Linda F. Stein Gold, MD: Let’s talk about phototherapy and that’s something that we still do at Henry Ford Hospital [Henry Ford Health System, Detroit, Michigan]. Jerry, I know you still have patients on phototherapy. Can you talk to us as there’s still a role out there for phototherapy?

Jerry Bagel, MD, MS: In 2021, we’re doing 50% narrowband, UVB [ultraviolet B] for people with psoriasis than we did, let’s say 5 years ago. However, during the pandemic many people preferred phototherapy because they thought that it was not immunosuppressive that they didn’t have to worry about being on a biologic agent. There was an influx of phototherapy to transpire. Now, it’s going back again towards biologics, but is there a role for phototherapy? Sure. Some people don’t want to take shots. Some people don’t want to take pills. There’s a role there. Even people with malignancies in the last few years, there’s a role there too. Pregnant women. There’s a role for women there too. But the bottom line was phototherapy and why it’s decreased so much is that it doesn’t take care of people suck out psoriasis and it doesn’t take care of people’s joints. And right there, you’re left with about 50% of the clientele that you used to take care of because you’ve got better options for them than to come in 3 times a week. Now we’ve all got a lot of phototherapy. I did my own study. We just finished up and it was about 50 people with phototherapy. And the bottom line is it works. You might get a PASI 75 [75% reduction in the Psoriasis Area and Severity Index] about 50% of the time in 12 weeks. Does phototherapy work really great? We didn’t have anything better to compare it to, but now we have stuff that’s much better. It’s costly. Three times a week, 12 for 12 weeks, with 36 copays.

Linda F. Stein Gold, MD: It’s very time-consuming and very expensive. Let’s move on and talk about some of our traditional systemic medications, and Jerry, I’ll stany with you just to start off. Is there still a role for the traditional systemics, methotrexate/cyclosporine?

Jerry Bagel, MD, MS: As far as methotrexate is concerned and people that need a little jump with their biologic, people have already failed a few biologics already and you don’t want them to develop antibodies to their biologic agent. You want to give them the best benefit of the doubt. And yes, I still use the methotrexate with that as a monotherapy, not so frequently, but in combination with biologic. Mostly for psoriatic arthritis or possibly for recalcitrant psoriasis.

Linda F. Stein Gold, MD: Let me ask the others to stay on methotrexate. Mark, I know that people were commonly using methotrexate, especially with our traditional biologics, a combination with methotrexate, are you doing that still?

Mark Lebwohl, MD: Its biggest advantage was shown with adalimumab [Humira®] and infliximab [Remicade®] where there was a common development of antibodies in the methotrexate suppress that. I still use methotrexate, but less often than in the past. The biologics that we have as monotherapy today are much more effective than methotrexate was. And even more effective than methotrexate in combination with some of the TNF [tumor necrosis factor] blockers. When I’m in a bind, it’s a very good add-on therapy to other treatments, but we also have apremilast [Otezla®], which is comparable in efficacy and much safer. And my first go-to combination therapy would be apremilast, whatever biologic the patient’s on, if the insurance will pay for that combination. And usually, they do. I avoid methotrexate because of its adverse effects. It’s got so many boxed [black box] warnings that are real and there’s an actual death rate. If you have a couple of hundred patients on methotrexate, chances are that you have either contributed to a patient’s death or close to death by suppressing their bone marrow unintentionally. And it’s often not the doctor’s fault. They go on your drug, I can’t tell you how often a patient on methotrexate, when I used to use a lot of it, would call me up, I would never give them more than 4 weeks at a time and they call me up and they’d say, “Oh doc, I’m going to miss my appointment. Can you give me a refill methotrexate?” And by the way, I took this antibiotic, is it OK? And I would say to them, remember I told you, if you take any medicine, you must ask my permission. And it happened all the time. I have to tell you, I do not miss those phone calls.

Linda F. Stein Gold, MD: Interesting. And, Leon, are you using the methotrexate still?

Leon H. Kircik, MD: I don’t remember when the last time was I used methotrexate/cyclosporine.

Linda F. Stein Gold, MD: Interesting. Jerry, let’s go back to you with cyclosporine. Is there still a role?

Jerry Bagel, MD, MS: More in atopic dermatitis than I do with psoriasis. It was a great drug for crisis management of people, but sometimes these biologics, especially the IL-17s [interleukin-17] with a loading dose, they work so quickly, you don’t need to use cyclosporine anymore that much, which is good.

Linda F. Stein Gold, MD: I’ll tell you being at an academic center where we don’t have biologics in our refrigerator, sometimes we must pull out the cyclosporine for the emergency patients. Mark, you mentioned apremilast and using it in combination as a replacement, more for methotrexate, are you using it as monotherapy?

Mark Lebwohl, MD: I use cyclosporine as monotherapy.

Linda F. Stein Gold, MD: No. I’m going to go to apremilast.

Mark Lebwohl, MD: Yes. I do in a small number of patients who don’t want to get an injectable medicine, but that’s a small number. I would say I use it more often in combination and I use it a lot off-label for other conditions that respond well to it. I would say combination therapy’s my number 1 use, off-label is number 2, monotherapy for psoriasis is there, but it’s a small number.

Linda F. Stein Gold, MD: It’s interesting because a lot of people do use it. Leon, what’s your apremilast usage look like?

Leon H. Kircik, MD: I use our apremilast quite a bit, especially with topicals, and we just finished a study. We did apremilast plus calcipotriene and betamethasone combination, and it does increase the efficacy. It does help to increase the efficacy and it’s such a safe drug. Why not to try? Why not to use it? I use it quite a bit. But again, in combination, mostly with topicals though.

Linda F. Stein Gold, MD: Interesting. And Jerry, what about you, apremilast, how do you use it?

Jerry Bagel, MD, MS: The less the better.I’m going to be honest with you. OK? Having 75 and 30%, I don’t want to tell my patients that I’m going to hang my hat on this one. I tell them I’m not going to hang my head. If you really want to push the button, I’ll write it for you. I’ll give you the samples we can get going. But you know what? At 30%, when we’ve got other medications that work 90% of the time unless you don’t want to take a shot then—and, quite frankly, there’s a lot of nuisance adverse effects that go along with it that you get phone calls from and people are upset with.

Linda F. Stein Gold, MD: And that’s true. The beauty of it is the safety. And there are about a third of the patients, even with severe disease who do get to a good result. In some patients, it does work quite well.

This transcript has been edited for clarity.