Tailored Strategies and Evolving Therapies for Plaque Psoriasis

During a recent Dermatology Times Case-Based Peer Perspective custom video series, “Optimizing Personalized Management: Case Studies in Plaque Psoriasis Treatment,” E. James Song, MD, FAAD, provided insights into psoriatic disease management.

Song, director of clinical research and co–chief medical officer at Frontier Dermatology in Mill Creek, Washington, delved into 2 patient case studies
to offer real-world, practical pearls for psoriasis treatment while emphasizing the importance of tailored, individualized management strategies. Song also reviewed current therapies in the plaque psoriasis armamentarium and the role of the clinical decision-making process.

Case 1: 45-Year-Old White Woman

The first patient case Song discussed involved a 45-year-old White woman with mild to moderate plaque psoriasis and generalized anxiety disorder, who presented via telemedicine due to her rural location and work commitments.

She reported that 6% of her body surface area (BSA) was affected, primarily on her trunk, limbs, and intertriginous areas, particularly under her breasts and on her thighs. Despite this moderate involvement, her Dermatology Life Quality Index (DLQI) score at baseline was an 11, indicative of a significant impact on her quality of life.

Given her history of limited success with topical treatments and her challenges with access to phototherapy, the treatment plan focused on systemic therapy.

“The more topicals we prescribe, and the more complicated we make it, the less likely these patients are going to be sticking with the regimen and following the instructions correctly, and therefore have a poorer outcome,” Song noted.

Clinicians prescribed apremilast due to insurance step-therapy requirements. After 16 weeks of treatment, she experienced a 60% improvement in her condition, and her DLQI score dropped to 2, reflecting mild impairment.

“When I see a patient back, I want to have them come back a little earlier, maybe 2 to 3 months, just to make sure that they’re receiving the medication right, and that they’re tolerating the medication well,” Song said. “If a patient’s response is not sustained...it may be time to talk about switching them to another therapy.”

Case 2: 58-Year-Old Black Man

The second case Song presented was that of a 58-year-old Black man with mild to moderate plaque psoriasis, primarily affecting his elbows and knees. Despite a relatively small BSA of 3%, the patient had significant issues due to scalp and fingernail involvement. His Psoriasis Area and Severity Index (PASI) score of 8 indicated moderate severity, and his Investigator Global Assessment of 3 reinforced this.

Additionally, he presented with psoriatic arthritis with persistent joint pain and stiffness, notably in his fingers. Obesity and poorly controlled type 2 diabetes further complicated his treatment options. Furthermore, his work as a truck driver presented unique challenges, particularly concerning the storage and administration of biologic therapies.

Song noted that the patient’s comorbid conditions would increase the risk of cardiovascular disease and potential hepatotoxicity, particularly with methotrexate, a common step therapy that could exacerbate his liver issues. Given the patient’s limited skin involvement but significant joint issues, systemic therapies would be warranted, Song said. However, the combination of his job constraints and comorbidities necessitated careful selection of treatments to avoid exacerbating his conditions.

“The way I think about this is trying to assess the severity of both the skin and the joint manifestations,” Song said. “I think about it in 4 different quadrants. You could have bad skin disease with limited joint disease, or you could have bad joint disease with limited skin disease.”

Topical treatments and phototherapy, including high-potency corticosteroids and vitamin D analogs, offered partial improvement but with notable adverse effects such as skin thinning and hypopigmentation. Phototherapy proved challenging due to his work demands and limited effectiveness on sensitive areas like the scalp and nails. Clinicians trialed methotrexate per insurance requirements for the patient, but it was poorly tolerated due to fatigue, headaches, and gastrointestinal adverse effects, with liver function tests showing concerning elevations.

After discontinuing methotrexate, the patient was started on apremilast. Despite initial concerns about gastrointestinal adverse effects, including nausea and diarrhea, a slow titration schedule and supportive measures helped mitigate these issues.

After 16 weeks of treatment titrated up to 30 mg twice daily, the patient’s psoriasis improved significantly, with a reduction in BSA to approximately 1% and a Physician Global Assessment score of 1, indicating nearly clear skin.

Song emphasized that although this level of clearance is significant, it is ultimately up to the patient to determine their definition of treatment success.

“This really should be patient-driven. I think target goals are helpful, just as a general framework,” Song said. “This is really where that patient-physician rapport is so important. You want to make sure this is a joint decision, and the patient should be ultimately the one who decides.”

Clinical Implications

Song concluded with an emphasis on the role of patient education.

“Our understanding of plaque psoriasis has evolved quite a bit over the years,” Song said. “First and foremost, we need to be good educators. We need to educate our patients about the systemic nature of psoriasis and the potential to develop comorbidities. If you don’t treat your psoriasis adequately, there are potential risks to not treating the disease.”