 presentation titled “Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives.” I’m Melodie Young. I’m a nurse practitioner at Mindful Dermatology in Dallas, Texas, and I’m part of the Modern Research Associates clinical trials company in Dallas. I’m joined today by a dear friend and colleague, Lakshi Aldredge. She is also a nurse practitioner, and she practices in the dermatology service at the VA [US Department of Veterans Affairs] Portland Health Care System in Portland, Oregon. 

Our discussion today focuses on the role of nurse practitioners in patient care and improving outcomes of plaque psoriasis. We shall also discuss the safety and efficacy of available treatment options. Welcome Lakshi, how are you?

I’m great, Mel. Thank you so much for having me. I’m delighted to be doing this with you.

 We’re going to talk, first of all, about an overview of the impact of psoriasis. We’re talking about plaque psoriasis, but we’re going to speak about it in general as a disease state and the impact it can have on patients, their caregivers, and their families. We know that it doesn’t just impact a patient, it impacts the entire family unit. As far as the physical aspect of psoriasis, in your practice, how do you see the physical impact of this disease affecting your patients?

It’s a huge burden, our initial understanding of it many decades ago was that this was simply a skin disease: you had some dry skin. In fact, it’s often misunderstood, misclassified, or diagnosed as eczema or a dry skin disorder. Patients are told that they need to moisturize and live with it. Our understanding has come along so far, especially in the last 20 to 30 years, in understanding that this is much more than just a skin disorder. This is an autoimmune condition that not only affects the skin, but it can affect every single organ of the body. We know it affects every race, every age group, and all genders. Everybody can be affected by psoriasis; there is no group that escapes its wrath.

I’m from Sri Lanka, and we have leprosy there. I call psoriasis a modern-day leprosy because it’s a disease that we don’t have a cure for and because of the physical aspect of it. This is an autoimmune condition that we wear on the outside of our skin that is visible to the world. Not only does it impact them physically with itching and burning, but there is also an emotional, psychosocial impact from wearing their disease for the world to see, especially for young individuals, but it can affect everybody psychologically as well. Plaque psoriasis is the most common form. You typically see it on the elbows, knees, and the scalp, but people can be covered from head to toe.

The Misunderstood Physical Impact of Plaque Psoriasis

 We know that it is a visible disease, but we also know there’s a misery index associated. It’s really itchy. Patients report their top complaints about their disease. We used to think it just embarrasses them, and I’ve had some providers say things like, “It's cosmetic,” and that maybe I shouldn’t look at using a biologic for a cosmetic condition. Of course, that makes my eyes want to pop out of my head and smoke come out of my ears because it is not just a cosmetic condition. It is a dangerous disease, and it’s something we can fix if we try.

Patients complain of itch and pain, but they also complain and tell stories about things like, “I have to be careful about what color the interior of the car is because if it’s dark and I sit down in somebody’s car to go to lunch with them, when I stand up, there will be flakes everywhere, and it’s so embarrassing.” Or they think about wearing dark-colored clothing or light-colored clothing because psoriasis bleeds. It cracks.

I heard it described as feeling like dried oatmeal on the skin, and when you move, you feel so constricted. You’re dying to just pick that plaque off. But of course, it bleeds, and it escalates the itching, the plaque, and the growing problem with it. We see that it has a well-documented impact on the psychological aspect, whether it’s depression or suicidal ideation, which is associated with psoriasis, and we also know that it can have an impact on your ability to make a living.

I have a couple of nurse anesthetists who have told me how miserable it was to try to pop the top off medications when you don’t have your nails, to try to draw medicine. Nails are really important. They’re not just here for looks.

There is also genital psoriasis. I know you could speak about that, you take care of a lot of guys in the VA [US Department of Veterans Affairs]. I’m sure you've had some discussions about that.

I’ve had folks come in, a husband and wife, where the wife was sure that her husband had been cheating on her and that the husband had caught a sexually transmitted disease. It was devastating for them as a couple in their relationship. They had been married for 35 years. You’re absolutely right.

First of all, the physical symptoms are not only pain and itching, but sleep is a huge issue because they’re scratching all night. I have even had a patient tell me that the morning routine for them was that her husband would peel her off of the sheets in the morning because she’d scratched so much, bled, and the sheets would stick to her. I know that the stories Mel and I are telling you sound dramatic, but they are true-life cases.

I had another lovely gentleman who worked for a big advertising company in New York, and he had been demoted because he was doing a sales pitch, and his hands were affected. As Mel said, when you’re out there advertising and talking with your hands, the company representative said, “We don’t want him working on our advertising campaign,” and it was literally a loss of livelihood for him and his family. To the suicidality issue, he considered taking his own life. He has twin daughters, and when they were 6 years old, he would take them for walks, and one day one of them said, “Daddy, could you not hold my hand today,” because she did not want to touch his psoriasis. These are real-life stories.

It is not just the physical itch, pain, and sleep disorders, but the psychology of this disease is devastating as well. As Mel mentioned, it’s not just a disease of that patient, it’s a disease that affects the whole family.

I had a 45-year-old female veteran who had never had a relationship with anybody because she had genital psoriasis, and she thought, “Who would ever want to be in a relationship with me with this disease we don’t have a cure for?”

If nothing else, I think Melodie and I would want you to leave with this: if you are a provider, and you have a patient with psoriasis sitting in front of you, think of them as a whole person. Ask them about what their disease is keeping them from doing and how it keeps them from experiencing joy in their lives. That’s what the goal is. We want them to have a joyful, healthy, productive life, and this disease often keeps them from doing that. We as providers, now can thankfully get them clear or near clear, and that is our goal.

The Devastating Psychological and Social Impact of Plaque Psoriasis

 I know you also have a big sphere of influence among a lot of other nurse practitioners, NPs, and PAs [physician assistants], and even physicians. They sometimes look to us and say, “You know stuff that we don’t know. You look at things a little differently because you’re trained as a nurse.” How do you encourage people to develop those relationships so that patients will tell you how much this disease is affecting them, and maybe begin to hope? How do you instill hope and trust in people?

Mel, you’ve done this for 30-plus years now with psoriasis, and that’s the No. 1 biggest thing. The average psoriasis patient sees anywhere from 4 to 7 providers before they find one that they say listens to them and that they trust. Developing that relationship is absolutely essential because they want someone who will listen to them and take some time. Yes, initially, it may take some time to develop that relationship and spend some time chatting with them.

I can tell you that visits with patients with whom I’ve developed those relationships have control of their disease. It’s a 5- or 10-minute visit, and they are the most rewarding patients to take care of. It’s one of the first things I love to do when I have a new psoriasis patient. I’m thrilled when I see them on my schedule because, to me and Mel, who is the same way, this is an opportunity. I think of it as a gift that we can give our patients to say, “I'm so glad that you are here.” This is absolutely the disease I love taking care of. I say, “You and I are going to become dear friends.” I tell them that I’m going to give their kids graduation cards, and they’re going to give me expensive Christmas gifts. I say, “We're in this for the long haul.”

One of the important things that one of my patients taught me was not to overwhelm patients in that first visit. I want to give them tons of information. As nurse practitioners, physician assistants, nurses, and physicians, we feel obligated to educate our patients, but patients can get overwhelmed. You tell them that they have psoriasis, that we don’t have a cure for it, and that there are all of these comorbidities associated with it. They could get joint disease, heart disease, and diabetes, but we can help them, and we’ve got injections for them. Their mind is going crazy.

I have learned that you give them bits of information. The first visit might be 20 minutes where we talk and say, “This is the disease that you have. You and I are going to be in this for the long haul. You’re going to let me know what your goals are and what your disease is keeping you from doing. I’m going to give you information about the different aspects of this disease in pieces. I’m going to give you all the different treatment options that are available and out there for you, and you and I will come to a mutual decision about what’s going to work for you, your family, and your lifestyle. We’re going to make this. My goal for you is that when you wake up in the morning, psoriasis isn’t the first thing you think about.”

 One of the first things I like to do is, I like to touch them because they feel like their skin is unclean, dirty, and ugly. I will often touch them. I don’t hesitate to touch psoriasis. I also tell them right off the bat, “Oh, I’m so excited to meet you. This is my favorite disease. It’s so exciting because we have some awesome therapies. We ought to be able to get this disease controlled for you. Tell me what your life would be like if you didn’t have to think about psoriasis, if I can help get rid of this disease.” A lot of times, that’ll bring tears for both of us, but when you instill hope, then they begin to trust you. Then you say, “We have lots of choices,” and I ask them a few questions. I try to zero in on what I maybe shouldn’t offer or what would be best for them, and then they begin to trust me.

Over time, we will talk about more things, and they’ll sometimes say, “What’s going on in research?” They used to ask that all the time. They’ll say, “I’m seeing new drugs advertised. Tell me about those. Should I stay what I’m on, or should I change?” They’ll ask about infections, immunizations, and other topics that we can delve into. Oftentimes, I make the whole pinky promise thing, or get them to commit. I’ll say, “If I get your skin clear, and I think I can because we’ve got drugs that can do that now, and if I don’t get it with the first agent, hopefully, I’ll figure out shortly thereafter what’s going to be the best drug for you. We’re going to start focusing on your general health.”

They will tell you that they often won’t get a haircut because nobody wants to touch their scalp. They haven’t gone to the doctor because they’re embarrassed to undress in front of an internist. They sometimes do not like to take their clothes off when you see them. You have to do it slowly. If you can do a full-body check, that’s great.

The other thing you said is, look at them as a whole. Get them to trust you. Show that you care. Show that you have therapies that will encourage them. If you’re not comfortable, if you know enough about psoriasis to say, “I can teach you about it, but I'm not the best at treating it. I don’t have enough of these types of patients.” Your expertise may be surgery, cosmetics, or something else. Then say, “I know people who are really good at this” and start working to try to get them to the right person.

What I’ve seen is that then I can also focus on other things. I know you know that as well, but I can’t tell you how many skin cancers we’ve found on patients or how many of them we’ve helped to take better care of themselves. I had a patient this morning, and he was so proud because his skin is the best it’s ever been. The first thing he said was, “I'm down 15 pounds,” because he just feels better about himself overall. I told him, “Look, the skin is no longer going to be your focus. Instead of spending hours a week rubbing on creams and ointments or trying to do phototherapy, if I can look at some of these other treatments, you can spend that time having fun with your family, enjoying your work more, and focusing on your health.”

Patient-Provider Relationships in Plaque Psoriasis 

 Do you get any pushback from patients now? We used to, when trying to move patients away from topical agents and move them onto other things.

 It’s an important question because you can lose a patient quickly if you do not address this. The first thing I say to patients is this: “Tell me what you have been doing to treat your disease either yourself or with other providers,” so I can get a feel for what they’ve been given and what they’ve been told before about their disease. I want to clear up any misconceptions, and I want to see what they’ve used before. The second thing I ask is this: “How did that work for you? How did that fit in with your lifestyle?” Often they’ve been given a topical cream, a tiny tube for their full body, and they're told to put it on twice a day, and it’s ridiculous. They’re not going to do that, especially if they are a young individual.

There were studies that have been done, and on average, patients with moderate to severe psoriasis, which covers a lot of their body, would spend 30 minutes a day putting on ointments and creams. Here’s an important aspect that another patient taught me about regarding the psychosocial impact of the disease: psoriasis is not unlike diabetes and heart disease in that it’s an autoimmune condition. With diabetes and heart disease, you don’t have to put on an ointment or cream. You take a pill or give yourself a shot, and you’re done. Every time you tell a patient to put an ointment or a cream on their plaques, they are constantly reminded that they have this awful disease, and I’ve had patients tell me that they weep every time they have to do that.

There’s a different paradigm now. I always give my patients a topical cream because there’s going to be a time, even if I get them clear, when they may flare a bit. They might have a bit on their elbow, arm, or on their lower back, and it’s perfect for them. It helps relieve itching, but that should not be the mainstay of treatment; for patients who have 1 or 2 plaques, that’s fine. But for patients who have more disease, you need to think about treating the inflammation systemically, and that’s when you talk to them. I describe it as a fire: they have this slow-burning fire inside them. When they think of psoriasis, every time they have a plaque, it’s a little spark or a tiny flame. We want to quash that flame internally. That helps give them a visual.

I’ve had veteran patients who are 60 years old who’ve said, “I don’t care about how my skin looks. I’m fine with the plaques on my legs,” and I say, “Are you fine with a little bit of high blood pressure? Are you fine with a little bit of diabetes?” No, they’re not. They want to get everything under control. You set the expectation that we want to normalize the immune system and normalize the body so that we’re not putting them at an increased risk for heart disease, diabetes, or joint issues. It’s important to set that expectation.

You then say, “I’m going to take you through the gamut of different treatment options.” When we treat it from the outside in, we have ointments and creams, and we have phototherapy. With more severe disease, we treat it from the inside out, and that’s with pills and injections.

The other thing that I have found to be helpful—and I say this with absolute sincerity—is this: I say, “If you were my husband, brother, wife, whomever, what would I do to treat you?” Or I may say, “If I had what you have, this is what I would do, and this is why.” Some of my patients will say, “Do you like your husband?” and I have to clarify that, yes, I do. It’s important to first ask them what they’ve been given before and if it worked for them. What are some limiting factors in their life? Is the patient a college student who’s really busy? Are they going to remember to take a pill every day, twice a day, or a group of pills once a week? Are they terrified of shots and are they completely averse to that?

Here’s another issue. Is the patient experiencing homelessness? Do they have secure housing to keep their medications? Do they have a refrigerator where they can keep an injectable biologic that needs to be refrigerated? These are some factors about which you may not think, and patients may not voluntarily share them with you because they might be embarrassed. We must ask about some of the factors that are limiting them right now or factors that might keep them from doing these treatments.

I will then ask them, “What are your struggles?” I can’t imagine having to spend an extra half an hour putting on topical agents or driving over to get phototherapy treatment 3 times a week in a clinic that is mostly open during office hours. Those are impossible asks for patients, and I’m not even sure that they’re compatible as far as the amount of clearance they can offer and how they can alter the course of the disease by using more systemic and biologic agents.

I try to tell them, “We're talking about medicines now. They’re going to take minutes out of your life to treat your disease as opposed to lots of time out of your day for your treatment. It will no longer be the focus.” I’ve had patients who would tell me that they had to stop their activities, particularly in pediatric situations. Thankfully, we have many therapies now that are also available for pediatric patients with plaque psoriasis or psoriatic arthritis. With the amount of time treatment takes, and the need to have family help you, it can be such an issue.

We must also constantly help them understand what the disease state is and the information that they get. Everybody’s got access to sources, and we know that even reliable, usually trustworthy sources, such as when you’re talking about one of the doctor shows on TV, when they talk about psoriasis, they make my blood boil because they can be ignorant and ill-informed. They are misleading people. If you look at some of the online sources, people who are promising them that if they go on the right diet, take the right vitamin, or alter their lifestyle, then they can impact the disease. One of the first things I’ll say is this: “This disease is not your fault. You didn't do anything to get it. There are some things you can do to make yourself healthier, but this is a disease that requires medication.”

We want to get as close to complete clearance as possible because, as you just mentioned before, we want tight control of blood sugars and blood pressure, and we want tight control of these immune-mediating diseases that can harm you if the inflammation is left unchecked. My job is to find something that works, and something that’s going to be simple and fit your lifestyle.

Facilitating Disease Management in Plaque Psoriasis

 As you begin to talk with patients about the disease, you have to remind them constantly about things that trigger flare-ups. For example, I have families who have kids, and the kids start bringing home diseases. They’ll get strep throat from their child, and for the psoriasis disease that’s done beautifully on 1 medicine for months or years, they’re now saying, “What happened? I haven’t had psoriasis in years. Suddenly, I’m breaking out. What’s going on?”

You then find out that one of the kids in their family has strep throat, and you say, “I bet you've been exposed to strep throat.” Or it may be that the disease changed, and you start digging to find out why. With the new drugs that we have and the stability of what they offer, you should not have a waxing and waning or flaring of disease, but some drugs cause it, as do sunburns.

I’m sure you’ve got other things that you can mention related to triggers as well. We also talk about things to make them healthier: lifestyle modification like diet and exercise, not really focusing on that as being meaningful or impactful for disease therapy. Even in Portland, where there are people who are focused on health and wellness. Is that a question that you get at the VA [US Department of Veterans Affairs Portland Health Care System]?

It’s a big deal here in the Pacific Northwest. Everybody wants to try a naturopathic remedy. Everybody swears by turmeric, and I say, “I have turmeric every day, and I still have eczema.” The 1 diet that I talk about with people that has been shown to help a bit in autoimmune-mediated conditions is the Mediterranean diet, and that’s a healthy diet. It’s low fat, it has less red meat, and it’s a healthier diet. There’s no diet that is going to keep this from happening. You hit on a good point, Mel, because patients will sometimes come in with a whole lot of guilt about what they did that caused this. They say, “Was it the cigarettes that I smoked in college? Was it that one-night fling that I had?”

We need to reassure them that there are myriad factors that can trigger psoriasis. There’s definitely a family hereditary factor to it: about 40% of people have a family propensity for the disease. Certain medications such as β-blockers can also trigger psoriasis. That’s why you'll see people who are in their 50s who have never had a skin issue suddenly break out in psoriasis. You can ask them, “What's happened in your life?” It could be that they just started having blood pressure issues, and their doctor put them on a β-blocker. That can be a trigger. Stressful events like loss of a loved one, loss of a job, loss of a house or home, emotional trauma, or stress can trigger psoriasis. Environmental factors can also trigger psoriasis. In the Pacific Northwest, we have a lot of mold. It’s very rainy, so it can happen if you move from one climate to another. I have many veterans who go abroad for deployments and are exposed to chemicals. Those kinds of things can trigger psoriasis as well, as can certain infections such as strep throat. We must reassure our patients.

As you mentioned, we know that certain lifestyle factors can make psoriasis worse or less amenable to the treatments that you give them, such as smoking, significant alcohol use, and a sedentary lifestyle. To the points that you made, once we get them on the right treatment and get their skin clear, we want to focus on the rest of their health. They all start feeling better. They want to go to the gym. They’ll start working out. They quit smoking. They decrease their alcohol intake. They start socializing. They start getting more confident. They work on lowering their blood pressure because they’re out running and working out. We are talking about it holistically. You hit on all of those points

There is no 1 treatment. If any of you are working with other providers, perhaps a supervising physician, and they say, “No. We’re only going to treat our patients with this medication or this modality,” then you need to find a new place to work because there is every treatment option available, and every patient should be given all of those options to consider. The big buzzwords in health care are mutual decision-making or shared decision-making, and that’s what this is about.

 You shouldn’t have to coax the patient into it. When the patient makes an appointment to come and see you, they’re paying you for your time. They want your expertise and your knowledge, and you owe it to the patient to do your very best and tell them, “Here's what I know,” and to stay current. We don’t do Mohs surgery in our clinic [Mindful Dermatology]. We have a lot of excellent Mohs surgeons in the Dallas area, so I’m fortunate. I say, “That's not something that we do, but I’m happy to help you find someone who’s going to meet your expectation, and that’s our goal.” That’s the same way it is with these therapies. Psoriasis is a complex disease, and there’s not just 1 pathway.

 That’s why, with psoriasis, we talk about the art of medicine, and this is it. Sometimes, it’s like mixing the colors on the palette to find what works for the patient. There’s not 1 thing that’s going to work the same for all patients, and it’s sometimes a bit of a witch’s brew to make sure that we’re looking carefully at other factors. They could be on 1 agent doing beautifully, and then they flare. You think that the medication has stopped working, but that may not be the case. Ask them what’s going on with their life. It may be that they’ve had more stress. It may be that they’ve had an infection, so their immune system is flaring a bit. That’s where a topical agent or even adding an oral agent to get them by, that can work very well.

 If they’re overweight and a smoker, losing weight and stopping smoking are the 2 most important things you can do. But those are things we talk about later; don’t make them think that they have to do that to get a biologic agent. All the data show that biologics are incredibly effective in overweight patients because most of the patients in the clinical trials are overweight. It’s the case for male and female patients no matter where they are in the world: patients with psoriasis tend to be heavier. 

The whole research community is interested in psoriasis because there are a lot of similarities with other diseases. It’s one of the things you mentioned when we were talking about drug triggering. We have seen patients who’ve had perhaps Crohn disease who get a treatment, and it’ll cause them to develop psoriasis because a lot of these different immune-mediated diseases will run in families. You can have more than one. You can be an unfortunate patient who has hidradenitis suppurativa, psoriasis, and psoriatic arthritis. For those patients, fortunately, there are some medications that can treat multiple diseases at once. That is what’s made our job fun and meaningful.

Individualizing Care for Patients With Plaque Psoriasis

 I’m of this mindset: When I see your psoriasis, I’m going for it. I’m going for the best therapy I can offer you right then. We’re going for it as opposed to wearing the patient down and getting them more frustrated.

Sometimes, I associate 2 different things. When you’re looking at the National Psoriasis Foundation, the American Academy of Dermatology, or other organizations that focus on guidelines of care and standards of care, we think about whether all drugs should be available to all patients or if we should put people in buckets. If you have mild to moderate disease, what is that? What’s moderate to severe? Is it different for certain people? Is it just the body surface area [BSA]?

Lakshi, talk a bit about how you have a preconceived idea of mild vs moderate. We all know what severe is. Severe is a bad disease. Severe people are miserable. They have widespread, uncomfortable disease, and people will definitely move toward using progressive—I wouldn’t say aggressive, I would say progressive—therapies for them. How do you handle this mild, moderate, severe conversation with colleagues or patients?

It’s a good point and an important question. Typically and traditionally, how we have categorized mild, moderate, and severe disease has to do with body surface area, where 1 palm-size equals 1 BSA. Traditionally, how we classified it was that 0 to 3 BSA was considered mild disease, 3 to 9 BSA was considered moderate disease, and anything over 10 BSA was considered severe disease. That’s somewhat true, and it’s what we use in clinical trials as well as some other complicated scoring mechanisms.

It’s important to ask the patient about what it is keeping them from doing and what is most symptomatic for them. You may have a small area on the genitals or on the palms and soles of the hands and feet, which would be 4% or 5% body surface area. If you told me that, that might be considered moderate, but if you have genetic psoriasis that is bad, that is a severe disease for some people. If you have scalp psoriasis, and it’s only affecting your scalp. If you have big, thick plaques in your scalp, it feels like someone has put papier-mâché on your head; it is dried, hard, itchy, and painful. That is a severe disease. If you have palm pustular psoriasis on your hands, and if you’re a health care worker like Mel and me who sees patients, or if you’re in sales—even if you’re typing on a computer all day, that can be devastating if you develop fissures and sores. Don’t simply go by the amount of body area that is covered. Ask the patient how it’s affecting them.

The next most important thing to ask is if they have any joint symptoms: stiffness or soreness, especially in the hands or the feet but also in the back and any other joints. It can be an indication that they have something called psoriatic arthritis. About 30% of patients with skin psoriasis can go on to develop joint inflammation called psoriatic arthritis. Unlike the skin, where we can produce new skin cells, once you start having joint inflammation, you can have a loss of function of that joint or that bone, and then they can’t get it back. This can lead to disability. Think about it: If they’re a mechanic, a machinist, or an electrician and can’t turn a screwdriver or even open a can of beans, this is disabling. We want to ask them about this as well.

They might have limited skin involvement, but they sometimes start telling me, “I wake up in the morning, and it takes me 30 minutes to get moving around,” or “When I have my cup of coffee, it helps warm my hands, and then I can start functioning,” or “I get in the shower and that loosens stuff up.” Some other things they’ll tell you are, “I get up in the middle of the night to walk around because it loosens up my back” or “If I go for a long car drive, I have to stop every so often to get out, so I can walk around.” That should cue you in to think about psoriatic arthritis in these patients. You can have mild skin involvement, but when you add early symptoms of psoriatic arthritis, that puts you in a different category. You need to treat those patients systematically either with a systematic oral agent or a biologic agent.

To answer your question—this was long-winded, I know—severity is in the mind of the beholder with the provider asking important questions about what areas are involved, asking about joint symptoms, looking at other comorbidities that they have, and making a decision about what the right therapy is. It’s less about the severity and more about that whole picture.

 With the typical therapies you’re going to give, as you said before, I tell patients, “Topical agents will help you with symptoms, but it does not do anything to control the disease.” Topical therapies may help with it, or they may make your skin not as dry, inflamed, cracked, and sore. But we still need to layer that with something else.

Approaches to Care in Plaque Psoriasis by Disease Severity

 You mentioned pills, so we’re going to talk about systematic therapy a bit. Going back to my career in the late 1980s and early 1990s, we had methotrexate, then acitretin, which is a retinoid. Then cyclosporine hit the market. It’s still approved, but only for a year of utilization and for severe patients. A few years back, we had a new oral agent that came onto the market, and it’s been widely accepted by patients and the dermatology community as well. I want to mention that. What do you think about systematic agents? How often do you use them, and do patients have more interest in them? Let’s talk about systematic agents a bit.

I know methotrexate is widely used worldwide. I’ve used so much of it, but a lot of practices are not comfortable with it. You have to be careful, particularly in certain populations. There are drug-drug interactions, and if the patient drinks, has hepatitis or liver disease, or is older, it can be an issue. It has its utility, but it’s tricky. I definitely want to talk about apremilast and its safety, and then we’ll mention any of the other oral agents that have been out longer. Do you have any pros and cons of how to use those within your clinic [Veterans Affairs Portland Health Care System]?

It’s important. Many of my veterans, which is the population I treat, have a lot of comorbidities. Methotrexate has been around for decades, and it’s a great drug. It has great utility in a lot of autoimmune conditions. What’s the downside of methotrexate? It can affect the liver, and it can affect the blood counts in some individuals. You have to know your patients. You have to know all their health history and all their medications. Methotrexate is a medication that is taken orally once a week. We give people folic acid as a vitamin to take with it on a daily basis to help absorb the methotrexate better and to prevent some of the adverse effects. What you want to watch for with methotrexate is that it’s an absolute contraindication in any individuals who are thinking about starting a family.

 For men or women, methotrexate should not be used.

 It’s not a good option, as well as acitretin.

Both are highly teratogenic, so they would be off the table to begin with. Other things to think about are the patient’s alcohol use because of that liver potential. With methotrexate, it’s also a slow onset; it’s the same with acitretin. You need to have them come in relatively often, every 2 to 3 months initially, for lab tests, so you can monitor their liver function and triglycerides with both methotrexate and acitretin. It has a slow onset, so this something that’s not going to give them rapid relief right away, and you start low and slow. You slowly titrate them up.

When is this a good drug to use? When patients who, unfortunately, do not have drug coverage or insurance, this might be 1 of the only options. It can also work well in the joints. Methotrexate is often used in the joints and oftentimes. Mel and I will add methotrexate to a patient who has a biologic agent where their skin is beautifully controlled, but they might have a bit of joint disease that is still bothersome. We might give them a bit of methotrexate to add to that. It works great. Methotrexate has its utility, but it’s not something I’m going to use as a first-line treatment in a young individual or perhaps even an older individual or for anybody who drinks, which is everybody now during COVID-19 [coronavirus disease 2019]. If they tell you they have 3 drinks a night, that means they really have 6. Ask me how I know. It can also be challenging because of the lab follow-up.

 I’m not a fan of systemic steroids for chronic disease period. They are the dirty little secret when we use them. We use them because we can give it to people, and they feel better for a while. You’re going to have hell to pay later, and you can have quite a significant rebound from it. It can turn mild psoriasis or moderate disease into an eruptive, disastrous disease from which they have to be rescued. I’m not a fan.

There is no good evidence, and if we’re going to promote evidence-based decision-making, you should look at the patient, look at the disease, and look at the drugs that are available that are FDA approved, and use those. I would be afraid if a person came in and had severe sinusitis or had a severe case of poison ivy and had psoriasis. I would be afraid for them to get systemic steroids because it can destabilize well-controlled, chronic skin disease if you use them. With the newer therapies we have now, whether it’s a systemic agent like apremilast or a biologic agent, I don’t have issues when a person has to have a systemic steroid for another reason. I’m not a fan.

That’s also risky legally because it is not part of the standards of care. It’s what is going to be recommended to do. For chronic diseases, you want to use as little as possible. There are cases when you have to because there are no FDA-approved drugs to treat certain conditions. To do it for psoriasis or atopic dermatitis, you’re putting yourself at risk, and you’re putting the patient at risk.

Current Role of Systemic Therapies in Plaque Psoriasis

 Apremilast is a beautiful new option that has been around for the last 5 years or so, and it has provided an excellent resource for patients who can’t take a biologic agent; for example, individuals who don’t necessarily have insurance or those who might be undergoing chemotherapy. It could also be patients with a more serious condition that prevents them from being on a drug that could potentially make them more vulnerable to infections such as a TNF [tumor necrosis factor]–alpha inhibitor. It could also be those who may have predisposing Crohn disease, in which IL-17–targeted agents might not be an option. It could be for whatever reason; ongoing chemotherapy or a major gastrointestinal surgery, for example.

It is sometimes their choice: a thirdof the US population is needle phobic.

Sometimes, you can’t go straight from “You have psoriasis” to “I’d like to start you on injections.” That freaks them out, but they might be more amenable to taking a pill, to using an oral agent. It is sometimes the provider’s choice that you would recommend it, and it is sometimes the patient’s choice.

 It’s also a great option. I’ve changed patients from biologic agents to apremilast. For example, if they suddenly have a diagnosis of cancer and are undergoing chemotherapy, their oncologist wants them off a biologic. It’s a lovely option to be able to put them on apremilast. There’s great efficacy with that drug. What are the potential adverse effects? Potential adverse effects include depression or mood changes, although I’ve seen little of that in my population [at the Veterans Affairs Portland Health Care System], which tends to have a high risk for anxiety, depression, and suicide. I haven’t seen it much.

The biggest concern people have and the biggest complaint I see is diarrhea or upset stomach. I also tell the patient that this is a real adverse effect of this drug, but it gets better over time. In fact, when they start out, it comes in a bubble pack, and they start at a low dose twice a day and titrate it up slowly. The symptoms of that are usually mild, but it’s something for them to think and know about, so they don’t come back to you and say, “I quit taking that because I had horrible diarrhea.” You can reassure them and say, “I expected that. That’s something we know about with this drug, but it usually gets better over time.” You can also, very rarely, see some weight loss. I asked for samples, but they wouldn’t give them to me.

It’s always the guys whenever you tell them, “It’s the adverse effect of this medicine. It’s GI [gastrointestinal] distress, and we can help you figure that out and work through that and weight loss. We’ll monitor your mood.” Those are the 3 major things, and they always say, “Weight loss? Tell me about the weight loss.” It can happen, and it’s usually going to be somewhere between 15 and 20 pounds in patients. It’s the people who want to lose weight. There’s no rhyme or reason who gets the benefit of that. If you had a person who struggled to keep their weight on–those few people out there in the world who have that issue–maybe they’re an older female who’s 100 pounds, that would be the 1 situation where I’d be hesitant to select that agent. Generally, it has tolerability if you coach people through the expectations of what might be.

 The other lovely thing about it is that there’s no lab monitoring that’s required, so this is great for people who have a busy lifestyle or those who don’t have the ability to come to see you. During COVID-19 [coronavirus disease 2019], they were some of the easiest patients for me to manage because I could do a phone call with them, and I didn’t have to have them come in for any blood tests. The 1 thing some of my patients say is that it’s hard to remember to take it twice a day. I say, “Do you brush your teeth in the morning and in the evening?” or “What in your routine do you do regularly every morning and in the evening? Match it up with that or set your cell phone alarm.” It’s very well tolerated, and they do well.

With apremilast, it has a couple of indications: This is for plaque top psoriasis in adults with moderate to severe disease, and it also can be effective in psoriatic arthritis. We also know that there are a lot of people out there who are using it in addition to other biologic agents.

You can’t use or don’t want to use methotrexate along with a biologic agent, and that can be because the skin is doing well on 1 agent and we need some help because we can’t get the joints under control, or there are other types of situations. It may be the case that the patient is taking a biologic for another disease, such as HS [hidradenitis suppurativa] or Crohn disease. You’re then going to add apremilast to try to help with psoriasis. That is all off-label, but we all know that this is being done. I’m sure you hear of that or have tried to get those as well. Can you even do that within the VA?

 Absolutely. I have spoken to several patients. There are a handful of patients who are on a biologic plus apremilast. It’s lovely because it has some symbiotic efficacy with other autoimmune modulators to work with some specific patients. The patients with whom I love this combination are those who have liver disease. They may have hepatitis or liver cancer, or they may be on other medications that are potentially toxic.

 It’s lovely to be able to add apremilast, and I don’t know how I managed to get this approved, but I will have them on a biologic agent as well as apremilast. It’s beautiful because some of them don’t have to come in for any monitoring whatsoever. Some of the biologic agents don’t even require that after the initial TB [tuberculosis] testing. Apremilast is a wonderful option, not just as a primary treatment but because it can be added as a secondary treatment alongside something else as well.

 If we can do monotherapy and find 1 agent that will work on all the aspects of that patient’s psoriatic disease, then that’s great. If not, then you’re going to have to mix phototherapy or use topical agents, systematic agents, or biologic agents. If you’re going to have to do more than 1 thing, then we’re hopefully going to see that apremilast can be that extra option.

I can tell you that, in the other specialties that focus on immune-mediated disease like gastroenterology and rheumatology, the NPs [nurse practitioners] I talk to who work in those diseases hardly ever get to use monotherapy. They almost always have to have a secondary option. Yet in dermatology, it’s a struggle to get insurance coverage to use more than 1 thing in those most difficult cases that can be controlled with just 1 thing.

 I also wanted to mention that apremilast doesn’t have any contraindications except for patients with moderate to severe renal disease. You might want to ask about that. We lowered the dose with that, so that’s something to think about. The other drug interaction that is rare is with other similar agents: cyclosporine, for example. You don’t want to mix that with this drug as well.

Apremilast for the Treatment of Plaque Psoriasis

 You mentioned infections, and you mentioned remote monitoring because it is 2020. With COVID-19 [coronavirus disease 2019] being what it is, let’s talk about that for the last couple of minutes that we have. Tell me some of the things related to managing your patients with psoriasis remotely, whether they are well controlled or you’re going to start something new. Talk about any other tips you might provide for your colleagues related to managing patients with psoriasis during COVID-19.

It’s been wonderful compared with some of the other conditions, such as skin cancers, moles, or something you want to biopsy. With psoriasis, once we have the diagnosis nailed down, it is about fostering that relationship, which can be done well via phone or with a telehealth visit like this. During this whole COVID-19 issue, I’ve done a lot of this, and I start out by asking them how they’re doing. Are they flaring? Are they having any reactions to their medications? What’s new?

If they’re a newer patient and they’re failing something or if I want to put them on something else, that may require some lab monitoring. For TNF [tumor necrosis factor]–alpha inhibitors, you want to check for TB [tuberculosis]. You want to check for hepatitis B.

Yes, and we check for liver function. I’ll have the patient go to their local clinic area, where it’s convenient for them to have that done, and then I’ll get the results sent to me. I can then mail the patient the medication. If everything looks great, I’m going to tell them that I’ll call them back in 4 or 5 weeks to see how they’re doing and how they’re tolerating it.

For patients who are established, it’s lovely and super easy. Most of the time, if we get the patient on treatments that are so effective that they get clear and are able to maintain that clearance with very little flaring, it’s a 5- or 10-minute discussion. For my veterans [at the Veterans Affairs Portland Health Care System], I’ll ask, “How’s the fishing?” We talk about fishing or hunting for about 15 minutes, and then for the last 2 minutes, they’ll say, “My psoriasis is great. No flares. I love my medication. Don’t ever take it away from me.”

Right, exactly. Then that’s it. I sometimes don’t even talk with them for another year. That’s how effective these treatments are and how little hand holding and management there can sometimes be. At that point, I leave it up to the patients. When do you want to come in and see me? When do you want me to reach out to you again? It’s less about me trying to manage their disease, because their disease is managed. It is about ensuring that their overall health is well. I ask them, “Have you seen your primary care provider? Have you had all your age-appropriate cancer screenings? How’s your blood pressure?”

 Patients need to be getting those cancer screenings. You still have to see them once a year to do the skin cancer screenings.

Exactly. COVID-19 has been a challenge in some instances because we can’t have them come in to do those skin checks necessarily. But with the management of psoriasis, this is something we can do well over the phone or with a telehealth visit.

 A lot of times with my patients, I’ll say, “Now that telemedicine has been approved for psoriasis, if you’re stable and well controlled, I’ll see you once a year and do your skin check. We’ll do your TB test if needed. The other time of year we’re going to do a telemedicine visit. We’re just going to check in. I want to make sure you’re OK.”

I want to make sure they’re adhering to the treatment and not getting advice about what to do about their psoriasis medicines from someone else, particularly if someone is telling them to stop it. I’ve had that happen before. I’ll say, “Don’t ever stop your medicine without me.” If you need to postpone it for a couple of days until you talk to me, fine, but whoever prescribes your medicine is the person you should always talk to related to stopping it. Stopping and starting medicine can make it more difficult for you to get clear and get treated. Sometimes, with those quick call-ins to our nurses’ desk or to a biologic coordinator, we always say, “If you’re sick or if you have a fever, just hold your medicine, call in, and let me find out what’s going on.” We then decide whether we want to postpone their treatment.

Managing Patients With Plaque Psoriasis During the Coronavirus Pandemic

 What do you think the unmet needs are? What are we missing? We have drugs now that are just average. Their mean PASI [Psoriasis Area and Severity Index] scores are 92% to 95% on some of the IL-17 and IL-23 inhibitors, with the systemic agents or apremilast being something that can be a pill that doesn’t require too much monitoring. That can help improve the disease. What are we missing? What would you like to see besides a cure? I know we’d love to see a cure.

 Is there a treatment missing, or do we think it’s more our profession that’s missing the opportunity?

It is a professional patient education piece, and that is educating one another as health care professionals about the ramifications of not treating this disease. It’s important to understand the comorbidities associated with this disease and the incredible burden of the disease physically, emotionally, and even monetarily to an individual and their family.

That’s the No. 1 educational gap, and the second most important thing is correcting myths or misconceptions, especially during COVID-19 [coronavirus disease 2019]. Almost all the treatments that we give for psoriasis are perfectly reasonable to continue or initiate during this pandemic. When you think about your whole patient, you talk to them about their concerns and fears, and you give them evidence-based data to show that most of the biologic agents are safe, including some of the oral treatments such as apremilast. It’s perfectly safe to start treatment during this pandemic. Patient education will help demythologize and correct misperceptions, with not only our colleagues but also our patients. It’s important to get them on that pathway of not only clearing their disease but having a healthier, more enjoyable life as well.

 A lot of the unmet needs are there because there are gaps in care. There are gaps in access. Some cities have multiple experts in psoriasis and multiple dermatologists. In Texas, as big as it is, you’ve got a lot of rural areas there as well. There’s so much of our country that doesn’t have dermatologists or rheumatologists who are current. I hate to even say 

 because we’ve had biologic agents for 20 years. They need to be aggressive or involved in treating a patient with psoriatic disease or other chronic skin conditions.

That’s what part of the unmet need is, and that’s another opportunity that we have as NPs [nurse practitioners] and PAs [physician assistants]: being able to do telemedicine for rural areas or places where dermatologists aren’t around. You can hardly do that if it’s basal cell carcinoma that you’re trying to deal with. That patient is going to have to come in and get a biopsy, or you need to get them somewhere to get a biopsy. For psoriasis, it’s awesome. It’s socially acceptable. It’s a standard of care within the medical and dermatology community to use telemedicine to treat and diagnose conditions. Psoriasis can usually be diagnosed by looking. That is exciting, and I would like to see a cure. I would love to see medicines for which we would know what we need to do from the get-go, so we know exactly what’s going to be the best therapy and continue to understand more about the disease and all the different areas that are being affected by it. Maybe patients and providers alike will be totally convinced like you and I are about how we need to treat this.

You also have to make sure that vulnerable populations have access to all the treatments. That’s legislation that needs to happen, but that’s the only unmet gap because we now have treatments for patients who are pregnant, those who have hard-to-treat areas, and those who have other comorbidities. We’ve come a long way in being able to offer our patients customized care for their disease. Mel, thank you so much for moderating this and having me.

 Absolutely. Thank you for doing this, Lakshi. I hope you have a great day. Thank you for watching this 

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Optimal Management of Plaque Psoriasis: Expert Nurse Practitioner Perspectives