Expert Perspectives on the Management of Plaque Psoriasis - Episode 14
Jerry Bagel, MD, MS, and Alexa Hetzel, MS, PA-C, discuss how clinical trials play an important role in the management of plaque psoriasis.
Alexa Hetzel, MS, PA-C: In terms of clinical trials, our office is unique. What was your thought process behind wanting to do research with psoriasis?
Jerry Bagel, MD, MS: We were taking care of a lot of patients in the late 1980s and very early ’90s and doing a lot of PUVA [psoralen-UVA] and UVB. Isotretinoin, methotrexate, and cyclosporine was just coming out. Then somebody was like, “There must be a better way.” I went to the chairman of the department at Rutgers University and told them what I was doing. He got in touch with somebody at Merck, and we started doing studies on people with cyclosporine and calcineurin phosphatase inhibition, which was the precursor for Protopic and Elidel. We started doing that, and then we worked with a medication that worked. It was the first medication: Diphtheria toxin with IL-2. The diphtheria toxin would get into the cell and kill the respiration of the cell. The cell would die, but the IL-2 was only hidden T-helper cells. That was the first study that showed that it was an immunologic disease. Then we were off to the races. People knew we were just starting to do studies. In the beginning, I opened it up in conjunction with a laboratory in Lawrenceville, Georgia, with a person who did a lot of the billing and analysis. I just had to recruit patients But after awhile, we started it on our own.
Alexa Hetzel, MS, PA-C: I love that we get to be first line. We know what’s coming.
Jerry Bagel, MD, MS: What’s the future? We’re pretty good right now. We’re dealing with some new oral medications, besides deucravacitinib from Janssen, that seem to be effective. That seems to be the way we’re going. I don’t see a drug that’s going to cure anything. The market is crowded from the fact that there are 12 different biologics, another pill, and maybe another shot. It’s hard to divvy it up that much. Until there’s a real breakthrough, I don’t think there’s going to be a big change. But if more people knew about the treatments available that are relatively safe—the problem is that between the end-of-the-world news and Jeopardy over the past 10 years, they still have psoriasis. They think, “My life is terrible. I went on this medication. I feel great, but I’m going to get cancer.” They’d be scared out of their mind, so they wouldn’t come in. The biologics commercials don’t have any of that. They basically say, “I have psoriasis. I went on this drug, and now I feel great.” I’m not getting cancer, but for a lot of people, in the back of their minds, they still have this fear. Education is what’s most important, within not just the patient population but also the medical community.
Alexa Hetzel, MS, PA-C: It’s important with our primary care and our cardiologists.
Jerry Bagel, MD, MS: It’s important with our pediatricians. I’ve seen people get divorced over their kids having psoriasis—3-year-old kids that we’d held in a light box was too much pressure for their relationship. Also, I’ve seen the benefit for some people who only wanted to be able to bowl again, but they have psoriatic arthritis [PsA]. When you put them on anti-PsA medication and they can bowl, they’re happy. Education would be the best.
Alexa Hetzel, MS, PA-C: What I love so much about psoriasis is having that moment when they come in and they can do what they want to do, or their kid will hug them again because they didn’t have scales that were falling off. With 1 patient, I went in to evaluate him and he was rubbing his skin. He’s like, “Look, I’m a snow globe.” That’s total deflection. It was funny, but it was total deflection. People start to look you in the eye again. They gain their confidence back. That ties back into that depression and their anxiety, so it’s a good moment for both of us.
Jerry Bagel, MD, MS: The other thing is that it used to be the whole office visit with psoriasis had to do with the treatment options that are available and trying to get them better. It was a hard slide. Now I can talk about the kids going to college and where they’re going on vacation, and you can be a person with them because you don’t have to deal as much with the medical problems. One of the things is that you get that person who’s a really bad psoriatic and 35 years old. The risk of them not going on a biologic is worse than if they don’t because of all the inflammation that they’ll get rid of.
Transcript Edited for Clarity