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Changing Treatment Approaches in the Management of Plaque Psoriasis - Episode 4

Current Treatment Approaches for Plaque Psoriasis

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Key opinion leaders in the management of plaque psoriasis review factors to consider regarding quality of life when treating patients with topical agents, phototherapy, and biologics.

Brad Glick, DO, MPH: Neal, let me ask you, how is quality of life impacted in these patients with psoriatic disease?

Neal Bhatia, MD: Quality of life has become the buzzword, obviously, in clinical research as well as in how we are talking to patients about disease. I always go back to something I was taught ages ago about the 3 signs to look for when a quality-of-life issue is consuming a patient. That is when you walk in the door and the first thing you see is the patient looking down. The second thing is when you greet them, and their voice is not very strong. The third thing is when their handshake is very small. That is when you know that you are dealing with somebody who is not only consumed with their disease, but it took them enough energy to want to come in and see the doctor, to actually come and talk about it. Those are 3 little things to always watch for when assessing quality of life. We give patients a lot of surveys, both on atopic dermatitis and psoriasis nowadays, and when they are researching products.

I think the No. 1 thing that we must think about is what would you do if you were in their shoes? What would you do if your palms and soles were covered with dense psoriatic plaque, or your scalp was covered in scales and you are dealing with it constantly? We mentioned genitals before. What would that be like for you in terms of your quality of life, whether it be sex life or bowel and bladder habits? Any of the things that we talked about with joints are relevant. We may have to go back to workshops of empathy, if you will, in one respect. 

I think the other part of it is, again, we have gotten so accustomed to thinking about the mechanisms of the therapies that we want to use, which is great science, but part of that equation means thinking, again, where are you going to be in terms of applying these medicines to your scalp, your back, or your arms? Are you comfortable using these pills that you may not have thought were part of the equation for you? Are you comfortable giving your own shots, or letting us do them for you? 

A lot of different factors impact quality of life. I think, again, I go back to what I said before: we cannot just think about getting patients started; we have to think about where they are going to be in a month, in 6 months, or in a year. We have to translate that message to patients, so that they understand their quality of life outcomes and have faith in the process of what is coming. There are a lot of things to bang around with quality of life, but I think a lot of it starts with us putting ourselves in their shoes and trying to do what we can to try to solve the big picture, and do the best we can for making things easy.

Brad Glick, DO, MPH: So well said. Erin, do you have anything to add there?

Erin Boh, MD, PhD, FAAD: No, but I do like that notion about putting yourself in their shoes. What I teach my residents is to think of every patient as your mother. What are you going to do for your mother? You cannot realize how these people are suffering unless you can really go there. Sometimes you are busy and you do not think about it, so I think it is important to do that.

Brad Glick, DO, MPH: Erin, I am going to stay with you. I want to ask you to briefly review the standard of care for initial therapy for patients with psoriasis and what the role is of topical therapy and phototherapy, even in plaque psoriasis. Are we over-relying on topical therapy?

Erin Boh, MD, PhD, FAAD: Well, that is a bundle of questions. I think, briefly, that the standard of care for initial therapy really is dependent on the extent of the disease that you are going treat. But say you have a patient who comes in and they do have 3% or 4% body surface area coverage, not involving scalp, not involving genitals. In that case, I do think there is a very good role for topical steroids and topical steroid-sparing agents. I love to use steroids with retinoids or steroids, depending on the location. However, I think once you start getting past 2% or 3% body surface area, it becomes a burden and an expense to use topical therapy as your sole monotherapy. You are going to have to start getting into things like calcineurin inhibitors, calcipotriene-type vitamin D derivatives, and those are quite expensive. 

Looking at what you spend and the bang you get for your buck, you really ought to think about your topicals. Now, having said that, I do think that topicals are very useful adjuncts even in the treatment of patients with severe disease, so you are going to have systemic therapies. The role, I think, of phototherapy—I still use phototherapy—for older patients, it is a very useful tool because many of our biologics just are not covered if you are in the Medicare population. Phototherapy is a useful tool in some regards, and that will take you to the mild to moderate. The patients with 5% or 6%, maybe they are not keen on injectables, or they have just some other reasons for not going there. Maybe it is the expense; maybe they are scared. I think phototherapy can play a role. It is limited because not everybody has it.

I do think we need to think about each patient. When I am talking about this, yes, we have this whole armamentarium of drugs, but each patient is unique with their own set of baggage. Your standard of care has to fit with their baggage. For very mild psoriasis, topicals are the way to go. Topical steroid-sparing agents—add those in early, because you have the marathon as Neal keeps referring to it. This is not a sprint. You are going to have psoriasis for your life. To use topical steroids forever is not really practical.

We need, as physicians, to get away from just giving a topical and saying, “Come back in a year.” That is not going to work. I think our patients are not happy with that. If you want to keep your patients happy, keep thinking about things that make their life easier. I do think that adding systemic therapies early, when you start getting 5% to 6% of affected body surface area, that is a lot of inflammation. You want to curb systemic inflammation so that, hopefully, we do not escalate in terms of other comorbidities.

If we can keep down systemic inflammation, we may stave off some of the comorbidities that share these common inflammatory cytokines. When I start seeing patients with 5% or 6% body surface area, I am already thinking about systemic therapy or biologics. I ask the patient what they want to do. If they travel for business, they are on the road, they cannot carry buckets of ointments and creams for the daytime or the nighttime. It does not work, nor does phototherapy. They need the ease of a shot that is once every 3 months or something akin to that, and they are happy. I think, by doing that, we probably will impact comorbidities down the line. Use them, but do not abuse them—the steroids.

Brad Glick, DO, MPH: That is a great segue to discussing where we go next, when we are talking about traditional systemic therapies, we’ve maybe utilized them, and we want to move our patients onto biologic therapy.

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Transcript edited for clarity.