Breaking the Topical Cycle in Plaque Psoriasis Management

Welcome back to another HCPLive Peers & Perspectives video series. In this episode, titled ‘Breaking the Topical Cycle in Plaque Psoriasis Management,’ Andrew Mastro, MS, PA-C, and Alexa Hetzel, MS, PA-C, open the conversation.

Plaque psoriasis remains undertreated in everyday practice, even as the systemic treatment menu keeps expanding. That is the starting point for this video series, in which Andrew Mastro, MS, PA-C, of the Illinois Dermatology Institute in Chicago, welcomes Alexa Hetzel, MS, PA-C, director of clinical research at Schweiger Dermatology in East Windsor, New Jersey, for a wide-ranging conversation on positioning oral and injectable therapies in plaque psoriasis. Across this 10-part series, Mastro and Hetzel work through the evolving oral and injectable landscape, from therapeutic inertia and topical cycling to the durability data behind newer agents like icotrokinra and how to sequence therapy in real-world practice.

The conversation opens with Mastro asking Hetzel to name the biggest gap she still encounters in real-world psoriasis care. Hetzel points to the volume of patients who remain undertreated or stuck cycling through topical therapy rather than escalating to a systemic option, even when guidelines suggest they should have moved on. She describes patients who arrive after seeing several dermatologists, each having tried a rotation of topical steroids and calcineurin inhibitors without ever breaking the underlying disease course.

Mastro and Hetzel then turn to the 2025 update to IPC guidance, which allows patients who fail two topical therapies after four consecutive weeks of use to qualify for systemic treatment, rather than relying solely on a 10% body surface area threshold. Hetzel calls out joint involvement as a particular red flag that should prompt rapid escalation, noting that skin can regenerate but joint damage from psoriatic arthritis cannot. She cites data showing 43% of patients have tried and failed at least three topical therapies, a statistic she hopes will push more clinicians to treat topicals as an add-on rather than a monotherapy.

The segment closes on the question of therapeutic inertia itself. Hetzel attributes some of the reluctance to escalate to unfamiliarity with updated guidelines and to provider discomfort discussing systemic therapy risk with patients. She frames the calculus plainly: there is a risk to undertreating psoriasis, given its systemic comorbidities, just as there is a risk to treatment itself, and clinicians need the confidence to have that conversation early.

In the next episode, ‘Oral Therapy Evolution in Plaque Psoriasis: From PDE4 to Peptides,’ Mastro and Hetzel trace how oral therapy evolved from PDE4 and TYK2 inhibition to once-daily oral peptides, and how that shift is changing conversations about adherence.