Novel Topical Treatments in the Management of Plaque Psoriasis - Episode 4

Standard of Care for Patients With Plaque Psoriasis

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Experts discuss the current standard of care for patients with moderate-to-severe plaque psoriasis, focusing on whether the patient is a candidate for systemic or topical treatment.

Brad Glick, DO, MPH, FAAD: What’s the current standard of care for the management of plaque psoriasis? Mona, just the basics from your optics.

Mona Shahriari, MD, FAAD: When we think of psoriasis, we would historically think of it as mild, moderate, or severe. This is really based on objective metrics like BSA [body surface area] data, PASI [Psoriasis Area and Severity Index] data and topicals, which were really considered standard of care for mild-to-moderate disease and first line, while orals and injectables are historically thought of for individuals who have moderate-to-severe disease. However, the International Psoriasis Council challenged this approach. I personally prefer the newer standard where we look at our patients as either candidates for topical therapy or a candidate for systemic therapy. The factors that we keep in mind beyond just those objective metrics of a BSA of more than 10%, if they have involvement of a special site, you should consider escalating therapy. If they’ve used a topical and it’s either not adequately controlling their disease or it’s just not working, you should also consider escalating therapy.

Brad Glick, DO, MPH, FAAD: Linda, anything to add there?

Linda Stein Gold, MD: Yeah. I totally agree. I think that most of us at this point, we look at our patients as they walk in the door and we discuss their disease and decide if this is somebody who can use a topical therapy alone or is this somebody who has comorbidities, such as psoriatic arthritis, where they’re going to need a systemic agent in order to holistically treat them.

Brad Glick, DO, MPH, FAAD: For both of you, share with me your perspective on comorbidities. Where do they play into your decision-making tree and your therapeutic selection for your patients? Linda?

Linda Stein Gold, MD: So, the first question, I think that we all want to understand is if the patient suffers from psoriatic arthritis. I know that we’re not all rheumatologists, but I think each one of us has gotten a little bit better as we’ve been treating our psoriasis patients with understanding the signs and symptoms of psoriatic arthritis, because we know this is something that can be devastating if missed. The good news is most of our systemic options actually do treat psoriatic arthritis. So, we know we’re pretty much going to be covered. Though, if somebody does have arthritis, they are going to be a systemic candidate and not a topical candidate. I do think that given the risk of the metabolic syndrome and cardiovascular-elevated mortality, I think that every one of our patients should have a good primary care physician. I know, as dermatologists, we don’t necessarily want to take on that role of being their primary care physician and making sure that their heart, GI [gastrointestinal] tract, and everything else is OK, but make sure that they understand that this is critical, that you have to have that holistic approach to your overall care. Then, we have that group of patients who might have a little bit of extra psoriasis, maybe between 10% to 15% BSA, where you can go either way. Maybe you’re going to want to use a topical. Maybe you’re going to want to use an oral. Maybe you’re going to want to use a biologic. Then, you really have to kind of delve into what’s going on with that individual patient to make that determination.

Brad Glick, DO, MPH, FAAD: Mona, what about comorbidities from your perspective?

Mona Shahriari, MD, FAAD: Yeah. I think Linda did a beautiful job talking about how important comorbidities are when we’re making decisions about biologics. The flip side of it is certain comorbidities would actually make you choose one biologic versus another from a safety standpoint. If a patient has congestive heart failure, has underlying neurologic issues like MS [multiple sclerosis], or solid organ malignancy, you’re going to shy away from something like a TNF [tumor necrosis factor] inhibitor. If someone, like I alluded to earlier, has inflammatory bowel disease, you’re probably going to pick an agent that can help treat both the skin and the gut as opposed to one that’s going to exacerbate the gut symptoms, but treat the skin.

Brad Glick, DO, MPH, FAAD: I think psoriatic arthritis and inflammatory bowel disease are 2 very important comorbidities that we have biologic therapies. In fact, you mentioned, Mona, the TYK2 [tyrosine kinase 2] inhibitor. We have drugs now that will cover the skin, joints, and gut now as well.

Transcript edited for clarity