Standard of Care for Plaque Psoriasis

Alexa Hetzel, MS, PA-C: Andrea, can you briefly review your go-to, commonly used therapies for initial treatment of plaque psoriasis in patients? What do you do when they walk in your doors?

Andrea Nguyen, MS, PA-C: You bring up a good question, and I was really enjoying listening to some of the conversation earlier about some of the considerations in treating our patients and some of the frustrations. Alexa, like you brought up, about how they’ve used so many different treatments, and sometimes they get really frustrated that they’re not heard. I think that it really is attributed to this evolution that we’ve seen with psoriasis. Historically, some of the treatment options may not have been as efficacious and were potentially limited as to who can render them. Not every facility is outfitted to potentially do these historical treatments like the Goeckerman regimen, phototherapy, or other therapies. So that has brought about the advent of a lot of psoriasis hunters who specialize in treating this.

Your run-of-the-mill clinician may or may not feel comfortable using some of the therapies for psoriasis, whether it’s topicals vs systemics. Historically we used a lot of topical corticosteroids. That’s been something that’s been in our toolbox for many inflammatory conditions, psoriasis being one of them, for a long period of time. We can also use, and some patients have historically used, tar. We can use vitamin D analogues. Now we have the advent of newer formulations of topical therapy in combination therapies with tazarotene and topical corticosteroids. Finally, we have the new class of topical PDE4 inhibitors or topical tapinarof. So really our options have changed.

Regarding topical therapy, traditionally, I think I can say the general statement for those of us in dermatology is that topical therapy is traditionally given to every patient for almost every disease we treat. But with psoriasis, topicals sometimes are not enough and it depends on where you have the psoriasis. If it’s in sensitive areas where there are limitations, if it’s in the scalp, you can imagine. You know, for me and Alexa, if we had scalp psoriasis, putting a topical in our head of hair, even for the gentlemen on this call who have full heads of hair, that’s not cosmetically acceptable for 99% of patients. And when you have large surface areas and you’re busy and you don’t have time to put on a cream twice a day all over your body, there will be limitations. So, that’s when we really start to think about systemic therapy, and if there’s a comorbidity of psoriatic arthritis.

With systemic therapy, you have your conventional DMARD [disease-modifying antirheumatic drugs] that was brought up. Some of the ones that we’ve used in the past are cyclosporine and methotrexate. These are medications that have been approved and in use and in our toolbox for decades at this point. But there are some considerations as far as efficacy, safety, tolerability, and longevity as well. So, you can start to run into some issues with using cyclosporine long term. So with the advent of some of the more systemic therapies, this is how it plays into our goal of thinking about comorbidities, treatment goals, patient preferences. We can ask do you want a pill or do you want an injection? Now, we have the opportunity to offer newer oral medications vs newer injectable medications.

So really its considerations for your patient. Do they have a disease that is mild, mild to moderate, moderate, or moderate to severe, and then what does your patient want? Does your patient want a systemic therapy? Do they want a topical only? Then you must see if they qualify for varying treatments. Phototherapy is also something that we use for treatment, but not everyone has access and not everybody has time. So, there are a lot of considerations at play, and really, it’s about categorizing our patients, and once we categorize them and talk to them about what their goals are, then we can make considerations from there.

Alexa Hetzel, MS, PA-C: Awesome. And then, Andrea, you talked about scalp psoriasis, and there’s been a lot of conversation among all of us APPs [advanced practice providers]that you can have one affected area and still be considered severe instead of just having so much body surface area [BSA]. So, aside from scalp, are there any other areas that you see a patient, and maybe they’re not completely covered from head to toe, but that you would consider moderate to severe?

Andrea Nguyen, MS, PA-C: Absolutely. We talk about body surface areas, how much involvement of the BSA, but then we also talk disease impact on quality of life. So when you have 1% BSA, but that 1% is on your face, that, for sure, is going to affect that patient’s quality of life. Same thing with genital psoriasis. I’ve had a number of patients who have thought they had an STD [sexually transmitted disease]. They were extremely distressed over this and having issues with their personal, interpersonal relationships because of where it is. Scalp psoriasis is historically very difficult to treat because of the limitations due to hair, as well as because it tends to be very itchy, so patients scratch, and they keratinize, which then creates more plaque, so it's a harder to target. So, genitals, face, and palmoplantar. When the hands and the feet are affected, this was really the only time in my clinical practice that I would have a lot of patients that would have issues with disability if we couldn’t get it under control because for them to do even something simple, like to open a jar with their hands and turn off that knob, is very painful. Anything working with their hands or walking. Thank goodness, now, for the advent of more effective therapies because palmoplantar has been very tough.

Really, sometimes it is dependent on the patient. You can have a patient who has a body surface area of 30% and they tell me it doesn’t bother me that much. Then I’ll have a patient with 3% BSA in tears in my office, telling me that they feel their life is ruined. So, it requires a little bit of perspective, perhaps, and quality-of-life impact in making those considerations.

Alexa Hetzel, MS, PA-C: Absolutely, we all have those patients, I think.

Transcript edited for clarity