Alexa Hetzel, MS, PA-C

In the final episode, ‘Shared Decision-Making in Plaque Psoriasis: Route and Patient Trust,’ the panelists explored how to build lasting trust with patients.

Shared Decision-Making in Plaque Psoriasis: Route and Patient Trust

Andrew Mastro, MS, PA-C, asks Alexa Hetzel, MS, PA-C, whether efficacy and durability drive first-time systemic treatment decisions or whether route of administration and patient comfort carry more weight in practice. Hetzel says the answer depends heavily on how much shared decision-making shapes the conversation. Some patients are simply anxious about injections without understanding what the experience actually involves, and while she notes that broader public familiarity with self-injection, driven in part by GLP-1 therapies, may be easing that hesitancy generally, some patients still perceive a pill as inherently safer even when that is not necessarily true. Having a genuinely effective oral option now makes it easier to say yes to that preference rather than working to talk a patient out of it. Efficacy and durability still matter first, she adds, which is part of why older options like TNF inhibitors have fallen out of her regular use for psoriasis given how quickly they can lose effect and the frequency of dosing they require.

Mastro then raises the patient who has cycled through multiple therapies and arrives skeptical that anything new will actually help. Hetzel says she never wants to gatekeep or overpromise, since no clinician can guarantee any single therapy will work for a given patient, and she considers that skepticism valid, especially in patients who have lived with psoriasis for decades and tried numerous biologics and older therapies like PUVA. What she can offer instead is confidence in the mechanism and a level-set conversation: they will monitor response together, and if a therapy is not working, they will move on rather than staying on something ineffective indefinitely.

Mastro and Hetzel close by reflecting on what that kind of honest conversation requires: nuance, experience, and comfort discussing uncertainty openly. Hetzel adds a note of humility, describing clinicians as imperfect people doing their best for patients, and says acknowledging that shared humanity, rather than projecting certainty, tends to build the kind of long-term trust that keeps patients engaged in their care.

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Andrew Mastro, MS, PA-C, asks Alexa Hetzel, MS, PA-C, whether efficacy and durability drive first-time systemic treatment decisions or whether route of administration and patient comfort carry more weight in practice.

In ‘Access Gaps and Treatment Failure in Plaque Psoriasis Care,’ our panel explores remaining barriers to optimal care.

Access Gaps and Treatment Failure in Plaque Psoriasis Care

Returning after a break in filming, Andrew Mastro, MS, PA-C, asks Alexa Hetzel, MS, PA-C, whether a persistent gap remains in plaque psoriasis care despite the expanding menu of oral and injectable options, whether tied to a specific patient population or to access itself. Hetzel answers that access remains the biggest unresolved issue. She describes patients facing wait lists of up to a year for a dermatology appointment, a delay she considers far too long for a visible, often painful skin disease, and notes that some of those patients end up seeking care elsewhere or turning to primary care physicians who may not be equipped to secure systemic therapy on their behalf. She frames the priority as getting patients to the right point of care where their disease can be properly understood and treated, rather than leaving them stalled outside the system entirely.

Mastro pivots to a related clinical question: how to think through a patient who either fails to respond as expected or begins losing response over time, whether on a biologic or an oral therapy. Hetzel breaks this down into primary and secondary failure. A true primary failure, in which a patient does not respond to any option, prompts her to revisit the original diagnosis, since she has come to expect meaningful response across the therapies available today. For patients breaking through on a pill or continuing to lean on topical therapy, she probes for the real story before assuming treatment failure, since patients do not always disclose missed doses or inconsistent use up front.

Hetzel says she gives a new therapy a full 16-week trial before drawing conclusions, unless there is no response at all, and likes to see patients back within a month to review photos, confirm access to medication, and catch early signs of nonadherence. That early follow-up, she says, lets her serve as an active advocate for the patient's continued use of therapy rather than waiting until a full course has already failed to intervene.

In the final episode, ‘Shared Decision-Making in Plaque Psoriasis: Route and Patient Trust,’ Mastro and Hetzel close the series with a conversation on route of administration, patient skepticism, and building lasting trust.

Returning after a break in filming, Andrew Mastro, MS, PA-C, asks Alexa Hetzel, MS, PA-C, whether a persistent gap remains in plaque psoriasis care despite the expanding menu of oral and injectable options, whether tied to a specific patient population or to access itself.

In this episode, ‘The Future of Plaque Psoriasis Treatment Over the Next 3 to 5 Years,’ the panelists, both practicing in dermatology, explore what lies ahead for the field.

The Future of Plaque Psoriasis Treatment Over the Next 3 to 5 Years

Andrew Mastro, MS, PA-C, closes out this stretch of the conversation by asking Alexa Hetzel, MS, PA-C, to look three to five years ahead and describe how she expects the plaque psoriasis treatment paradigm to evolve. Hetzel says her hope is straightforward: that every patient who needs advanced systemic or biologic therapy is actually on it, an outcome she believes depends on continued clinician education translating into better patient education down the line.

She notes there is still meaningful activity in the pipeline, including potential oral options and biologics dosed as infrequently as every six months or once a year, depending on how efficacy data develops. Hetzel frames that pipeline as good news for patients who will be managing this disease for life, since more mechanisms and dosing formats give clinicians a more customizable approach for each individual. She also points out that she and Mastro, despite both treating psoriasis extensively, do not necessarily follow identical treatment algorithms, which she sees as evidence that having a range of options benefits the field rather than complicating it.

Mastro builds on that point, describing the growing menu of therapies as reason for clinicians to stay current on the literature and maintain fluency across mechanisms, since patients increasingly arrive at appointments having already researched their options themselves. He describes the field as a constantly evolving array of choices that requires ongoing effort from providers to track, comparing it to a smorgasbord that keeps expanding rather than settling into a fixed set of options.

Hetzel agrees and adds a final piece to the future outlook: access. Even as the range of effective therapies grows, she says ensuring patients can actually obtain the medicine they need remains the last, and arguably most persistent, barrier to translating better treatment options into better outcomes. A wider menu of oral and injectable choices does little for a patient who cannot get in the door or secure coverage for the agent that fits them best, which is why she views access, alongside continued clinician and patient education, as the piece the field still needs to solve as the treatment landscape keeps expanding over the next several years.

In the next episode, ‘Access Gaps and Treatment Failure in Plaque Psoriasis Care,’ the panelists address lingering barriers to access and how to distinguish primary from secondary treatment failure.

Andrew Mastro, MS, PA-C, closes out this stretch of the conversation by asking Alexa Hetzel, MS, PA-C, to look three to five years ahead and describe how she expects the plaque psoriasis treatment paradigm to evolve.

This episode, titled ‘Positioning Icotrokinra as First-Line Therapy for Plaque Psoriasis,’ features panelists making the case for first-line use.

Positioning Icotrokinra as First-Line Therapy for Plaque Psoriasis

Andrew Mastro, MS, PA-C, widens the lens and asks Alexa Hetzel, MS, PA-C, where icotrokinra sits within the broader plaque psoriasis landscape, including whether route of administration itself shapes patient preference. Hetzel says icotrokinra has become her first-line choice over other oral therapies in the roughly 12 weeks she has had access to it. She adds that it also holds value even before biologic therapy is considered, since patients in the clinical trials who had previously tried and either failed or lost insurance coverage for a biologic still responded to the oral peptide. Because no single therapy works for every patient, Hetzel says the goal is not a one-size-fits-all answer but a wider set of options that increases the odds any given patient finds one that works long term.

Hetzel also flags a messaging shift she considers important: earlier oral agents were sometimes positioned as a stepping stone toward eventual biologic therapy, but she does not see icotrokinra the same way, pointing to sustained response through 52 weeks as evidence it can serve as a durable, standalone choice rather than a bridge.

Asked to name the single most practice-changing takeaway from the discussion, Hetzel offers three. First, icotrokinra works through a mechanism, IL-23 receptor inhibition, that clinicians are already comfortable with, lowering the barrier to adoption. Second, she urges clinicians to use updated guidelines not just to guide their own prescribing but to advocate for patients facing insurance denials or delays in accessing systemic therapy. Third, and somewhat unprompted, she raises the simple importance of patients answering the phone, noting that even the most effective therapy cannot help a patient who does not follow through on next steps. Hetzel likens hesitant patients to an online shopper who saves an item for later rather than checking out, and stresses that clinicians have to actively walk patients through that final step rather than assuming they will follow up on their own.

In the next episode, ‘The Future of Plaque Psoriasis Treatment Over the Next 3 to 5 Years,’ Mastro and Hetzel look ahead at how the treatment paradigm may continue to evolve.

Andrew Mastro, MS, PA-C, widens the lens and asks Alexa Hetzel, MS, PA-C, where icotrokinra sits within the broader plaque psoriasis landscape, including whether route of administration itself shapes patient preference.

Alexa Hetzel, MS, PA-C

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