Mastering Game Changers in Psoriasis

In this exclusive interview with Dermatology Times®, Jerry Bagel, MD, MS, director of the Psoriasis Treatment Center of New Jersey & Eczema Treatment Center of New Jersey in East Windsor, and a member of the National Psoriasis Foundation (NPF) board of directors, takes a deep dive into the advances driving change in psoriasis treatment and offers practical tips for customizing the growing list of possible solutions to each patient’s needs.

Q: What are the hot topics in psoriasis treatment?

Jerry Bagel, MD, MS: Metabolic syndrome is one. We’ve known for a long time that psoriasis is more than skin deep. In 2006, Dr Joel Gelfand [vice chair of clinical research and medical director of the Dermatology Clinical Studies Unit, and director of the Psoriasis and Phototherapy Treatment Center, University of Pennsylvania] conducted a population-based cohort study of UK patients with psoriasis aged 20 to 90 and found that people with severe psoriasis have a 5-fold increase in the frequency of heart attacks and strokes compared to the general population.¹ There truly is a heartbreak to psoriasis to the point where there’s heart disease. Psoriasis increases inflammation of the skin, but not only of the skin. The inflammation molecules also can attack the blood vessels, resulting in thrombosis.

Metabolic syndrome expands on that. It is a group of factors that can increase a person’s risk of heart disease, obesity, diabetes, high triglycerides, high cholesterol, high blood pressure, and other health problems. This constellation of factors results in increasing mortality in people with psoriasis to the point that the average male patient with psoriasis lives 3.5 years less and the average female patient lives 4.4 years less than a person without psoriasis.² Roughly 50% of the people with psoriasis that dermatologists see in their practice are going to be obese, diabetic, have high triglycerides, smoke, and/or drink alcohol. So they have a litany of factors to contend with.

Patients with psoriasis come to my practice because they want me to take care of their skin. But they need to understand that medication is just one aspect of achieving clear skin in the long term. In 2021, we have some great, really safe medicines that can make people clear. I tell patients, “I’m going to get you clear. But once you get clear, I’m passing the baton to you, and you’re going to have to lose weight. You’re going to have to exercise, …stop smoking, and…decrease your alcohol intake.”

Q: How much have clear rates improved?

Bagel: If an 18-year-old came into my office in May with 20% body surface area [BSA] involved, I can pretty much guarantee that kid would matriculate at college in 3 or 3½ months and have clear skin. The data from research published over recent years indicate there’s about a 60% chance that I could clear a patient within 12 weeks right now. There is an 85% chance that I can get that patient 90% better, and there’s a 95% chance I can make the patient 75% better, but 75% isn’t good enough anymore. I was involved with the NPF’s medical advisory board and we concluded that treating to target 1% or less BSA is what is acceptable right now.

Q: Did COVID-19 stall progress toward that goal?

Bagel: We were still coming out of a period in the pandemic when many people and, in fact, many physicians were concerned about the utilization of biologic agents when people were exposed to coronavirus. I really wasn’t, and I think I was right. Biologic agents decreased the chances of people having the cytokine storm of COVID-19 more than they would have had they not been on a biologic agent. I think the biologic agents suppressed the COVID-19 response. I had fewer people who have been on biologic agents during COVID-19 who died or suffered adverse events than those who were not on biologic agents. I had 1 patient who had problems, but that was an aberration. Four weeks later, he was 50% improved. But he wasn’t happy. And I said, “I told you, it’s going to take about 12 to 16 weeks to see the total benefit of this medication.”

Q: Are biologics the first-line, first-choice treatment?

Bagel: I’m not going to say everybody who takes them will be 100% better. It’s not that biologics don’t work, they do. It’s just that in about 20% of the people, they work for a while and then they peter out. The dermatologist then has to switch the patient to something else. There are also high responders that do well and they just continue to do well forever. Then there are other people that don’t; they just do okay. And then, too, biologics tend to lose their efficacy and the dermatologist must switch them around. 

Q: Did the pandemic sideline research?

Bagel: COVID-19 decreased research. 2019 was a banner year for us. Clinical trials make up about 25% of what we do. With the pandemic, we had to shut down for about a month. On the practice side, we launched a telemedicine program. Starting in about July 2020, we were starting to see about 50% of our normal volume. But the clinical trial department suffered the most because it was supported by the pharmaceutical companies. They shut down because they would have faced so much bureaucracy they weren’t familiar with; that was a real loss but we started ramping it up with that in July of last year as well. We’re pretty close to where we were.

Q: What does the future look like regarding psoriasis treatment? Will it be about oral medications or injectables?

Bagel: There’s a new pill being studied that looks efficacious and pretty safe. So then the question is do you want to take a pill every day or do you want a shot every 12 weeks. It’ll be interesting to see what people choose. If it was 10 years ago, I think all patients would take the pill. Now I think they’ll take the shot once every 12 weeks. But it’s nice to have options. There’s still some research in psoriasis but not as much as before because the medicines we have now are really good.

Q: What’s new on the horizon?

Bagel: I’m involved with the NPF. We fund more than $4.5 million dollars a year in research, and a lot of the research is going into psoriatic arthritis, specifically to determine how we predict who’s going to get psoriatic arthritis so we can prevent it before it happens.

Q: What other big changes do you see in patient care?

Bagel: We need to address the psychological effects of psoriasis, especially those related to self-esteem. Think of a 17-year-old girl walking to the swimming pool on a hot summer day. She’s going to matriculate at college in about 6 to 8 weeks. She’s ready for a beautiful day. The attendant looks at her hands and arms and legs and sees a rash. Because the attendant does not know that psoriasis is not contagious, the girl can’t get into the pool. How did that affect her? Well, it put a cramp in her day. But how about the psychology in her self-esteem? Forty percent of people with psoriasis think they’re ugly. Twenty-five percent don’t want to have children.³ So there’s a major impact in self-esteem, in what [you] want to do with your life, because of the way you perceive other people looking at you. 

Fortunately, in the last 4 or 5 years, there have been a few biologic agents that have been FDA [Food and Drug Administration] approved down to the age of 4. Some of them are just 1 shot every 12 weeks. I’ve seen kids turn around completely from being nonsocial and embarrassed to becoming social butterflies, doing well at school, and experiencing much better self-esteem after being treated. That’s a direction we’ll continue to explore.

Disclosure:

Bagel is a speaker for AbbVie, Janssen Pharmaceuticals, Leo Pharma, and Novartis; a consultant for AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen Pharmaceuticals, Leo Pharma, Novartis, and Pfizer; and an investigator for AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen Pharmaceuticals, Leo Pharma, and Novartis.

References:

1. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735-1741. doi:10.1001/jama.296.14.1735

2. Gelfand JM, Troxel AB, Lewis JD, et al. The risk of mortality in patients with psoriasis: results from a population-based study. Arch Dermatol. 2007;143(12):1493-1499. doi:10.1001/archderm.143.12.1493

3. Wan MT, Pearl RL, Fuxench ZCC, Takeshita J, Gelfand JM. Anticipated and perceived stigma among patients with psoriasis. J Psoriasis Psoriatic Arthritis. 2020;5(3):93-99. doi:10.1177/2475530320924009