4 Tips and Considerations for Selecting a Systemic Treatment for Your Patients With Psoriasis

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At the 2023 Society of Dermatology Physician Assistants (SDPA) Annual Fall Dermatology Conference in Nashville, TN, Douglas DiRuggiero, DMSc, PA-C, presented a session titled, “Psoriasis: How to Choose the Best Systemic Treatment for your Patient,”¹ where he discussed considerations and best practices for determining an appropriate systemic treatment for patients with psoriatic disease.

“Make sure you know what you're diagnosing because you’ll never have the right treatment if you've got the wrong diagnosis,” DiRuggiero said. “Always put the patient first, because while we have 12 biologics—creams, 2 orals, multiple topicals, and a lot of other treatments: The best treatment for your patient is the thing that fits their needs best.”

There are several factors involved in determining an appropriate treatment path for a patient with psoriasis. DiRuggiero notes that these include severity of disease, body surface area, involvement in sensitive areas, pre-existing or comorbid conditions, patient quality of life, and most importantly, patient choice.

Psoriasis is a Black Box Warning in and of Itself

“Psoriasis by itself is its own black box warning,” DiRuggiero said.

DiRuggiero went on to note that for patients with psoriasis, the risk of developing conditions such as fatty liver disease, metabolic syndrome, and cardiac disease, for example, are greater than in patients without psoriasis or psoriatic disease.

Psoriasis is a part of an umbrella known as the psoriasis-associated autoimmunity spectrum. DiRuggiero said that because of this, there is a considerable amount of overlap between cutaneous psoriasis and numerous other autoimmune conditions. For example, approximately 2% to 6% of patients with psoriasis, DiRuggiero noted, will develop irritable bowel disease (IBD). Patients may even have IDB at the time of their diagnosis with psoriasis and not even know it. This background is important to consider when deciding how to best manage or treat a patient’s psoriasis.

Always Develop a Differential Diagnosis—and Note That Presentation is Not Equal in All Patients

Psoriasis does not present equally in all patients, particularly in patients with skin of color and more darkly-pigmented skin types.

DiRuggiero said that it is important for health care providers to develop differential diagnoses for their patients and to consider that while something may appear to be psoriasis, it does not always make it psoriasis.

“Never assume it’s a slam dunk case,” he said.

Shared Decision Making is a Difficult Venture

“Shared decision making is a little bit of a difficult venture,” DiRuggiero said. “I call it controlled decision making.”

When a patient comes into a practice with potential drug names in mind that they may have heard of or previously researched, it is important to acknowledge that while the particular treatment may be effective and a great choice for another patient, not every patient is created equally.

“I don’t think PASI is the thing to drive all decisions,” DiRuggiero said.

Instead, he suggests guiding patients through acknowledgment of their input while also ensuring they are aware that a full examination of their medical history may mean their preferred treatment option is not the best fit for them.

Remind Patients That There is Hope in Treatment

“[Patients] need to hear that there's hope, that there's positivity to a disease. The fact is that if someone develops liver dysfunction, or liver failure, or develops macular degeneration and becomes blind, to the public, that brings a sense of sympathy and empathy,” DiRuggiero said. “But when someone develops a disease of the largest organ in the body and it’s invisible, it doesn’t earn sympathy. It brings repulsion.”

He went on to describe the present treatment landscape and era for psoriasis as a great time to be living with the condition, simply due to the wide variety of treatment options available for patients and their respective, individualized needs.

“I'd never dreamed I have 20 new approved products for psoriasis in my prescribing career,” DiRuggiero said. “Don't lose the fact that we are prescribing hope, and we have a chance to put on a cape every day and become someone's hero."

Reference

1. DiRuggiero D.Psoriasis: How to Choose the Best Systemic Treatment for your Patient. Presented at: 2023 SDPA Annual Fall Dermatology Conference: October 26-29, 2023; Nashville, TN.

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