Linda F Stein Gold, MD: In this section, let’s discuss the goals of treatment and our therapeutic approach. We will explore individual treatment approaches for the patient with psoriasis and discuss treatment goals. FNP [National Psoriasis Foundation] defined a clear set of treatment goals that were published in November 2016 in the Journal of the American Academy of Dermatology. The idea behind these treatment goals was to ensure that psoriasis only affects 1% of body surface area after 3 months or less. There were a few extra goals because it’s a very high goal, and these recommendations provide an acceptable response after 3 months, which would be maybe just 3% of body surface area or less or achieve a PASI 75 [75% reduction in the Psoriasis Area and Severity Index] improvement. Mark, I’ll start with you. I know our goal is obviously to make our patients completely clear, but when a patient walks into your office, can you explain to me your thinking process as they stand in front of you? What factors influence the drugs you will choose? We have so many.
Mark Lebwohl, MD: Yes, looking at the patient, I judge right away, are they big or small? Are they obese or of normal weight? Because it will have a profound impact on the choice of my therapies. One of the first questions I will ask them is, “Do you have joint pain? Then I will examine their joints. If they say they don’t have joint pain, I won’t. I look at their systems review. Do they have cardiovascular risk factors that will affect the drug I choose? Do they have a history of malignancy, which affects the drug I choose? Do they have a history of inflammatory bowel disease, multiple sclerosis, hepatitis, HIV, etc. ? There are a lot of other factors that we are looking at. Sometimes I’ll ask them, “Do you need to be cleared quickly for a major event?” This has a big impact on the choice of therapy. Is this someone who won’t like to get regular injections? I could think of using an IL-23 [interleukin-23] blocker, which has infrequent injections. Many factors that we consider you get from the history and the physical.
Linda F Stein Gold, MD: That’s great Mark, and I know you wrote an article that helped us explain everything, and the co-morbidities you mentioned are key to getting an overview of who this patient is and where do we want to go with them . You mentioned the fact that you were asking questions about joint disease. But have you ever had that moment when someone says, “No, no, no. I don’t have joint disease ”and then you put them under a good biologic that affects psoriatic arthritis. Then they come in and say, “I feel better than ever. They didn’t realize that low back pain was something.
Mark Lebwohl, MD: There is no question. Not only that, and it happened when ustekinumab came out. TNF [tumor necrosis factor] blockers were great for arthritis. And the patients who never said they had joint pain, we never diagnosed psoriatic arthritis, they weren’t doing very well with their skin, so we passed them over to it. ‘ustekinumab. And their skin was clearing up, but all of a sudden their joints started to ache, and they realized that from the start we were removing it with the TNF blocker.
Linda F Stein Gold, MD: Yes, interesting. Let’s start with the basics. Leon, I’m going to ask you to explain to us what about topical therapy? And we know that many of our patients have localized disease. Can you tell me about your thought process when choosing a topic, are we appropriate for using them? Are we abusing them? Where do you start? Explain that to us.
Léon H. Kircik, MD: We are dermatologists; the way i think about it is that we’re in the business of topical treatment, aren’t we? We love the topical treatment, and there may not be over-dependence, but there is favoritism for the topical treatment. In my office, anyone who presents will receive topical treatment first until I complete the paperwork for systemic treatment. As Mark mentioned, no matter how much biologic I use, I use concomitant topical treatment. You cannot give the biologic and let the patient go home. They want something. I always give a topical prescription no matter what, it definitely helps. And in the end, when they start biological treatment, most of them will still have 1 or 2 patches. I prefer to give them topical treatment. They can take care of it because I don’t like to switch people from one biologic to another every 6 months. Then if that doesn’t work, I go to Kenalog intralesional. But the bottom line is that topical treatment is traditional treatment for us, and it will remain so.
Linda F Stein Gold, MD: It’s an interesting point that you raise because sometimes our patients are not entirely clear about a systemic therapy. They have residual plaques. Jerry, I know you wrote an article about this on the use of potent topicals in these patients. What I found interesting in your article is that when someone has residual plaques you wonder if those super plaques just aren’t going to respond to anything and that’s why they just aren’t going to respond to anything. do not improve? But Jerry, you have found that topical therapy works quite well with systemics. Can you comment on this?
Jerry Bagel, MD, MS Yes, we did it in a few different groups with TNF and IL-17 inhibitors, for people who were only 5% or more body surface area after 12 weeks of treatment. We added a topical, whether it was betamethasone in addition to calcipotriene, or sometimes a … and we found that in about 4 weeks, about three-quarters of all people ended up feasting. And even after you stopped the drug for another 4 weeks, about 50% still had the treatment to target. There is certainly an advantage to be added. In dermatology, we use a lot of combination therapies, and topicals with systemic work, topicals with biological work. But on the other hand, some people don’t want to use a topical. Some people make up 2-3% of body surface area and say to themselves, “I’m fine. Hot topics for them are a bad dream, for some of them. They’ve had too much psoriasis, too many dermatologists have only tried topical steroids with them, and they haven’t improved. But if you get that selective person who knows they can get even better, then yeah, that’s used well and for sure.
Linda F Stein Gold, MD: Thank you, Mark, Jerry and Leon for this rich and informative discussion. Thanks for watching this HCPLive® peer exchange. If you enjoyed the content, please subscribe to our email newsletters to receive future updates. Peer-to-peer exchanges and other great content straight to your inbox.
This transcript has been edited for clarity.