Defining On-Treatment Remission in Psoriasis and PsA

In "Defining On-Treatment Remission in Psoriasis and PsA," the panel examines whether clear should now mean completely clear.

Dr. Han recounts his work with the National Psoriasis Foundation and its earlier treat-to-target guidelines. Some clinicians resisted them, and he was initially skeptical too. But he came to see the point. With so many effective medicines, the commitment behind systemic treatment is to let patients live a normal life without thinking about psoriasis.

Dr. Han explains the reasoning behind the target. The minimal response worth having on a measure like PASI is around 50%, which is a low bar, and 50% clear is happier but still not where a patient can be. Because current therapies can do far more, he argues clinicians should hold themselves to a higher standard. A cure does not exist yet, so full remission off treatment is not attainable. What is attainable is on-treatment remission: no psoriasis on the body, defined as 0% BSA, PASI 100, or IGA 0.

Dr. Han concedes there is no equivalent on the psoriatic arthritis side, describing patients who bounce between improving joints and flaring skin as therapies get layered on, sometimes back to a TNF. Dr. Wright agrees the field has only nudged from ACR20 to ACR50. She stresses that rheumatology must think across domains, so clear joints with active skin is not remission.

Dr. Wright introduces minimal disease activity, framed as her rule of zeros and ones across enthesitis, dactylitis, and other measures. She notes that MDA requires 5 of 7 criteria, while the stricter VLDA requires all 7. She also flags the harder problem: patients whose joints stay painful despite clear skin, forcing a distinction between residual inflammation and truly treatment-refractory disease.

The next episode in this series, "Targeting the Pathways: TNF, IL-17, and IL-23 in Psoriasis," opens the second section as Dr. Wright walks through the key biologic pathways that drive psoriatic disease.