Anthony M. Turkiewicz, MD:Steve, can you share treatment options with nonbiologics and DMARDs [disease-modifying antirheumatic drugs] that are used in psoriasis and in psoriatic arthritis.
Talk to me specifically about DMARDs such as methotrexate, apremilast, hydroxychloroquine. In the dermatology community, can you tell me examples when these DMARDs are used? What is your experience overall with them?
Steven R. Feldman, MD, PhD: Most patients with psoriasis have very mild disease. If you’re taking care of psoriatic arthritis and have a few little spots, I don’t know if we think of them as DMARDs, but topical therapy would be the way to start. We typically start with a very high-potency topical steroid, like a clobetasol or a betamethasone dipropionate, in an appropriate vehicle. Maybe an ointment if they’re willing to use it on elbows and knees. Solutions for the scalp. They work great if you put them on, which is huge. Compliance and getting people to take their pills is hard enough. Getting them to rub slop paste in their hair and onto their scalp is like the mother of all compliance problems. Compliance is ridiculously poor to topical therapy. But if you get people to do it, it does work well.
The next whole class we shouldn’t forget is that phototherapy I mentioned earlier. Dermatologists would be happy if you sent patients for ultraviolet light treatment. If you felt like the patient had psoriatic arthritis without joint destruction and you were thinking, “I can give them a nonsteroidal anti-inflammatory, but they have skin disease,” you might want to refer them to the dermatologist who might use topicals or phototherapy to manage the skin disease. They might not need a biologic.
If they do need systemic therapy, what do we have? In the old days we had methotrexate and cyclosporine, and they seemed reasonably effective. Cyclosporine, if you gave enough of it, would clear patients up. But psoriasis is a chronic disease, and cyclosporine is not something that dermatologists want to give [these] people.
For us dermatologists, our idea of adverse events that we are concerned about is when an acne patient gets dryness from the topical therapy we prescribed. Cyclosporine is not what we want to be giving people, even methotrexate. You all probably think methotrexate is like water. But to us, it’s 1 of the most serious drugs we prescribed.
Steven R. Feldman, MD, PhD: We shouldn’t forget oral retinoid therapy, which is another 1 that you probably would never use for joints. But it might be an effective way of improving pustular disease of the palm and soles and making phototherapy and topicals more effective. Then we have apremilast, the phosphodiesterase-4 inhibitor. It’s not the most effective drug, and it’s not the most well-tolerated drug because 1 of 6 people get diarrhea or headaches. But from a serious adverse-event standpoint, it seems safe. Many people in dermatology think of it as the marijuana of systemic therapies for psoriasis. You know, it’s the gateway drug. Let’s start with this. We don’t have to do any lab tests, we don’t have to do monitoring. I don’t know that you have to use it that way. I feel comfortable going straight to more effective therapies that are even better tolerated.
John Tesser, MD: Steve, can I ask you about light therapy? Do you and your colleagues have concerns about long-term effects of malignancy issues due to phototherapy?
Steven R. Feldman, MD, PhD: Gosh, yes. Studies done at the Mayo Clinic with office-based UV-B phototherapy were with and without tar, which is another carcinogen. With 30-year follow-up, there is no detectable increased risk of skin cancer with UV-B phototherapy. With UV-B phototherapy, I’m sure there must be some increased risk, but it’s small. PUVA, psoralen plus UV-A light, is more carcinogenic, and we hardly use that anymore now that we have many good systemic therapies for the disease.
Dermatologists feel pretty comfortable telling patients with psoriasis to go out in the sun. We use home phototherapy. Dermatologists think I’m crazy when I recommend tanning beds because they think about, well, what do we see with tanning beds? We see skin cancers. But the vast majority don’t get skin cancer. The UV-A light and the UV-B in most tanning beds are perfectly adequate for treating psoriasis in many patients. In fact, it’s probably the most common form of phototherapy that patients use.
Transcript Edited for Clarity