins to break out. It’s a thin, red, guttate type psoriasis. I call it a “thousand points of psoriasis” lighting up my skin. Lots of little dots or eraser head size lesions that peel and leave a dark pink to red raw skin underneath.

I call it a “thousand points of psoriasis” lighting up my skin. Lots of little dots or eraser head size lesions that peel leave a dark pink to red raw skin underneath.

I asked Dr. Carroll, my new dermatologist starting here in 2018, if I could take Tremfya more frequently. Ideally, I could get an injection every four weeks, but I asked for every six weeks. Predictably, my insurance denier provider said no. Upon appeal they also said no.

Like a petulant child I thought I could proverbially stomp the ground by appealing until I broke the insurance company down to give out another couple injection a year. But they are stubborn, like I am as a parent. I asked why and they gave me the “there are no studies to substantiate the effectiveness of taking Tremfya more frequently,” and the “FDA approves Tremfya for every eight weeks” so you are out of luck kind of answers.

I get it. It’s $10k for one injection. But that one or two extra injections could make a huge difference in my quality of life. Thankfully, they approved the normal dosage so that my quality of life is substantially improve already.

But wow it would be great to get a little more.

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Here is my right arm taken on September 18, 2018 at the end of my eight week Tremfya cycle. Relatively flat, red spots that more peel than flake and not itchy. They tend to start going away a couple weeks after taking the injection.

It Would Be Great for Stress Events

It’s not just that I want to pry the insurance provider’s fingers off of that precious box of Tremfya comes in for selfish gain. I need it for those stressful times I’m working at the church, helping out the family, or madly meeting blog deadlines. Continue reading →

Tremfya is much, much harder to get than I imagined

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I took this photo of the sunset over the ocean on last month’s Alaska cruise. It reminds me of calmer waters and more joyful times as I persisted in getting my Tremfya prescription right over the past few weeks since.

The journey began in May simply enough: get Tremfya renewed for another year at a new specialty pharmacy. I have continued to use my previous dermatologist’s prescription this year, but with a new doctor I needed a new prescription at a differeent pharmacy starting this summer.

My dermatologist and I decided to request every 6-week dosing, which we both thought would be denied. But it was worth a try, right? No. Denial came swiftly and ended up costing me a lot of time waiting and on the phone.


My dermatologist and I decided to request every 6-week dosing, which we both thought would be denied. But it was worth a try, right? No.


For me simple is never that simple when it comes to getting the newer, more expensive (good) medications to treat severe psoriasis.

(Barely) Qualifying to Receive Tremfya Coverage

After the DENIAL for every 6-week dosing schedule for Tremfya, I was glad to see they approved every 8-week schedule. It’s what I expected anyhow since it makes financial sense for the insurance provider to not pay more than it has to, even though I’ve shown I need a higher frequency dosing.

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With that letter describing how 6-week dosing is not covered, WHA did explain the criteria for receiving coverage for Tremfya. I couldn’t believe how incredibly restrictive the criteria are, including failing two of the newer medications/biologics:

WHA [Western Health Advantage] covers Tremfya when all the following criteria is met:

[1] when prescribed for moderate to severe plaque psoriasis confirmed by a dermatologist (psoriasis affects 10% or more of the body; psoriasis involves hands, feet, and neck or genitalia).

AND

[2] prescribed by a dermatologist

AND

[3] the patient has tried and failed topical therapy (e.g., Dovonex, Tazorac, or other topical steroids),

AND

[4] documented failure or clinically significant adverse effects to one of the following therapies alone or in combination, unless contraindicated: methotrexate or (if methotrexate in contraindicated) cyclosporine, acitretin, or a trial with PUVA or UVB for at least 3 months unless intolerant,

AND

[5] documented failure or significant adverse effects to at least two of the following: Humira, Otezla, Stelara, or Cosentyx.

Initial approvals are considered for 3 months to assess patient’s response and renewals for one year.


I couldn’t believe how incredibly restrictive the criteria are to receive Tremfya, including failing two of the newer medications/biologics.


This is how I imagine the insurance provider reviewer went about his job when fe came to my case: Continue reading →