Practical Approaches to the Management of Plaque Psoriasis - Episode 3
Erin Boh, MD, PhD, FAAD: Good question, thanks. We have our more recent guidelines for how to approach a patient with psoriasis, so the AAD [American Academy of Dermatologists] and the NPF [National Psoriasis Foundation] have updated their guidelines. That’s a good source for people to look at.
In general, what I like to do is separate mild, moderate, and severe. When patients have limited disease and no other systemic complaints, topical therapies are still going to be the mainstay of therapy. What we’re addressing today though gets you past that. Again, the chronicity of the disease warrants in general a different approach from just topicals, unless the disease is quite limited.
Because mild disease is less than 3%, topicals are fine. When you’re in that middle range of moderate, to moderate to severe, so 5% to 10%, with no comorbidities, phototherapy is a very useful therapy to look at topicals. Sometimes we even rely on systemic therapies for that.
If you get to severe psoriasis, which is greater than 10%, that’s when the door opens for all these choices. The way I approach it is limited disease. I use topicals and phototherapy unless the patients tell me they are quite bothered by their disease, or they complain of fatigue, tiredness, frustration. They get depressed having to do topicals for years. I do move on to systemics and to biologics probably earlier than many, but I think it’s warranted, especially in patients with comorbidities, because I want to stop progression of the comorbidities if I can.
When I get to patients who have 10% or greater, or they have psoriasis in the genital, the scalp, palms and soles, areas very difficult and not amenable to topical therapy or phototherapy, I will try to go straight away to the biologics, especially if my insurance companies allow it; they often don’t. I set the stage very early and start people on systemic therapy. Even if I start them on methotrexate and I give it to them and tell them, “Don’t take it; take it; whatever.” I get them on biologic as soon as I can, and I use as my index of choices what their other comorbidities are, or what they have been treated with in the past and their response.
I like to move early on to systemic therapies because this disease is 1 of chronicity; it’s 1 of foreverness. If we can intervene and make people more comfortable and possibly mitigate some of the effects of comorbidities, we really should do that. And the biologics are the way to go with doing that.
Mark Lebwohl, MD: We’ve spoken a lot about psoriatic arthritis and other comorbidities. What factors will tell you to use 1 biologic over another? Start with psoriatic arthritis, for example. We can talk about obesity, diabetes, cardiovascular disease, history of malignancy. There are many things that influence our prescribing patterns. What would play a role here? I’ll ask each of you to pick a comorbidity and show how it would influence your pattern of prescription of a biologic.
Leon Kircik, MD: Mark, that’s your lecture at the Mount Sinai [Winter Symposium].
Mark Lebwohl, MD: I’ll tell you a story. I was once invited to give this lecture to a group of patients at the [National] Psoriasis Foundation [Residents] Meeting. I came in the room and there were over 100 patients in the room. I said to everyone, “I want you to stand up.” And I said, “I’m going to read a list of signs and symptoms and conditions. I don’t want to embarrass anyone, so don’t sit down until the end. But if you have any of these conditions, at the end I want you to sit down.”
We started with, “Do you have joint pains or psoriatic arthritis? Are you obese? Do you have cardiovascular risk factors? Smoking, hypertension, diabetes, family history of heart disease? Have you had a malignancy? Do you have or has someone in your family had multiple sclerosis, Crohn disease, lupus?” I went through a long list of different comorbidities. Then I said, “Anyone who had any of those diseases, sit down, because they all influence the prescription, we’ll give you.”
At the end, of more than 100 people in the room, 1 person was left standing. [Laughter.] Clearly, when insurance companies say to us, “Here’s our order. You’ve got to give this drug first and that drug second,” they don’t care. They don’t care about the patient. They’re getting more money from Company A to give that drug, even though the patient might have a history of squamous cell carcinoma, which is caused by that drug. They just don’t care. For example, you mentioned, Erin, palms. Some of the drugs are fairly well; some don’t work at all. Take the comorbidity and tell me how it would influence your prescribing pattern. Leon, why don’t we start with you?
Leon Kircik, MD: The simplest 1 is psoriatic arthritis. If the patient has a psoriatic arthritis, I’ll shy away from IL-23; I will not do an IL-23. If I can, I will start them on an IL-17 drug. If I can’t, usually we have to use a TNF [tumor necrosis factor]–alpha inhibitor first, which is fine. I can use a TNF alpha inhibitor first, and actually American College of Rheumatology recommends first-line drugs for psoriatic arthritis with a TNF-alpha inhibitor. The problem is, they may not work as well on the skin. If the patient is obese, which most of them are, as we know, TNF-alpha inhibitors lose their efficacy in obese patients.
Leon Kircik, MD: It’s a catch-22.But that’s what I would be doing.
If a patient has IBD [inflammatory bowel disease], I would certainly avoid IL-17. I will not use an IL-17. I would pick a drug such as IL-12/23, which is approved both for IBD as well as psoriasis.
Mark Lebwohl, MD: I agree with you, Leon. It’s interesting: The American College of Dermatology [Clinical] Guidelines, almost came out too early in the course of the data we now have on IL-17 inhibition. The IL-17 blockers are safer and as effective as TNF blockades. Also, new data are that most of the drugs, even ustekinumab, which is not the best drug for psoriatic arthritis, is approved for psoriatic arthritis. But recently guselkumab released data. It’s interesting: If you give that drug every 4 weeks—and you know it’s only approved for every 8 weeks, but if you give that drug every 4 weeks—not only does it give comparable reduction in ACR [American College of Rheumatology] scores to the every-8-week administration, but interestingly it was statistically significant in preventing the radiographic progression of joint disease. That is something the TNF blockers and IL-17 blockers certainly do. If they get approval for every 4 weeks, they may also enter that competition there.
Leon Kircik, MD: You know it’s ironic because it always requires more drug than all other drugs. But in this case, the joint is requiring more.
Transcript Edited for Clarity