Lauren Miller, MPAS, PA-C

developments in the treatment landscape of plaque psoriasis, novel oral systemic treatment options to alleviate the burden of this chronic disease.

A Patient-Centric Medcast on the Journey Through Moderate Plaque Psoriasis

07:48 Absence of treatment or under treatment of plaque psoriasis

12:50 Prescribing novel systemic medications in plaque psoriasis as an advanced practice provider

15:46 Classifying moderate disease in plaque psoriasis

19:43 Getting payer approval for your patients with plaque psoriasis

23:18 Novel oral systemic treatments for plaque psoriasis

25:03 Pivotal clinical trial data on deucravacitinib

27:58 Deciding on aprimilast versus deucravacitinib for your patients with plaque psoriasis

31:53 Mechanism of action of deucravacitinib

38:13 Selecting a therapy in the evolving treatment landscape for your patient with plaque psoriasis

43:08 Educating your patients on injectables and orals systemic treatments

Videos

Advanced practice providers in dermatology discuss exciting developments in the treatment landscape of plaque psoriasis. Listen to their insights into the often-challenging journey patients go on. The arrival of novel oral systemic treatment options offers opportunities to alleviate the burden of this chronic disease.

A Patient-Centric Medcast on The Journey Through Moderate Plaque Psoriasis

To watch the video series component of this episode, click here.

Podcasts

As we wrap up, you already mentioned one of my pearls. I was going to ask you: What are some practice pearls that you would offer to guide other dermatologists and employees who are treating plaque psoriasis and how they manage the disease for their patients? Do you have any key pearls that you like to use?

[My]key pearl is: Don’t be afraid to treat these patients. If you don’t know how to treat them, definitely send them to somebody who does. Reach out. There are so many resources. MSLs [medical science liaisons], too, are wonderful resources. Invite them into your office, sit down, have lunch, look at the data. Make those relationships and then peers too. And don’t be afraid to treat patients with psoriasis, but definitely educate yourself. It does take time and investment. It does. You’re investing in your patients, you’re investing in their care, and they’re depending on you because not everybody can do this either. And it’s very frustrating, but it’s a very important disease.

I find a lot of providers, even outside of maybe primary care. Obviously we have specialties, so we’re all in dermatology, but we all tend to have our niche where maybe we like psoriasis, maybe we like atopic dermatitis or acne. And so, you know, for providers who maybe this is not their wheelhouse, inflammatory diseases just maybe scare them, they’re overwhelming to them. All of the treatment options overwhelm them. What you spoke to was one of my pearls. If you don’t feel comfortable offering all of the options to the patient, send them to someone else in your clinic, send them to another colleague who you know does feel comfortable. Imagine they’re your sister or your mom or your dad or even yourself. You would want them to get every option possible. Another one of my pearls I spoke to earlier was just if this is something that is a little bit overwhelming and maybe you’re early on in your career and you’re trying to figure out “How can I start prescribing medications?”—pick your favorites. Maybe try one and utilize that one when you need a topical therapy that’s a nonsteroidal, when you need an oral therapy, when you need a biologic. Maybe pick 1 in each class so that you can get comfortable with what it does and the nuances behind it. And then you can start to slowly break out of that. And then finally, don’t forget about the joints. I think that’s big. And even us. It still can be very difficult even being seasoned 15, 20 years in practice. Don’t forget to check the joints or at least ask about joints. Look for the risk factors in the nails, the scalp, because you’re really doing those patients a disservice by forgetting to do that because this isn’t just skin deep. We know that they have inflammation going on beneath the surface that can affect other organ systems and their joints. And so those would probably be my pearls.

Yes, absolutely. And those are those are excellent pearls, because really, we are here to help those patients and follow up with them. They need a lot of support. You know, a lot of them have been traumatized because they haven’t had the help that they need for a long time. And they really need that support. So don’t just see them and…give them 2 of something and see them a couple of weeks later. Just follow up with them, make sure that their medications are working, make sure that they’re getting their medications through their specialty pharmacies. And if you have a question, reach out, find out.

Yes, that’s right. It’s perfectly fine.

I still have to do that.… It’s a constant learning journey.

It is. And it’s perfectly fine to say to a patient, “I don’t know, but I’ll get back to you.”

[Say,] “I haven’t encountered this. Let me let me reach out to a colleague who maybe has so that we can try to figure this out.”

Well, I thank you for joining me today. Thank you for joining us today for this 

Transcript is AI-generated and edited for clarity and readability.

Experts share practice pearls for managing patients with plaque psoriasis, highlighting the need to educate health care providers about any dermatologic therapy before they commit to treating a patient.

Practice Pearls for Treating Plaque Psoriasis

We’ve talked about this a little bit, but because now we have all of these options, we have numerous topicals, we have a few oral options, we have biologics now, [about] 12 or 13 on the market. How do you personalize a treatment plan for a patient with all of the options? And I preface that with saying personally what I’ve had to kind of do over time is pick my favorites. And maybe every class I typically have 1 or 2 favorite topicals. I have 1 or 2 favorite systemic therapies, orals, and then I have a favorite maybe in each biologic class. How do you streamline your approach when there are so many and we only have so much time in that patient visit to discuss the options?

I think I do that too. The one element of it is those patients on Medicare. So they’re also carved out as: How do I get them here? So, unless they have patient assistance programs that they can qualify for, or if it’s an in-office injectable or an infusion that falls under their medical instead of their pharmacy, because that’s really important for Medicare patients. I really have a hard time understanding how people can work hard all their life and then have to go on Medicare or they retire. And then it’s not that their psoriasis goes away. They still have their psoriasis. So when I look at options for care, I have to, and I often say to the companies themselves, “What are you doing to help Medicare patients? So that also there is an IL-23 that is through one or the other with one of the companies that also has a TNF [tumor necrosis factor] with their IL-23 we have access for Medicare patients. We have another IL-23 that’s an in-office injection, or the insurance company requires them to go to an infusion center. There also is an infusion of usable medication, which has become very difficult to do through the insurances. Lots of times they go ahead and say that there’s coverage, but it’s not because the amount that is expected for the patient to pick up for responsibility is not feasible at all. The people who really get stuck in the middle are the people who have worked all their life and haven’t relied on society and haven’t saved yet. They can’t afford to buy these medications out of pocket every month. And they have horrific psoriasis. So there are just those patients who don’t have treatment. They just go back to having severe psoriasis and not even moderate psoriasis.

So would you say that that’s one of the biggest barriers right now in plaque psoriasis treatment, chronic disease treatment? I would say that probably one of the biggest hurdles and obstacles is access to the medications.

Oh, absolutely. In in our state of Michigan, even with Medicaid, you have much more access right away to appropriate therapy than you do if you have commercial insurance. And insurance does dictate, like we talked about, even doing DMARDs [disease-modifying antirheumatic drugs] before. You know, once they’ve done the DMARDs and they’ve failed the DMARDs because they’re just not as efficacious, or else they start developing problems with lab abnormalities or with cyclosporine, their blood pressure is shooting through the roof besides lab abnormalities. And with cyclosporine itself, it’s not a long-term medication anyway. It’s a short-term medication. It’s just a bridge. I just call those stopping blocks for the insurance companies. Once we’ve gotten past that, it’s like opening up the Golden Gate. But for Medicare, it’s not the same. With even with pediatric care. We have more now for pediatric care for psoriasis, which is wonderful. But I see that there is 1 really specific population that really is just not getting the care that they need. As far as the other, oral medicines are not appropriate for all people. We do a tremendous amount when we work with patients with psoriasis and their medications. We make sure that they’re going to be safe for patients. I know you probably have patients come to you and they’ve had histories of cancer. They’ve had solid tumors. What are you going to put them on? Well, you know, you work along with an oncologist, but usually it’s IL-23. IL-23s are always acceptable, and they usually work pretty well for those patients. So that’s why in those cases, it really has to be individualized. We have to have a tremendous amount of education [and] knowledge when dealing with these medications. This is not something that we do haphazardly at all when we do this. We are truly professionals in what we do, and we truly do specialize in that. The one thing is that if you don’t know how to treat patients with psoriasis and they need medications in mild to severe psoriasis, to try this alone is not going to do it. Please have the compassion enough to send those patients to somebody who can treat them. I hate it when I have a patient in front of me who says, “If you can’t help me with this, I’m done.” And they mean it.

Because they’ve had so many [health care] providers.

Yes. That physically they’re going to take their own life. I had a patient who came back and said to me, “It’s your birthday today too.” And I said, “Why?” He said, “Because when I came to see you on my birthday, if I wasn’t clear by my following birthday, I was going to kill myself.” So, you know, I don’t want to see that ever happen. But we need to recognize also as APPs [advanced practice providers] in dermatology, if you don’t specialize in this, send these patients to somebody who does. It is not a cookie-cutter approach, and you do need to continue to educate yourself and to educate your patients.

I look at it kind of as a puzzle, essentially, and there are so many pieces. How old is the patient? Are we talking about an adolescent or an adult? Because that’s going to put us in a bucket of treatment options. Do they have signs or risk factors for psoriatic arthritis? Because then that’s going to put us in a bucket of options. What other comorbidities do they have? And we know a lot of times these patients have heart disease, they have obesity and other things, high cholesterol, things of that nature that we know that these systemic options can help, where topical therapies we know unfortunately can’t help with those comorbidities. But I agree with you, there is no cookie-cutter approach. You literally have to sit down and look at that patient’s story and kind of put together this picture in this puzzle. And it’s just really cool that we had only a few options that we could utilize when we started. And now we have so many that the problem is we don’t have enough time in our visit to do it, so we’re having to actually have the conversation of how we streamline our office visit. That’s our biggest problem, how we streamline our office visit because we have so many options that we’re able to provide for the patients to get them where they want to be and where we want them to be. If that’s our worst [and] biggest obstacle—how do we strengthen our office visit and get them all of the information they need in that office visit—then I think we’re doing pretty good.

So one of the other big parts of that puzzle is women in childbearing years, because there are a lot of younger people who are female who do have moderate to severe psoriasis. Then we look at specific[s]; the years that they’ve had disease, or do they have nail and scalp disease? Are they going to be at increased risk for severe arthritis because of [having] a chronic disease? We need to think of their overall health and, you know, decreasing those comorbidities as they move forward in life too.

We’re treating that. We’re treating the patient as a whole and not just their skin.

Experts discuss access to treatment as one of the biggest barriers in plaque psoriasis and highlight the importance of individualizing therapy for each patient.

Lauren Miller, MPAS, PA-C

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