Changing Treatment Approaches in the Management of Plaque Psoriasis - Episode 14

Treatment Challenges in Plaque Psoriasis

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A panel of experts builds a lively discussion on the evolving treatment landscape in plaque psoriasis and highlights the emergence of IL-23 inhibitors as a new class of biologic agents.


Brad Glick, DO, MPH:Speaking of treatments and treatment challenges, let’s talk about such challenges that we may have regarding patient selection and drug selection. What about unmet needs? What are some of the challenges that you’re facing when we manage psoriasis or psoriatic disease? As 1 question, what can be done to help patients to overcome the psychological components of this disease? Erin, why don’t you chime in first?

Erin Boh, MD, PhD, FAAD: To answer the last question, something we all can do is educate. If patients understand the disease, if they understand the natural course and the responses that we have, they’ll be better prepared. That’s a big hurdle right there. It’s very important to reiterate to your patients details about the disease and about the safety of the medicines. We should make sure that everybody is onboard. Then I talk to people about watching for triggers and understanding that the disease is forever and that these drugs don’t cure it. They only control it, so everybody has to be onboard. Education—for the drugs and the disease itself—is very useful in getting people onboard for managing and understanding when things don’t go exactly as they’re supposed to.

Brad Glick, DO, MPH:It seems that that plays into adherence and compliance as well. Education is power. Do you find that patients with psoriasis have some challenges with adherence?

Erin Boh, MD, PhD, FAAD: No. If the drug works in the beginning, you cannot get them off it. It’s on us to make sure that we get them the right drug. If you keep giving them topicals, they’ll get deeper and deeper in the hole because it’s frustrating. They don’t want to hear that. They’ve done it for years, and so if you’re going to have a patient be compliant, you have to make it easy to comply. The biologics, as a group, do that. They don’t have to frequently come in. You must get them to that point. Listening, looking, and educating are the 3 big things that will go a long way in compliance.

Brad Glick, DO, MPH:I love that. I have to write that down. George, what about typical triggers for flare-ups in these patients? How do we manage the flares in conjunction with these triggers?

George Han, MD, PhD: Regarding flare-ups, there’s some seasonality psoriasis, and the stressors we were talking about throughout the pandemic caused some people to be getting bad flares. There would be anxiety because of vaccines or other reasons. Especially for the patients on biologics—I agree with Dr Boh—we’d like to save it for them as much as we can. Meaning if they get a little breakthrough flare, we can manage it with a topical. There are actual data on that looking at newer agents like betamethasone calcipotriol foam. There are data looking at adjunctive treatment. Not only does that help maintain them, but patients may get back to a level of clearance. They can stay on that medicine, so it’s a known entity. We know they’re responsive. We know they’re not reacting to it negatively. That’s definitely helpful. Other than that, life happens. One of the things we must do is assess for compliance. That’s 1 of the things that’s a great unknown.

Back in medical school, 1 of our preceptors told us about how they found their patient in the parking lot scribbling down their glucose diary and basically—almost like Christmas—treeing it, writing what they really wanted. It happens. Having that open relationship with your patient and saying, “We don’t want to necessarily search you, but let us know if you missed a dose or you’re behind on something. Stuff happens.” All those are things we need to keep in mind. The more stability, the better. That helps with all those other aspects: keeping patients on a stable regimen, making sure they know what to expect. When the psoriasis comes back, after you’ve cleared and it’s coming back, that psychological impact is different from the patient who just had that amount of psoriasis to begin with. It’s probably worse because they remember how bad it was. It’s important not to overreact in that sense too.

Brad Glick, DO, MPH: If you’ve enjoyed the content, please subscribe for to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your in-box. Thank you, everyone.

Transcript edited for clarity.