Question 1: How do you navigate the initial decision to prescribe topical vs systemic therapy for patients with plaque psoriasis?

The average age of onset for plaque psoriasis is 28 years, but psoriasis can occur in both the very young and the very old. The classic presentation would be somebody with mild psoriasis involving just the elbows, knees, or scalp. In this situation, a topical steroid would be appropriate. In patients with moderate to severe disease, in which they have psoriasis all over their body, a biologic drug should be considered.

Numerous considerations must be made when navigating the initial decision to prescribe topical vs systemic therapy for patients with plaque psoriasis. Typically, if a patient has mild psoriasis, we usually start treatment with a topical steroid. Mild psoriasis is defined as ≤3% body surface area (BSA) involvement, with the size of a patient’s hand being considered 1% BSA for reference. When a patient has 3% to 10% BSA involvement, this is considered to be moderate psoriasis. More than 10% BSA involvement is considered severe psoriasis.

There are some notable exceptions. If a patient can’t perform their daily functions or walk because the psoriasis is on their hands and feet, their psoriasis can be classified as severe. Involvement of the genitalia can also change the severity because that can affect their social life or relationships. We can upgrade disease severity classification depending on what part of the body is affected and how significantly the psoriasis affects a patient’s daily function; however, percentage of BSA is used by definition.

If a patient has very localized psoriasis — perhaps they just have psoriasis on their elbows, knees, or scalp — we would typically start treatment with a topical steroid. We would consider systemic treatment when patients have psoriasis that is beyond what can be handled with a topical agent. Sometimes patients have plaques all over their body, so it would be impractical for them to be spending hours a day applying a topical ointment on their whole body twice daily.

Question 2: Can you discuss your treatment decision algorithm after deciding that systemic therapy is warranted for plaque psoriasis?

I see a lot of people with suboptimal health insurance plans where basically the insurance company dictates what I can give them. I see a lot of patients with Medicaid as their primary insurance. For these patients, adalimumab is usually the first drug started because of health insurance formularies. However, if insurance were not an issue and biologic therapy is warranted, we have a number of biologics to choose from. There are currently 11 biologics approved by the US Food and Drug Administration for plaque psoriasis: 10 of these biologics are administered subcutaneously and 1 of them is administered intravenously.

I usually do not start with the biologic that requires intravenous administration. I used to give this biologic years ago, but now we have 10 other biologic options that can be administered subcutaneously that I would choose first.

If insurance coverage were not an issue, I would choose a drug that blocks the pathway involving type 17 helper T cells (TH-17). More than a decade ago, it was thought that psoriasis was a TH-1 disease. We now know that it is more of a TH-17 pathway disease. So I would pick a drug that blocks that TH-17 pathway first. In addition, the most recently available biologic drugs are interleukin (IL)-23 inhibitors. So, as IL-23 drives the TH-17 pathway, an IL-23 inhibitor is very a good treatment option.

Question 3: How do you address treatment goals for patients with plaque psoriasis?

When discussing the goals of the treatment with my patients, I explain to them that we now have many drugs that come close to completely resolving plaque psoriasis lesions. I tell them that these medications work so well, and that they are going achieve total skin clearance or almost total skin clearance. However, this does not apply to etanercept. I don’t typically use etanercept for psoriasis unless I have to because the other biologic drugs work better.

I like to explain the treatment timeline to each patient, in particular discussing how long it is going to take for the medication to achieve its full effect.

When it comes to addressing adherence to systemic therapy, I think that most people adhere to regimens because they see that they are getting better. One thing that would contribute to nonadherence is if the drug isn’t working that well or if patients are experiencing side effects. For example, I saw a patient today who had been prescribed apremilast for his psoriasis who later decided to stop taking it because of the side effects. He was experiencing diarrhea and believed treatment wasn’t working very well because apremilast takes a few months for its full effect. However, if a patient is on a biologic that works well, I think that typically they are adherent to treatment because they see the benefits of using it. Adherence to treatment with topical steroids may be difficult because usually we’ll prescribe an ointment for the body, and ointments can be messy, so I can see why patients may not always adhere to therapy.

Question 4: Can you elaborate on other comorbidities seen with plaque psoriasis?

When I trained 30 years ago, we thought psoriasis was just a skin disease. But now we realize that psoriasis is really associated with many other systemic diseases such as metabolic syndrome.¹ With metabolic syndrome, the patient can have high blood pressure or diabetes, obesity, and increased risk for strokes or myocardial infarctions.² With psoriasis, patients can be affected psychosocially because they’re too embarrassed to go out because of their condition. So when our clinic sees a patient with psoriasis, we do tell them to see their primary care physician, explaining that psoriasis is not just skin deep, but is associated with other comorbidities.

Question 5: Do you have any further advice for dermatologists who are treating patients with plaque psoriasis?

Dermatologists should be more aggressive in treating psoriasis because some studies have shown that more aggressive treatment can decrease overall inflammation. In fact, there are studies that indicate that treatment of systemic inflammation can potentially decrease the risk for cardiovascular events.² So there is evidence that it may be better to be more aggressive when treating psoriasis, rather than just giving a topical steroid when the patient could benefit from systemic therapy. I see patients who have seen other dermatologists, and all they were given was a topical ssteroid. I believe many dermatologists shy away from biologics, perhaps because biologics weren’t available when they were in training or they weren’t trained on using them during their residency.

Dermatologists should also make sure that they get the patient’s primary care physician involved in patient care. Patients with psoriasis really need to be assessed for other comorbidities such as obesity, diabetes, hyperlipidemia, and hypertension.

References

1. Gisondi P, Fostini AC, Fossà I, Girolomoni G, Targher G. Psoriasis and the metabolic syndrome. Clin Dermatol. 2018;36(1):21-28.

2. Ridker PM, Everett BM, Thuren T, et al. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N Engl J Med. 2017;377(12):1119-1131.