Treatment Selection for Patients With Plaque Psoriasis

Brad Glick, DO, MPH: Let’s talk about how you decide. How and when do you decide? You talked a little bit about the topical, but how do we size up oral vs topical vs biologic? I’ll take it 1 step further, and you can both answer this. We’ve talked mostly about monotherapy. We haven’t talked aloud about combination therapy. Linda alluded to adding in the topical when you’re on the biologic or sometimes vice versa. We have a pretty good response with topical, and then maybe it’s time to move on. Linda, how do you decide for your patients?

Linda Stein Gold, MD: I look at each patient individually to see if a patient has an extensive amount of involvement. First, with psoriatic arthritis, they’re going to get a biologic agent or an oral agent for sure. But let’s say they don’t have that. If they have extensive involvement, you can’t practically treat topically. That might be 20% to 25% body surface area. That can be very difficult to get under control. There are some patients who says, “I’m not going to take anything systemically,” and that’s OK. Though as you get up in your extent of involvement, it’s not practical to consider a topical agent. I worry about the overall amount of systemic inflammation in our patients who have very significant disease.

If they have localized disease, and if it’s not in an area of special interest—it’s not in the genital area, the scalp, the palms, the soles, or the face—some topicals can do much better than we’ve ever expected. Then we have that overlap group, where it’s a little more extensive. You could treat it topically, orally, or with a biologic. That’s when I look at the patient and their lifestyle. I want to give them a medication that they’ll be successful with.

I’m a little different for a lot of individuals. I don’t give them the smorgasbord of treatments and say, “Here are 14 different options. Which 1 do you want?” I give them a choice of 2 to 3 options that I think are best. It’s overwhelming to present a multitude of options. I like to decide for the patient: these are the 2 or 3 things that I think are practical and appropriate. Where are you leaning?

Brad Glick, DO, MPH: Mona, comment on combination therapy. Transitioning a little from what Linda said, do you use a lot of combination therapy? Do you like to stick with 1 particular therapy? We’ve got amazing drugs in the toolbox. Tell me your approach.

Mona Shahriari, MD, FAAD: Combination therapy in the space that we’re in is quite important for treating our patients because the heterogeneity of psoriasis and all the different factors involved can lead to some patients responding to 1 monotherapy but maybe needing a little touch-up from another agent. The place where I tend to use a lot of combo therapy is combining a topical with an oral or with a systemic agent. The reality is, when you look at the guidelines from the AAD [American Academy of Dermatology] and the National Psoriasis Foundation, topicals are a cornerstone when it comes to treating mild, moderate, or severe disease. A lot of these agents can be safely combined with our armamentarium of oral and injectable agents.

Also, some of the newer agents that have hit the space, even though it’s not explicitly stated on the label, can be combined with other medications. This is great for patients who are doing well and maybe flaring. Now they need something to give them a little touch-up in terms of the extra psoriasis that broke through. An example is a patient who historically I might switch to a different oral or systemic agent. With the right topical combination, I can keep them on that medication longer and get them those higher levels of efficacy that they’re looking for. Off-label, sometimes I combine our oral agents with our injectable agents, and I have put a patient on 2 biologics at times. That’s the art of medicine. You do what’s best for your patient, but combo therapy definitely has a role in this space.

Brad Glick, DO, MPH: I love your artistry. That’s fantastic.

Michael Cameron, MD, FAAD: Much of this is driven by the patient. We’re not treating cancer, obviously. We’re treating incurable inflammatory diseases. Given that these treatments have become so safe, my thresholds for starting them is quite low, as long as they meet those prerequisites. I’m bringing it up early and often. The other thing we have to think about with psoriasis is all the systemic inflammation you could potentially be treating, whether it’s early smoldering psoriatic arthritis or the cardiovascular risk factors associated with psoriasis. Pretty much all my patients who have psoriasis are made aware of the option for biologics. Some of that may be that my practice skews to moderate to severe disease, but I’m bringing up that conversation early with my patients. For apremilast, I’m bringing up to all of them that we have the mild indication.

In terms of when I start it: as soon as we get to the point where they’re going on and off steroids, or they’re not completely clearing with topicals, we’re going to it right away. A lot of times there are patients driving it in my experience.

Brad Glick, DO, MPH: Speaking of topical therapies, 80% to 90% of patients who walk in our doors have plaque psoriasis that can likely be treated with topical therapies.

Transcript edited for clarity