Dermatological Strategies for Challenging Cases of Severe Psoriasis

Announcer:
Welcome to Clinician’s Roundtable on ReachMD. Here’s your host Dr. Matt Birnholz.

Host:
From the ReachMD studios, I’m Dr. Matt Birnholz. On this episode, we spoke with Dr. Mark Lebwohl, professor and chairman of the Department of Dermatology at The Mount Sinai School of Medicine. Dr. Lebwohl shared perspectives on the strategies he uses to personalize therapeutic approaches for patients with severe psoriasis. Here’s what he had to say.

Dr. Lebwohl:
I often get asked the question, “What medication do you use? Now that we have so many treatment options for psoriasis, what’s your best one?” Literally, last night people said, “Well, pick 1,” and the answer is, “It depends on the patient.” And there are so many comorbidities and other conditions that we have to consider when we’re treating a patient that there is no 1 single answer. So, for example, if a patient has bad psoriasis and they also have psoriatic arthritis, TNF blockers and IL-17 blockers are effective for psoriasis and psoriatic arthritis, so those would be the classes of drugs that I would think of most often. In patients who are obese, there are some drugs that are given in mg/kg doses, so the weight affects the dose of the drug we use or we adjust up the dose for those heavier patients. The other kinds of drugs, though, that we think of more recently are the IL-23 and the IL-17 blockers are very—they are super effective, even in patients who are very overweight, so we often will go to IL-17 or IL-23 blockers for those patients. If someone has cardiac risk factors, TNF blockers have been shown to reduce heart attacks. If someone has a history of squamous cell carcinoma of the skin, we know that TNF blockers increase those. So far, the data on the IL-12/23 blocker and also the IL-17 and IL-23 blockers, appears to be good regarding malignancy, so I might think about using one of those drugs in a patient with a history of cancer.

There are many other factors we look at. Do patients have concomitant infections, hepatitis C, hepatitis B? Do they have a history of a positive TB test? Every one of those factors affects the selection of drug that we have. We know, for example, that Crohn’s disease is increased in patients with psoriasis. Well, it turns out that IL-23 blockers and TNF blockers treat Crohn’s disease. IL-17 blockers might make it worse. So, we always consider that as well. If a woman is of childbearing potential, there are certain drugs that don’t cross the placenta, so we might think of pegylated antibodies that don’t cross the placenta. On the other hand, many of the other biologics are fairly safe during pregnancy but do cross the placenta, so we have to keep all that in mind when we pick the medication that we’re going to use based on what the patient’s background, illnesses or demographics are. And so we have many new drugs. They really enable us, more than ever before, to clear patients with psoriasis and give them normal lives, but the selection of which drug is optimal for which patient has a lot to do with the background of the patient.

Host:
That was Dr. Mark Lebwohl providing strategies to selecting the right treatment options for challenging patients with severe psoriasis. For ReachMD, I’m Dr. Matt Birnholz, and thanks for listening.

Announcer:
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