Available Psoriasis, Patient Involvement, and Holistic Treatment

"We used to beg, borrow, and steal from other specialties,” said Alexa Hetzel, MS, PA-C, a physician assistant at Schweiger Dermatology Group in East Windsor, New Jersey. “Now we have so many options.” Hetzel led a panel of her colleagues in conversation for a Dermatology Times Clinical Case Collective custom video series on the treatment landscape for the management of plaque psoriasis.

Hetzel was joined by colleagues Andrew Mastro, MS, PA-C, a physician assistant at Illinois Dermatology Institute in Chicago; TJ Chao, MPAS, PA-C, a physician assistant at Atlanta North Dermatology in Georgia; and Terry Faleye, MPAS, PA-C, a physician assistant at DermSurgery Associates in Houston, Texas.

Psychosocial Impact

Hetzel began the conversation by reflecting on her previous experience treating psoriasis, stating that, despite familiarity, it is still essential to revisit fundamental aspects. She noted the significance of emphasizing to patients that this is not a skin condition but a chronic condition, bringing along with it comorbidities and a large psychosocial impact.

Hetzel goes on to recount a specific conversation she had with a patient, where he shook off his plaques and scales jokingly. She said she laughed alongside him at first but quickly realized the patient was using humor to deflect his feelings about his condition. “He wanted to make the joke before somebody else could,” Hetzel said. “That is just years of how he learned to deal with his psoriasis because we didn’t have great options for him.”

Mastro stated this interaction brings up an important topic, which is getting patients to move past their defenses to understand how they are truly feeling about their diagnosis. He suggested asking direct, pointed questions about how the patient is doing. “Those same patients [who] are very robust with their jokes will [often] take a step back and let you in a little bit,” Mastro said.

Treatment Options

This gives patients and clinicians 17 options to choose from, not including topical therapy. Hetzel said this is a benefit for patients who did not respond to previous therapies, but it can make for a difficult decision for new or complex patients.

Case Study 1

The first case study brought to the panel was that of a 42-year-old man with extensive erythematous, scaly plaques and significant itching and discomfort. Hetzel shared that his body surface area (BSA) is at 30%, his Psoriasis Area and Severity Index (PASI) score is 18.5, and he reported a significant psychosocial impact with a Dermatology Life Quality Index (DLQI) score of 18. The patient has a medical history of asthma and recurrent sinusitis.

Right away, Chao recognized that this patient has multiple options and suggested talking to him about his specific needs and desires. Chao stated that when a patient has a say in their treatment, he feels that they are more likely to stick to their treatment plan. With the patient’s medical history, Chao noted that there may be a concern about affecting the immune system, which may drive some of the decision-making.

Mastro highlighted the patient’s high DLQI score, stating that continuous ruminating can begin to affect the patient’s view of themselves and their relationships. Faleye agreed, emphasizing the importance of recognizing just how long the patient has been challenged by their diagnosis and, more than likely, trying creams and lotions in an attempt to alleviate symptoms.

Hetzel gives a bit more patient history, stating that he was diagnosed at 25 years old after previous evaluations ruled out alternative conditions. He has also tried topical corticosteroids and vitamin D analogues, which provided only temporary relief for brief intervals. The patient has no history of joint involvement or psoriatic arthritis.

Chao says the patient has a lot of options to keep in mind and once again stated the importance of involving the patients in the creation of their treatment plan. Mastro noted that he sees patients like this in his clinic regularly and that many of them also have psychosocial difficulties. “They’re here wanting that next option that’s going to be their last option,” Mastro said.

When asked which therapy he would choose for this patient, Mastro said considering the high BSA, DLQI, and involvement areas, he would first suggest a biologic. “I would probably go with the IL-23 class just in terms of speed,” Mastro said, noting that without any joint involvement, the main concerns to focus on are the skin and psychosocial impact.

Faleye and Chao shared Mastro’s opinion on suggesting an IL-23 but were also open to using an IL-17 on hand to clear the patient quickly. Chao noted that if the patient was not keen on injection therapies, there are many other options, including oral therapy. In the end, the dermatologist treating this patient went with adalimumab, which provided positive results for 9 months, but a gradual loss of response was observed over time. The patient was then switched to deucravacitinib 6 mg daily, which the panel found to be sufficient.

Evaluating Treatment Plans

Faleye stated that comorbidities and lifestyle factors are major players in treating patients, affecting the dose or drug choice itself. She said that although these factors do play major roles, the main effect they have on her treatment of the patient is the educational factor.

Hetzel said she often finds that dermatology clinicians end up treating patients as a whole rather than focusing only on 1 condition. She also mentioned monitoring labs and making sure the patient is not at risk for stroke or heart attack, as “making sure they’re healthy overall is huge.” The panel agreed that, overall, the most important factor when creating a personalized treatment plan is including the patient in the discussion and educating them on their options.

Case Study 2

For the panel’s second case study, they discussed a 38-year-old woman with plaques on her scalp, elbows, and calves, who was diagnosed with psoriasis at 22 years old. She had a BSA of 35 and a PASI score of 22.5, with her symptoms continuing to worsen over the past year. She reported considerable discomfort and social embarrassment. Hetzel stated that the patient has tried various topical agents, phototherapy, and methotrexate, and she had an inadequate response to all. The patient presented with multiple comorbidities, including obesity (body mass index of 34), well-controlled hypertension and hyperlipidemia, and a family history of coronary artery disease.

Faleye noticed right away how young the patient was at diagnosis and the significance of her disease for this extended period of her lifetime. She also noted that there are several options available, with Hetzel adding that a topical isn’t quite what she would pre- scribe to someone with a BSA of 35. Chao brought up that this patient, unlike the previous, has more comorbidities at play to keep in mind when prescribing treatment options. Chao said he would also consider a biologic for this patient, considering the heart disease, stating that he does not yet have that confidence in oral options. Specifically, Chao suggested an IL-17 due to its quick response. “I’m just wondering how bad [it could] can be. Is it where she’s reclusive? Is she missing out on life?” Chao said.

Mastro agreed with Chao, recalling Hetzel’s earlier point of a dermatology visit that then becomes a primary care visit. “You now feel responsible for all these factors, even though we’re treating the skin and the joints,” Mastro said. “I would like her to get better quickly, considering everything going on.”

The dermatologist treating the patient prescribed a complex combination treatment: topical corticosteroid ointment, vitamin D analogues, and apremilast
30 mg twice daily. A lack of adequate response was noted with extremely limited improvement, leading her provider to transition her to deucravacitinib 6 mg daily. The panel thought this was a good idea considering the long-term data, noting the importance of talking through potential adverse effects of each therapy option with the patient.

Recent Successes and Treatment Guidelines

Each panel member noted seeing success with deucravacitinib since it received FDA approval in September 2022. Faleye specifically mentioned the dosing of the drug working well, finding that with twice-daily medications, patients often take dose concerns into their own hands. Mastro agreed with Faleye, mention- ing the importance of explaining the medication and its time line to the patient to set realistic expectations. “Once I did that and the patient was prepared, I had a much better outcome,” he said.

Overall, he found that his anecdotal numbers were very close to the study data. “I’ve been so appreciative of having this medication in my [toolbox],” he said. “It’s definitely made its way to be a first-line treatment for me.”

Chao was in complete agreement with the rest of the panel, stating that it will take more time to pay off because it is an oral medication, but it will be a steady response when it does. “I get patients coming back very happy on the treatment,” he said. Hetzel said the same, stating that she has patients who have had life- changing experiences with deucravacitinib.

With more therapy options becoming quickly available, there has been some concern about psoriasis treatment guidelines keeping pace. Chao noted the National Psoriasis Foundation has put out statements that encourage keeping patient outcomes in mind, but he believes more needs to be done. Hetzel agreed, saying that there is plenty of time during trial periods to work ahead on guidelines before approval.

Conclusion

Throughout the discussion, the most important factor for every panelist was keeping the patient’s needs and desires front of mind. Faleye and Chao emphasized the importance of educating your patients on what a drug is really doing for their disease.

“If I know you have cardiovascular issues at play, as well as other comorbidities, then I have to believe this biologic agent is, at the same time, controlling that as well,” Faleye said.

Hetzel spoke on not only treating the patient’s dermatological challenges but also monitoring their overall health, especially when newer drugs are involved. Finally, Mastro brought up the factor of time in several cases, noting that it is important to recognize just how long patients can suffer and how much it takes for some to seek help.