Advances in the Management of Plaque Psoriasis - Episode 4
Mark Lebwohl, MD: We’re very quickly getting to the discussion of treatments. It’s come up already several times, and you all know that new National Psoriasis Foundation/AAD [American Academy of Dermatology] guidelines have come up, with a committee that’s put a lot of work into these guidelines. We haven’t seen all the guidelines yet, but many of them are out. Brad, do you want to tell us about those?
Brad Glick, DO, MPH: Well, we have 2. There are 2 that were just published in February of this year. The first 1 is essentially about biologic therapies and the use of biologic therapies and their role. Obviously, it reviews a lot about the current targeted pathogenesis of psoriasis. And the second one is focusing on comorbidities that we discussed already and how we sort through those comorbidities, and as I mentioned before, how we approach our patients and the questions that we ask them. And there are many comorbidities, even beyond the scope of those that we’ve talked about already: psoriatic arthritis, cardiovascular disease, inflammatory bowel disease.
There are other comorbidities: nonalcoholic fatty liver disease, chronic kidney disease, chronic obstructive pulmonary disease. With many of these comorbid phenomena, as a clinician right now, I’m starting to see them more frequently in my psoriasis patients where I really didn’t recognize them and where I didn’t take heed to them as much. The guidelines are really useful, in my view, having looked through them, in addressing these factors that even go beyond current common comorbidities. And there are emerging comorbidities, too, so I think these guidelines are very important for all of our colleagues in dermatology.
Mark Lebwohl, MD: I think early guidelines have dealt with every facet of therapy, for example, oral therapy. Why don’t we start with that? I’m sure every one of you uses lots of oral therapies in our psoriasis patients.
Scott Gottlieb, MD: For me not so much anymore, actually. In an historical perspective I’ve used a lot of agents for psoriasis: methotrexate, cyclosporine.
Mark Lebwohl, MD: Topical?
Scott Gottlieb, MD: Topical therapy as well. But I think I’m more apt to hear about quality of life and decide to maybe transition from topical therapy to a systemic agent quicker or even phototherapy. I also think that my head always goes toward systemic inflammation these days. And so whereas I use topical therapy often, in moderate to severe psoriasis patients, I still use phototherapy, but I think about whether having ebbs and flows of systemic inflammation is really a good thing for the patient. And I’m really going much more quickly toward at least offering a biologic to a patient, either because I believe that their psoriasis is in the moderate to severe category by BSA [body surface area], or they do in terms of the impact on their quality of life.
Mark Lebwohl, MD: I want to address one issue.
Brad Glick, DO, MPH: Sure.
Mark Lebwohl, MD: Because the majority of patients still have mild to moderate disease, probably 80%. There’s a huge proportion of patients who have just plaques on their elbows. And I think sometimes we will give them a systemic therapy, but most of the time we’ll give them topical therapy. Wouldn’t you agree?
Scott Gottlieb, MD: Yes, I would say definitely agree. Although I have to say, certainly 80% of the patients in my practice do not have mild psoriasis, from the patients that I see. But yes, of course, most of the patients have mild disease, and certainly topical therapy is appropriate.
Brad Glick, DO, MPH: I was going to say the same thing, that my topical monotherapy patients really have a limited amount of plaques. Just like Scott, I’m really thinking of systemic therapies because I think it’s more than just treating their skin, even when they have very limited disease. And I look at their nails, I look for pits. I’m worried that even someone with the least amount of psoriatic skin disease may move on to get psoriatic arthritis. And so I think much the same way you do, but it is true that most of our patients seem to have reasonably localized skin disease. And most of our colleagues are just giving topical therapies. But in my practice, and I think in Dr Gottlieb’s as well, I’m really thinking more of systemic therapies because we’ve all, I believe, bought into that this is a systemic immune-mediated, autoinflammatory disease. I think it requires, in most patients, more than topical therapy.
When I think of topical therapy, I either think of it in the mild disease category or I look at it as add-on, just as we were talking about before for residual plaques. And we’re able to use the topical therapies that before we were using on large body surface areas, and they weren’t that successful. And now they’re much more successful, whether it be corticosteroids, whether it be a topical vitamin D analog and topical calcineurin inhibitors for unlimited areas like the folds where we struggled before. Our patients were overusing corticosteroids. So systemic therapies have really helped us be better users, if you will, of even topical therapies.
George Han, MD, PhD: I see it as a puzzle. It’s interesting because we have these pieces. We know psoriasis is linked to underlying increased inflammation, increased cytokines. And those same cytokines play a role in atherosclerosis, and we know that our patients have a higher cardiovascular morbidity and mortality. I think it’s only a matter of time probably until that last link of when we put our patients on these systemic therapies and have really convincing data that we’re doing them a disservice by not doing that. I think we’ll change the thinking. I think we’re getting there. We’re getting close.
Brad Glick, DO, MPH: George, you think mainly in that mild population, too, because clearly patients with mild diseases have cardiovascular risk as well, too. It may not be to the extent of patients with severe disease, but I’m with you because we may be offering up a disservice to our patients if we’re not treating aggressively at all levels of psoriasis.
Mark Lebwohl, MD: Right. I do want to put a little perspective on here. When Joel Gelfand MD, MSCE, and his group published the data on the association to myocardial infarctions and psoriasis, he separated out into mild, moderate, and severe and defined them. The mild patients were the ones using topical therapy, the severe ones were the ones on systemic therapies or phototherapy. And the mild patients had very little increased risk. There was an increased risk, but it was much less than the severe patients, much less. And it was not statistically significantly increased. I think we need to actually be concerned about systemic inflammation in patients with severe disease. And I’m not saying to ignore it in patients with mild disease, but it is less worrisome. You said something, Brad, which was I think completely on target, which is you can have very mild psoriasis and horrific psoriatic arthritis. That’s what we have to be on the lookout for.
Transcript edited for clarity.