Helping Patients Navigate the Plaque Psoriasis Treatment Landscape


Douglas DiRuggiero, DMSc, PA-C, shares his approach to building trust in the patient-provider relationship when counseling patients about treatment of plaque psoriasis.

Alexa Hetzel, MS, PA-C: So, Douglas, let’s talk about the role of APPs [advanced practice providers] in helping patients understand all the available treatment options. What are some key points that help you not only counsel your patients and educate them about plaque psoriasis, but also help build a trusting patient-provider relationship?

Douglas DiRuggiero, DMSc, PA-C: To manage patients that have psoriasis and to do it in a way that’s empathetic and that is complete, you have to pause and ask questions. I like to tell patients when they come in and I see that they have severe psoriasis, I just ask them one question. “If I could offer you a medication that is safe and has the potential to clear most of the psoriasis, would you be interested in it?” And it’s rare that they don’t say, “Yeah, I want to hear about it.” Then I say, “Before I can tell you about all the different ones—there are 11, 12, or 13 of these things available now—I need to ask some questions to find out which class or which type of medication is going to be best. And it’s based on their prior failures, their prior tries, the presentation, the severity of their disease, and their comorbidities and past medical history.

So how do I try to counsel the patients? For female patients, you’ve got to ask: Are you trying to have a family now? What’s your family planning? Age also plays a part. Some medications are indicated in pediatrics; some are indicated in adolescents; some are indicated for patients 18 and older. There is a learning curve, as we have 11 biologic medications, 2 oral medications, and maybe a 12th biologic that’s on the way next year. You've got to be able to sit down [to talk]. It’s nice to have something printed on a piece of paper; I use that to sit down with patients and say these are called TNFs [tumor necrosis factor inhibitors]. We have 4 of these to choose from. We have an IL [interleukin]-12/IL-23, we’ve got 3 [drugs that are] IL-17s, and we’ve got 3 drugs that are IL-23s. So you’ve got to ask these questions because if a patient has a history of CHF [congestive heart failure] or a history of MS [multiple sclerosis] or a history of ulcerative colitis, all of those questions and the responses to those questions are basically, in your mind, either opening or closing doors regarding treatment.

It’s shared decision-making, but it’s directed, shared decision-making. If somebody comes in and says, “I saw a commercial for this medicine. It’s called an IL-17, and I really want to be on it.” Then with the shared decision-making process I’ll say, “Let me ask you a few questions.” Or if they come in and say that they have really poorly controlled ulcerative colitis, then I would say to them that this is not the best class of medicines to be on. So, it is merging and marrying together the review of systems, the past medical history, the comorbidities, and the desires of the patient with all of these things that we have in our armamentarium. What a nice problem to have—there are so many choices—but it does put the burden on the prescribers, on us as NPs [nurse practitioners] and PAs [physician assistants], to take the little bit of time that it takes to understand these products and take the little bit of time that it takes to go through just a series of 4 or 5 questions. It doesn’t lengthen your visit by 20 minutes, it lengthens your visit by 120 seconds, to ask the right questions, to get people into the right category. Do they have joint pain? Do they not? All these different things will help them understand. And those questions are educating them. Why do you ask about joint pain? Well, because this disease can cause it.

So, even the questions you ask are a way to educate at the same time. I use questions to try to point people in a certain direction because this disease has certain problems associated with it that we know of, and I want to know if they already have some of these problems. It’s a dynamic exchange that ultimately leads to a happy patient because we see them. We get to be the heroes, to put people on these medications and have them come back and hug us and tell us that they’ve never seen themselves as clear as they are now. It’s really exciting.

Alexa Hetzel, MS, PA-C: Just playing off that, I think less so now because people realize they can just come to the dermatologist, but before, I used to get patients that were so frustrated and showed up with bags of creams that they had tried, and they just wanted somebody to listen to them. When you’re listening to them, I think they appreciate that, and they buy in a little bit more. Do you guys have that same experience?

Douglas DiRuggiero, DMSc, PA-C: Yes, I certainly do. And I didn’t mention this, but we get the psychosocial issue with plaque psoriasis. The prevalence of depression and suicidal ideations is twice in the psoriatic population than it is in the general population. This has a heavy impact on people’s quality of life and on their mental status, and so you’ve got to address that too. And so it’s got a big impact, at least as I see it in my area of the country and in my practice. I’d like to hear about what the others have to say.

Jayme M. Heim, MSN, FNP-BC: Another part of it is that not all dermatology practices are the same. Many of us specialize in patients who have psoriasis. It really saddens me, it deeply saddens me, when people come to me and say, “I have been to 3 or 4 dermatology practices before I came to you.” I’ve literally walked into a room and had somebody look at me and say, “If you can’t take care of this, I’m going to end my life.” That is very impactful. It’s very difficult. To be able to say, “I’ve got you,” and talk to them about their disease process, and talk to them about care—all of a sudden you see the relief that they feel that, finally, there’s somebody that can help them; it’s just amazing.

Transcript edited for clarity

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Mona SHahriari, MD | Credit: Central Connecticut Dermatology
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