Expert Perspectives on the Management of Plaque Psoriasis - Episode 8
Dr Jerry Bagel and physician assistant Alexa Hetzel comment on other agents available for the treatment of plaque psoriasis.
Jerry Bagel, MD, MS:We’ve discussed the biologic treatments that are available and the new oral systemic medications available. What other treatments are you still using for the treatment of psoriasis?
Alexa Hetzel, MS, PA-C: If we think about how far we’ve come with psoriasis, we still sometimes throw cyclosporine at patients because it gets them clear quickly. If they’re having a horrible flare, I remember a story of yours where patients would come in after Hurricane Sandy and they were so badly involved. Cyclosporine works so fast, but it has many adverse effects. You’ve got the methotrexate that some people use, especially with joint disease, which can help too. Maybe UV-B [ultraviolet B] phototherapy full body, where patients can step into a light booth and get a dose of ultraviolet light to help calm the inflammation. It’s a little tricky because it doesn’t get into the scalp or the nails, but it works for patients who are pregnant, or who can’t be on a biologic. We have PUVA [Psoralen plus ultraviolet light A], where patients take a pill that makes them more susceptible to the light. We see a lot of skin cancers in those older patients who were on PUVA for so long. We have Xtrac laser, which helps with patients who have maybe less than 5% body surface area; it’s basically like taking the photo booth and putting it in a handheld device. We have a lot of other treatment options plus topical therapy. We have so many different topical therapies out for patients.
Jerry Bagel, MD, MS: We were doing about 350 UV-B treatments a week prior to biologic agents, and now for psoriasis, we’re doing about 125 treatments a week because biologic agents are so effective for the joints and the scalp. Where I use it a lot, I just saw it today, even PUVA with acitretin, a vitamin A derivative, in an individual who had prostate cancer within the past year, had to go off of his Humira and was very upset. We have him on what I call, rePUVA: retinoids and PUVA. He was losing his hair from the retinoids and was upset about that. But overall, UV-B is still an effective modality. It has no risk. There’s no increase in skin cancer with UV-B, and people can do well. On the other hand, I had another guy today who had spinal cancer, and had to go off of his biologics, and I put him on methotrexate, 15 mg per dose, and within 6 weeks, he was clear. I dropped the dose by 2.5 mg to see how he’s going to do there. As you mentioned, cyclosporine sometimes is a bridge when people are really severe, and you need to get them better. They’re almost erythrodermic. You put them on cyclosporine, and you gradually taper it once they’ve improved. Not to say that we don’t use apremilast, or Otezla, sometimes. I don’t often use Otezla as a treatment for psoriasis anymore, but let’s say somebody’s joints aren’t doing well and they’re on a biologic, I might add Otezla instead of methotrexate because I like the safety profile, or vice versa, if their joints are doing well and their skin isn’t, I might add Otezla. As dermatologists, we tend to mix and match a lot with our treatments.
Alexa Hetzel, MS, PA-C: It is kind of eye-opening to me how methotrexate originally helped to continue the efficacy and prevent antibody development for the TNF [tumor necrosis factor inhibitor] class, and how it doesn’t have that effect for the IL-17s [interleukin-17 inhibitors] and the IL-23s.
Jerry Bagel, MD, MS: I don’t think that you get as many antibodies with these drugs as you do with the others, with the TNFs. If you look at the recapture data with IL-17s, they’re usually pretty good. Methotrexate’s kind of messy because it has drug-drug interactions, it can affect your liver. If you want to talk about comorbidities, unfortunately, 40% of people with bad psoriasis also drink. That’s like an absolute contraindication for methotrexate.
Transcript Edited for Clarity