George Han, MD, PhD

In "The Next Five Years in Psoriasis: Remission, Access, and Combinations," the panel looks ahead to the advances and the unfinished work of the coming years.

The Next Five Years in Psoriasis: Remission, Access, and Combinations

Dr. Han hopes the field will embrace all components of psoriatic disease equally and reach consensus on remission for the joints, not just the skin. He points out that even very low disease activity still allows up to one joint, so the definitions themselves show how far the joint side has to go. He is encouraged that development has not truly slowed.

Dr. Han previews a next era of biologics using dual inhibition and multi-active designs that target several cytokines at once. He notes patients may soon face a once-a-year injection, something few would have believed five years ago, and stresses that even a strong landscape leaves room to improve quality of life. He returns forcefully to access, describing patients who watch drug commercials with a call to action they cannot fulfill because the nearest dermatologist is a four-hour drive and six months away.

Dr. Wright picks up the access thread, citing recent work showing that where a patient lives shapes which drug they receive first and maps onto disease burden. She calls these the social and commercial determinants of health that decide who ever gets a chance at remission.

Dr. Wright wants the field to unpack what challenging-to-manage and treatment-refractory truly mean, ideally with predictive biomarkers so patients do not cycle through drugs while damage accrues. She insists on treating the whole person, including mental health, obesity, and cardiovascular risk, summed up in her line that bones hurt but heart kills. She predicts combination therapy will be essential for complex patients, even without large randomized trials to guide it.

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"The Patient Who Is Better but Not Clear: Shared Decisions in Psoriasis" takes up the common scenario of a patient content with partial improvement.

The Patient Who Is Better but Not Clear: Shared Decisions in Psoriasis

Dr. Han says fear of the unknown is powerful. A patient who remembers how bad things were feels better and hesitates to switch. It is the devil they know versus the one they don't. They wonder whether a new medicine will truly be better or carry some side effect, and they have grown used to their current injection.

Dr. Han describes a gentle, repeated approach across visits. He reminds patients he still notices them changing their clothing or dropping activities they used to enjoy. He tells them the arsenal now holds tools he is confident can help more, possibly with a better dosing regimen. Crucially, he does not lead with numbers like a PASI 90 comparison. He leads with seeing the patient as a person who is struggling and a bit fearful, backed by his own confidence and experience.

Dr. Wright calls that genuine shared decision-making rather than dictating a switch. She recounts a patient she had followed for milder rheumatic disease who suddenly presented with a scalp covered 100%, plus enthesitis, dactylitis, and synovitis. The patient's risk threshold favored the safest option even if slower, so Dr. Wright started with that drug.

Dr. Wright reports the patient improved only about 45% and returned frustrated by the slow pace, now willing to try the faster agent originally recommended. Within days the patient felt dramatically better and was grateful. Dr. Wright frames this as the art of medicine, moving someone from fear to confidence, and understanding that patients ultimately choose not a pill or a shot but where they want to land in their lives.

In "The Next Five Years in Psoriasis: Remission, Access, and Combinations," the panel closes by looking ahead at where psoriatic disease management is heading over the next five years, and what is still missing.

In "Putting On-Treatment Remission Into Practice: A Patient-Defined Target in Psoriasis," the panel returns to remission and grounds it in what patients actually live with.

Putting On-Treatment Remission Into Practice: A Patient-Defined Target in Psoriasis

Dr. Han starts by qualifying the 0% BSA goal. Clear skin with swollen, painful joints is not remission by any human standard. He frames the real target as a life free of psoriatic disease, where a patient functions normally and does not have to think about it. He points to DLQI items that reveal how disease shapes what people wear and whether they go out.

Dr. Han highlights skin of color patients, describing Hispanic patients cleared for two years who still have post-inflammatory hyperpigmentation and still will not wear shorts. He reframes early, effective treatment as appropriate rather than aggressive. He argues clinicians talk too little with patients about realistic steps, which drives poor compliance and the shopping bags full of expired creams that arrive at second opinions.

Dr. Wright defines remission through the patient's lived experience rather than her measures. In New York, a patient who always wore black suddenly not wearing black tells her the skin is bad without a word. A patient who cannot get to dinner, the theater, or down to the floor with grandchildren signals disease interfering with existence. She ties this to depression and social context.

Dr. Wright describes herself as treating to a target of zero, so function is restored. She acknowledges ACR50 and MDA are useful for trials, but real-world MDA tops out near 40 to 60%, and only 5 of 7 domains. She wants the specific domain bothering a patient gone. Her patients name tangible milestones: dancing at a granddaughter's wedding, walking down the aisle, holding a baby.

Our next episode, "The Patient Who Is Better but Not Clear: Shared Decisions in Psoriasis," features Dr. Han and Dr. Wright on the patient who is better but not clear, and how shared decision-making guides the next step.

In "Real-World Evidence and Systemic Inflammation in Psoriasis," our experts scrutinize the evidence behind popular claims about disease progression.

Real-World Evidence and Systemic Inflammation in Psoriasis

Dr. Wright reduces the retrospective claims data to two damning words: retrospective and claims. Retrospective analyses cannot substitute for prospective study. Claims data lack the ICD-10 granularity to tell whether a patient has one small patch or is covered head to toe. She takes such findings with what she calls a 25-pound bag of salt rather than a grain.

Dr. Wright adds confounding by indication. A clinician facing severe disease may reach for a TNF, an IL-23, or an IL-17, which then shapes that patient's trajectory and skews the data. She urges close attention to how data were collected, on whom, and how they are analyzed before drawing conclusions, warning against treating any such finding as definitive.

Dr. Han notes that overreliance produces contradictory studies. Just last year the rheumatology literature reported IL-17 carried a lower incidence of psoriatic arthritis, the opposite of newer claims. Dr. Wright observes the field was not even discussing obesity's impact a year ago and now is, pointing to the inflammatory contribution of adipose tissue and the need to consider the whole person and all modifiable factors, not just skin, joints, gut, and eyes.

Dr. Khattri raises an influx of patients asking about systemic inflammation, often prompted by social media, that usually circles back to obesity and weight-loss medications. Dr. Han says clinicians should get used to hearing about GLP-1s as the pipeline explodes and new agents win approval quickly. He is intrigued by evidence that GLP-1s may act on inflammatory pathways directly, not only through weight loss. Dr. Wright closes by distinguishing what inflammation feels like from what inflammation is, even in a patient with a BMI of 21.

The next episode in this series, "Putting On-Treatment Remission Into Practice: A Patient-Defined Target in Psoriasis," opens the final section as the panel defines what on-treatment remission looks like in daily practice.

George Han, MD, PhD

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