Fabrizio Galimberti, MD, PhD

Panelists discuss how the future of psoriasis treatment is evolving toward more personalized approaches with earlier biologic intervention for patients with high-impact disease regardless of body surface area, improved assessment tools that better capture disease burden, greater consideration of comorbidities and quality-of-life impacts, increased diversity in clinical trials, expanded patient education, innovative delivery systems, combination therapies, and targeted treatments for specific psoriasis phenotypes—all aimed at addressing current treatment gaps and moving closer to disease modification rather than merely symptom management.

Panelists discuss how although SPECTREM was groundbreaking as the first randomized controlled trial specifically targeting moderate psoriasis in high-impact areas, other valuable evidence exists including subgroup analyses from pivotal trials of interleukin-17 inhibitors (secukinumab, ixekizumab, brodalumab) showing efficacy for scalp and nail psoriasis, dedicated studies like GESTURE (secukinumab for palmoplantar psoriasis), IXORA-Q (ixekizumab for genital psoriasis), data on TNF inhibitors for inverse/intertriginous disease, and observational real-world evidence supporting various biologics for difficult-to-treat locations—though most preceding studies were limited by focusing on patients with higher overall body surface area rather than the clinically important population with limited but high-impact disease that SPECTREM specifically addressed.

Panelists discuss how the SPECTREM trial (Glick, 2024) revealed guselkumab’s exceptional site-specific efficacy for psoriasis in traditionally difficult-to-treat areas, achieving complete clearance (Investigator’s Global Assessment [IGA] 0) in remarkably high proportions of patients compared with placebo—with 60% clearance in scalp (vs 9% for placebo), 76% in facial sites (vs 24%), 77% in intertriginous areas (vs 24%), and 73% in genital regions (vs 33%)—while maintaining a favorable safety profile without new signals, demonstrating the biologic’s particular value for patients with limited but high-impact disease in these psychologically and functionally significant locations.

Panelists discuss how the SPECTREM study (Stein Gold, 2024) demonstrated guselkumab’s remarkable efficacy for moderate psoriasis in high-impact areas, with 74% of treated patients achieving clear/almost clear skin (Investigator’s Global Assessment [IGA] 0/1) at week 16 compared with just 12% on placebo, while importantly showing consistent effectiveness regardless of baseline body surface area (BSA)—suggesting that BSA alone shouldn’t determine treatment approach and validating biologic therapy for patients with limited but highly impactful disease.

Panelists discuss how patients similar to those in the SPECTREM trial—individuals with limited body surface area (BSA) but significant disease in high-impact areas like the scalp, face, hands, feet, or genitals—represent a substantial and often undertreated population in everyday practice, highlighting the importance of recognizing that these patients with moderate psoriasis frequently experience disproportionate quality-of-life impairment despite not meeting traditional severity thresholds, potentially benefiting from earlier biologic intervention as demonstrated in the guselkumab study.

Panelists discuss how treating psoriasis in anatomically challenging areas such as the scalp, face, genitals, intertriginous zones, palms, soles, and nails requires specialized approaches due to unique barriers including limited penetration of topicals, skin sensitivity, mechanical friction, and psychological impact, necessitating tailored treatment strategies that may include modified vehicle formulations, careful steroid use, targeted phototherapy, or earlier consideration of systemic agents including biologics for these high-impact sites even when overall body surface involvement is limited.

Panelists discuss how despite limited but encouraging efficacy and safety data from studies like VISIBLE (guselkumab) and various subgroup analyses supporting biologic use across diverse skin tones, clinicians must still consider unique presentations and concerns when treating patients with skin of color, including postinflammatory hyperpigmentation, follicular presentation patterns, cultural perspectives on treatment, and historical underrepresentation in clinical trials, while emphasizing the importance of personalized discussions about treatment expectations and outcomes specific to different skin phototypes.

Panelists discuss how undertreatment in psoriasis persists despite expanded therapeutic options due to multiple barriers including limited physician awareness of disease impact, insurance restrictions, socioeconomic disparities, patient concerns about medication safety, inadequate screening for comorbidities like psoriatic arthritis, outdated treatment paradigms, health care access challenges, and the failure to recognize that even limited disease in high-impact areas may warrant systemic therapy.

Panelists discuss how undertreatment remains pervasive in psoriasis management, with recent data from Gondo (2024) revealing that nearly one-third of patients with moderate to severe disease receive only over the counter (OTC), complementary, or topical therapies, while similarly high percentages of patients with mild disease but high-impact location involvement are undertreated, with disparities particularly affecting patients of color, those of lower socioeconomic status, and individuals whose limited body surface area (BSA) involvement in sensitive or visible areas significantly impacts their quality of life despite not meeting traditional severity thresholds.

Panelists discuss how selecting among the numerous approved biologic therapies for psoriasis requires a personalized approach that weighs factors such as efficacy data, safety profiles, comorbidities, insurance coverage, and administration preferences, with patient preferences playing a crucial role in the decision-making process, as involving patients in treatment selection enhances medication adherence and satisfaction and ultimately improves long-term outcomes.

Panelists discuss how biologic therapies for psoriasis are increasingly considered earlier in treatment algorithms based on the American Academy of Dermatology-National Psoriasis Foundation (AAD-NPF) Guidelines and updated International Psoriasis Council (IPC) severity classifications, with decisions influenced by disease extent, impact on quality of life, presence of psoriatic arthritis, treatment history, patient preferences, and the recognition that prompt intervention with biologics can prevent disease progression and comorbidities in patients with moderate to severe disease.

Panelists discuss how psoriasis severity assessment requires a holistic approach that integrates objective measures of skin disease (PsO) such as extent, location, and symptom intensity with evaluation of joint involvement (PsA), considering the profound impact that even limited psoriatic lesions in visible or sensitive areas can have on a patient’s quality of life, functionality, and psychological well-being.

Panelists discuss how despite multiple psoriasis severity measurements having clinical value—body surface area (BSA) providing quick area estimates but lacking quality assessment, psoriasis area and severity index (PASI) offering comprehensive scoring but requiring training, Physician Global Assessment (PGA) delivering simple standardized physician evaluations with potential inconsistency, and patient-reported outcomes capturing critical quality-of-life impacts often missed by clinical metrics—each measure has distinct limitations that necessitate using complementary approaches for optimal treatment planning.