Treatment Approaches to Plaque Psoriasis and the Importance of Topical Therapy

Linda F Stein Gold, MD: In this section let’s discuss the goals of treatment and our treatment approach. We’ll explore the individual approaches to treatment for the patient with psoriasis and discuss treatment goals. The NPF [National Psoriasis Foundation] set out a clear set of treatment targets that were published in November of 2016 in the Journal of the American Academy of Dermatology. The idea behind these treatment targets was to get psoriasis to involve only 1% body surface area at the 3-month time point or less. There were some additional goals because that’s a very high goal, and these recommendations offer an acceptable response after 3 months, which would be maybe just 3% body surface area or less or achieving a PASI 75 [75% reduction in the Psoriasis Area and Severity Index] improvement. Mark, I’m going to start with you. I know our goal is obviously to get our patients completely clear, but when a patient walks into your office, can you walk me through your thought process as they’re standing before you? What factors are influencing which drugs you’re going to choose? We have so many.

Mark Lebwohl, MD: Yes, as I’m looking at the patient, I am judging right away, are they big or small? Are they obese or normal weight? Because that will have a profound impact on the selection of my therapies. One of the first questions I’ll ask them is, “Do you have joint pain?” Then I will examine their joints. If they say they don’t have any joint pains, I won’t. I look at their review of systems. Do they have cardiovascular risk factors, which will affect the drug I pick? Do they have a history of malignancy, which affects the drug I choose? Do they have a history of inflammatory bowel disease, multiple sclerosis, hepatitis, HIV, and so on? There are many other factors we look at. Sometimes I’ll ask them, “Do you have to be cleared quickly for any major event?” That has a big impact on the selection of therapy. Is it somebody who’s not going to like giving themselves injections on a regular basis? I might think of using an IL-23 [interleukin-23] blocker, which has infrequent injections. Many factors that we consider you get from the history and physical.

Linda F Stein Gold, MD: That’s great Mark, and I know you wrote an article that helped lay it all out for us, and the comorbidities that you mentioned are critical to get an overview of who is this patient and where do we want to go with them. You mentioned the fact that you ask about joint disease. But do you ever have that time where somebody says, “No, no, no. I have no joint disease,” and then you put them on a good biologic that affects psoriatic arthritis. Then they walk in and say, “I feel better than ever.” They didn’t realize that low back pain was something.

Mark Lebwohl, MD: There’s no question. Not only that, and this occurred when ustekinumab came out. TNF [tumor necrosis factor] blockers were great for arthritis. And patients who never said they had joint pain, we never made a diagnosis of psoriatic arthritis, they weren’t doing that well skin-wise, so we’d switch them to ustekinumab. And their skin would clear up, but suddenly their joints started hurting, and they realized that all along, we were suppressing it with the TNF blocker.

Linda F Stein Gold, MD: Yes, interesting. Let’s start with the basics. Leon, I’m going to have you walk us through what about topical therapy? And we know that many of our patients do have localized disease. Can you talk to me about your thought process when you’re picking a topical, are we appropriate in using them? Are we overusing them? Where do you start? Walk us through that.

Leon H. Kircik, MD: We’re dermatologists; the way I think about it is we’re in the business of topical treatment, right? We love topical treatment, and there’s maybe not overreliance, but there’s favoritism for topical treatment. In my office, anybody who comes in, first they will get a topical treatment until I do the paperwork for a systemic. As Mark mentioned, no matter how much biologic I use, I do use concomitantly topical treatment. You cannot give the biologic and let the patient go home. They want something. I always give a topical prescription no matter what, it certainly helps. And at the end, when they start the biologic, most of them still are going to have 1 or 2 plaques. I do prefer that I give them a topical treatment. They can take care of that because I don’t like to switch people from one biologic to another every 6 months. Then if that doesn’t work, I go to intralesional Kenalog. But the bottom line is the topical treatment is mainstream treatment for us, and it will stay as such.

Linda F Stein Gold, MD: That’s an interesting point that you bring up because sometimes our patients are not completely clear on a systemic therapy. They have some residual plaques. Jerry, I know you wrote an article on this about utilizing potent topicals in those patients. What I found interesting from your article was that when somebody has residual plaques, you wonder are these super plaques that just aren’t going to respond to anything and that’s why they’re not getting better? But Jerry, you found that topical therapy works fairly well with systemics. Can you comment on that?

Jerry Bagel, MD, MS Yes, we’ve done it in a few different groups with TNF inhibitors and IL-17s, for people who were down to 5% or more body surface area after 12 weeks of treatment. We added a topical, whether it was betamethasone in addition to calcipotriene, or sometimes an…and we found that within about 4 weeks about three-fourths of all people ended up treat-to-target. And even after you stopped the medication for another 4 weeks, about 50% still maintained treat-to-target. There is definitely a benefit of adding on. In dermatology, we use a lot of combination therapy, and topicals with systemic work, topicals with biologics work. But on the other hand, some people don’t want to use a topical. Some people are 2% to 3% of body surface area, and they’re like, “I’m fine.” Topicals to them is a bad dream, to some of them. They’ve had too much psoriasis, too many dermatologists tried just topical steroids with them, and they weren’t getting better. But if you get that selective person who knows that they can get even better, then yes, it’s well used, and it’s safe.

Linda F Stein Gold, MD: Thank you, Mark, Jerry, and Leon for this rich and informative discussion. Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

This transcript has been edited for clarity.