Navigating Psoriasis Treatment Across Patient Populations

During a Dermatology Times Case-Based Roundtable event, Michael Lewitt, MD, FAAD, led a collaborative conversation for clinicians to explore complex cases related to psoriasis management. Lewitt, a board-certified dermatologist at Rosalind Franklin Chicago Medical School in Chicago, Illinois, and a member of the National Psoriasis Foundation’s medical board, highlighted the importance of personalized care, the decision-making process in treatment, and the role of patient education.

Case 1: A 32-Year-Old Woman With a History of Psoriasis

The first case discussed was that of a 32-year-old woman with a 10-year history of plaque psoriasis. The patient had a history of hypertension and gestational diabetes, which she managed with lifestyle changes post pregnancy. Lewitt and the panelists underlined the need for a personalized approach, where practitioners assess both medical and lifestyle factors. As Lewitt noted, psoriasis severity may vary widely in patients’ eyes, regardless of clinical measures. Therefore, questions like “How is this condition impacting your life?” and “What are your goals for treatment?” are vital in aligning treatment plans with the patient’s expectations.

Regarding therapy options, discussions centered on balancing patient needs and treatment types. For instance, practitioners addressed the pros and cons of systemic vs topical treatments and when to escalate or de-escalate therapy based on patient-specific factors. This led to an exploration of biologics, especially considering this patient’s background of gestational diabetes and hypertension, where systemic management could potentially benefit both psoriasis and related comorbidities.

The conversation further delved into patient apprehensions regarding injections and frequent blood tests associated with some systemic treatments. Suggestions like using less frequent injection-based biologics, such as risankizumab (Skyrizi), were proposed for patients concerned with injection schedules and lifestyle compatibility, which the patient did see some success with but did not want to continue.

In the end, the patient was prescribed an IL-23 inhibitor, as she wanted to avoid injections and lab work as much as possible. With this therapy, the patient is receiving 1 injection every 3 months, which Lewitt said she has seen relief with so far.

Case 2: A 55-Year-Old Man With Psoriasis and Psoriatic Arthritis

The second case was that of a 55-year-old man with a 15-year history of plaque psoriasis presenting with thick, pruritic plaques on his palms and soles. The patient reported that this is accompanied by recent psoriatic arthritis symptoms in his fingers and Achilles tendon. Although he had previously resisted systemic treatments, he made an appointment to specifically address his worsening symptoms, which were now interfering with his daily activities. His psoriatic arthritis added to the challenges, making walking and other movements painful.

Given his preference for oral medications over injections, the discussion centered around apremilast (Otezla), a PDE4 inhibitor that does not require frequent lab work monitoring. The team considered the drug’s suitability, especially for his psoriatic arthritis and palmoplantar psoriasis, areas known to respond well to this treatment. However, the panel also cautioned him about possible gastrointestinal adverse events, particularly nausea and diarrhea, which are common in the early weeks of therapy. Suggestions to mitigate these effects included a slower, staggered dosing schedule and supplements like zinc to help reduce nausea. Despite these potential issues, Lewitt stated that the oral treatment was appealing to the patient, who could avoid needles and frequent lab work.

For additional support during flare-ups, the panel discussed the potential for combining apremilast with topical treatments. For example, topicals could target persistent lesions on his scalp without interrupting his primary oral therapy. This strategy would allow him to maintain consistent treatment for his systemic symptoms while managing local flare-ups as they occurred. Lewitt and the panel also considered the option of using nonsteroidal topicals like roflumilast cream (Zoryve) for his scalp psoriasis, which could reduce the risk of long-term steroid adverse effects.

Case 3: Holistic Treatment of a Pediatric Patient

The roundtable then shifted focus to pediatric psoriasis in a 7-year-old girl diagnosed 1 year prior. She presented with erythematous plaques on her face, elbows, and knees, affecting 3% to 5% of her body surface area. Her condition was beginning to impact her quality of life, with school peers commenting on her visible lesions, leading to distress and missed school days. As the primary caregivers, her parents expressed significant concern about both the physical and psychological effects of her condition, which required careful consideration during the dermatology consultation.

The conversation began with a conservative approach, suggesting topical corticosteroids and roflumilast cream, which is approved for use in children 6 years and older. Recognizing that many parents are wary of steroid overuse, the team also offered nonsteroidal options, taking into account the logistical challenges of regular application within the family’s daily routine.

After a few weeks of topical therapy, the patient returned with increased emotional distress related to her condition, prompting the team to explore systemic options, including the possibility of biologics. While the panel was cautious about systemic treatments in pediatric patients, they recognized the importance of mitigating her distress and ensuring long-term management of her psoriasis. They provided her family with educational resources on the chronic nature of psoriasis, emphasizing that while the condition could be managed effectively, it would require ongoing attention.

After several months of treatment, the patient showed improvement in both her physical symptoms and emotional well-being. The combination of roflumilast and carefully monitored low-potency corticosteroids managed her visible plaques, significantly reducing the inflammation on her face and joints.