Shared Decision-Making in Plaque Psoriasis: Route and Patient Trust

In the final episode, ‘Shared Decision-Making in Plaque Psoriasis: Route and Patient Trust,’ the panelists explored how to build lasting trust with patients.

Andrew Mastro, MS, PA-C, asks Alexa Hetzel, MS, PA-C, whether efficacy and durability drive first-time systemic treatment decisions or whether route of administration and patient comfort carry more weight in practice. Hetzel says the answer depends heavily on how much shared decision-making shapes the conversation. Some patients are simply anxious about injections without understanding what the experience actually involves, and while she notes that broader public familiarity with self-injection, driven in part by GLP-1 therapies, may be easing that hesitancy generally, some patients still perceive a pill as inherently safer even when that is not necessarily true. Having a genuinely effective oral option now makes it easier to say yes to that preference rather than working to talk a patient out of it. Efficacy and durability still matter first, she adds, which is part of why older options like TNF inhibitors have fallen out of her regular use for psoriasis given how quickly they can lose effect and the frequency of dosing they require.

Mastro then raises the patient who has cycled through multiple therapies and arrives skeptical that anything new will actually help. Hetzel says she never wants to gatekeep or overpromise, since no clinician can guarantee any single therapy will work for a given patient, and she considers that skepticism valid, especially in patients who have lived with psoriasis for decades and tried numerous biologics and older therapies like PUVA. What she can offer instead is confidence in the mechanism and a level-set conversation: they will monitor response together, and if a therapy is not working, they will move on rather than staying on something ineffective indefinitely.

Mastro and Hetzel close by reflecting on what that kind of honest conversation requires: nuance, experience, and comfort discussing uncertainty openly. Hetzel adds a note of humility, describing clinicians as imperfect people doing their best for patients, and says acknowledging that shared humanity, rather than projecting certainty, tends to build the kind of long-term trust that keeps patients engaged in their care.