Shifting Treatment Approaches to Plaque Psoriasis

Brad Glick, DO, AOCD: When we think of this rapid expansion of the armamentarium, we have had our approaches shifted in terms of our treatment of plaque psoriasis. Comment on the importance, in that context, of long-term disease control. It’s nice to see that we have things that work quickly, and we need quickness in the beginning for our psoriasis patients, but what about long-term control for a chronic condition like plaque psoriasis?

Neal Bhatia, MD: We’ve seen some of the surveys from the NPF [National Psoriasis Foundation] and some of the discussions we’ve had at different meetings about how quickly patients will turn on a topical therapy if they’re not seeing results within a week. We also hear about the difficulties of getting drugs obtained and the time frame for when the patient is coming in to see us vs what are we doing to get them their first dose, whether it’s an oral or a biologic agent. I think the 3 of us would agree that [it’s important to stratify] the patient so that they understand where they fit into mild, moderate, and severe disease. The approaches of various combinations will optimize at least some sprint effect for them. Then, of course, getting into the mindset of shying away from steroids as much as we can because the bandage vs remedy concept has to kind of sink in to the patients who’ve been just putting triamcinalone on left and right. When we see patients with 3% to 5% [body surface area coverage], we’re thinking that we can probably get this under control because now we have systemic agents for 3% to 5%, which is great. When we’re dealing more and more with 10%, obviously we’re checking the nails, the scalp, the joints, and then talking about cardiovascular risk and everything else. Those patients have to understand that the marathon is going to be something that’s systemic. The dermatologist has to be accountable for how those talking points come into play.

Brad Glick, DO, AOCD: Disease progression is a big issue, too. Patients can be clinically one way at a time point in our clinic, and then their condition may change. Not only the skin disease, but, as you referenced, progressing potentially to joint disease or perhaps developing some other comorbidities in the background. George, what do you think about long-term disease control? What’s your perspective?

George Han, MD, PhD: It’s interesting because we all, and certainly I’m included in this, naturally think about psoriasis as the long-term battle. I think we should acknowledge that we live in a society where instant gratification is the name of the game. I’m always interested to see these patient surveys that are put out there among different countries, and different practice environments. What always seems to be consistent is that the rapidity scores, when you ask patients, are always a little bit higher than when they ask the providers, doctors, and practitioners. It’s a very different concept when the patients are thinking about what their expectation is. We see this in any treatment. When you think about teenagers with their acne treatment, they come back at 3 months and say, “This didn’t work for me.” When you really press and ask how long they used the retinoid and it’s a week, then you kind of know what happened. I think in some ways this separates a good dermatologist from a great one. You can find the right treatment regimen, but to really be able to concisely explain it to patients is important. I think up front we need to have that discussion with patients that this really is something you’re in the long haul for. We need to make sure that patients understand that psoriasis is something that we don’t have a cure for yet, and it’s something that we expect to have to manage for the long term.

Even with patients going on biologics, we know that the average time patients spend on a given biologic is not as long as we’d like to see. We know that patients out there are actually not using and filling the biologics in the way that we are writing for them. There’s a lot going on in the real world that we’re maybe missing out on. Some of that I think we can overcome by just having better talking points about what to expect from these medications and what to do a year or 2 out when you’re doing well and you’re pretty clear. It’s hard to remind that person what it used to be like when they had terrible psoriasis all over their body. I think it’s going to be some combination of counseling and making the point that we’re in this for the long-term treatment of your psoriasis, and we’re in it to make sure that we’re optimizing for that efficacy and safety in the long term. For the short term, I always say if a person’s getting married next week or in 2 weeks and they’re coming into you with terrible psoriasis, that certainly will push rapidity to the top of the list of your treatment goals. That might adjust the way you look at it, but outside of that, for most people, a few months plus 2 or 3 months is not going to make a huge difference. I would probably tell that person if they’re going to treat their marriage with the same level of procrastination as their psoriasis, it’s not likely to be terribly successful. So, hopefully, they’ll get some life skills out of that, too.

TRANSCRIPT EDITED FOR CLARITY