Expert Perspectives on the Management of Plaque Psoriasis - Episode 1
Jerry Bagel, M.D., M.S. and Alexa Hetzel, M.S., PA-C discuss an overview of plaque psoriasis and how plaque psoriasis impacts quality of life.
Jerry Bagel, MD, MS: Welcome to this HCP Live® Peers & Perspectives®presentation titled “Expert Perspectives on the Management of Plaque Psoriasis.” I’m Dr Jerry Bagel from the Psoriasis Treatment Center of Central New Jersey in East Windsor, New Jersey. I’m joined by my colleague Alexa Hetzel to discuss considerations and strategies for the practical management of plaque psoriasis.
Alexa Hetzel, MS, PA-C: My name is Alexa Hetzel, and I’m a physician assistant at the Psoriasis Treatment Center. I’ve been honored to be part of over 50 clinical trials within the psoriasis space. I’ve been able to publish over a dozen articles about psoriasis and treat psoriasis patients on a regular basis, so I’m excited to be here with you, Dr Bagel.
Jerry Bagel, MD, MS: You’ve been working on behalf of many different pharmaceutical companies, teaching dermatologists, physician assistants, and nurse practitioners around the country on psoriasis. Could you provide an overview of plaque psoriasis, including the clinical manifestations of plaque psoriasis, and discuss the progressive nature of the disease and the risk for developing other diseases?
Alexa Hetzel, MS, PA-C: When you think of psoriasis, you think of a classic patient. You’re looking at plaque on the elbows and the knees. Even generalized full-body plaque psoriasis is what a patient could come in with, depending on what the triggers were. You see not only skin symptoms but also nail involvement—the crumbling and pitting of the nails. You see involvement of the scalp, which can be significantly uncomfortable for patients, and the groin, underneath the breasts. You have to think about how it can affect those areas as well. Then you think about how it can also affect the joints. Psoriasis can affect patients at every level of inflammation of the skin and the joints.
In terms of the progressive nature of it, it can start very mild for patients as a solitary plaque that goes misdiagnosed for so long because it may look like eczema. You could have a patient who just had surgery and then a month later they have full-body psoriasis. It depends on what the trigger is, what patients see, and what’s going on.
In terms of the progression, the big thing to realize is that there are a lot of other comorbidities associated with psoriasis, especially untreated psoriasis. If somebody has generalized full-body psoriasis and they have this constant inflammation, they’re more at risk for developing psoriatic arthritis, Crohn disease, or ulcerative colitis. They’re more at risk of stroke, heart attack, diabetes, or a metabolic syndrome, where they have high blood pressure. These patients are not healthy. That can lead to a cascade that we want to prevent from happening in the first place.
Jerry Bagel, MD, MS: Psoriasis is no longer thought of as a skin-deep disease.
Alexa Hetzel, MS, PA-C: It is not.
Jerry Bagel, MD, MS: It’s multisystemic.
Alexa Hetzel, MS, PA-C: Exactly.
Jerry Bagel, MD, MS: Could you provide a brief overview of the impact and burden of plaque psoriasis and how it affects the patient’s quality of life? To what extent does disease burden the patient? How do quality-of-life outcomes impact treatment decisions?
Alexa Hetzel, MS, PA-C: We’ve become very much about technology. We’re able to work from home. We work from our phones. If somebody has nail psoriasis that’s crumbling and they’re trying to type, that can be very painful. If they have scalp involvement, you have to think about the shedding. I love to wear black, but psoriasis makes it a little difficult for patients to do so. If they want to wear shorts in the summer, they can’t because they want to go to the beach. That’s a huge impact on quality of life.
Think about how patients could have scalp involvement. If they’re shedding onto their clothes, that’s a huge discomfort when they’re trying to go out and meet somebody new or go to a family reunion. Think about how patients want to wear shorts in the summer. They can’t do that because their legs are completely involved. That’s a huge quality-of-life aspect, and they’re trying to hide who they are. Think about the depression and anxiety that can go with this when patients think about how they’re going to cover this. It’s not an easy disease to have.
Jerry Bagel, MD, MS: As far as nails, a study showed people who had a body surface area of 8%. But their quality of life was equal to somebody who had 15% body surface area and no nail involvement. Nail involvement has a major impact on quality of life and scalp; many people come in with just scalp psoriasis. I shouldn’t say just because they say nothing topical works. You open the bag, and 2 of the things they haven’t even tried. They’re so frustrated. The only thing that will work is being aggressive and using a biologic agent with them. You might not consider 3% body surface area to be severe, but if it has an impact on the quality of life like that, and nothing else topically is working in the groin or under the breast, then it has a major impact on quality of life. To what extent does disease burden and quality of life affect outcomes and treatment decisions?
Alexa Hetzel, MS, PA-C: Exactly as you said, 3% of scalp and groin is way more impactful, or equally as impactful, as a full-body surface area. It’s important to make sure we treat those patients right away and aggressively, so we can stop making them frustrated with another lotion or foam. We have the option to clear them.
Transcript Edited for Clarity