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Strategizing Psoriasis Treatment

Currently, there are 11 FDA-approved biologics for psoriasis. At the 2019 Fall Clinical Dermatology Conference, Boni E. Elewski, MD, and David M. Pariser, MD, presented on strategies for treating patients with psoriasis. Dr Elewski is the James E. Elder, MD, Endowed Professor for Graduate Education and chair and residency program director in the department of dermatology at the University of Alabama School of Medicine in Birmingham, AL. Dr Pariser is professor of dermatology at Eastern Virginia Medical School in Norfolk, VA.

“How do we begin?” Dr Elewski asked at the beginning of her presentation. “I like to look at the nails,” she stated. According to Dr Elewski, the nails can tell a provider a lot about the patient’s health and whether they have psoriatic arthritis (PsA). Dr Elewski recommended using tumor necrosis factor (TNF) inhibitors and IL-17 inhibitors for patients with nail disease.

Children with psoriasis can receive etanercept (Enbrel) and ustekinumab (Stelara), added Dr Elewski. Etanercept is approved for children aged 4 years and older, and ustekinumab is approved for children aged 12 years and older.

Dr Elewski also reviewed options for women who are considering having children or are pregnant. According to the American Academy of Dermatology and National Psoriasis Foundation guidelines, TNF inhibitors are considered safe, she said, but caution should be used for neonates and infants because suppression can last for up to 3 months. IL-17 inhibitors have not been found to cause harm in animal studies, while data on safety in pregnancy for IL-23 blockers is still limited. In addition, biologics have not been found to increase the risk of preterm birth or infection in the first year of an infant’s life, added Dr Elewski. Most biologics are category B, she said. She also stressed the importance of collaborating with the patient’s OBGYN.

Other considerations for selecting appropriate treatment that Dr Elewski reviewed included cancer history, comorbid inflammatory bowel disease, tuberculosis, and hepatitis B or hepatitis C infections.

Dr Pariser discussed the important of including patients in the decision-making process. “We don’t have the time to adequately work up new patients with psoriasis,” he said, adding “patients think the psoriasis speaks for itself and if they show it to me, I should know but I don’t.” Dr Pariser emphasized the importance of asking patient what really bothers them about their psoriasis during office visits and how it impacts their quality of life. He also suggested asking, “what would your life be like today if you didn’t have psoriasis?”

There is discordance between patient and provider expectations, added Dr Pariser. Physicians use objective measures to assess psoriasis severity and determine the efficacy of treatment. In the US, the National Psoriasis Foundation considers 1% or less body surface area affected by psoriasis as treatment success. However, patients usually have completely different expectations and views of their disease. Patients own targets, he said, include being able to wear short sleeves, go to the beach, play sports, go to a beauty salon, among other types of activities that can be limited by their skin disease.

“Patients need to be a part of the selection process,” he concluded. He recommended setting realistic expectations, give treatments a chance to work, and have mid-level providers perform follow-up appointments, as well as see patients when their psoriasis is well-controlled.

Reference

Elewski BE, Pariser DM. Strategies in patient selection for psoriasis therapies. Presented at: 2019 Fall Clinical Dermatology Conference; Oct 18, 2019; Las Vegas.

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