Transcript
Announcer:
This is On the Frontlines of Psoriasis on ReachMD. Here’s your host, Dr. Mary Leuchars.
Dr. Leuchars:
Welcome to On the Frontlines of Psoriasis on ReachMD. I'm Dr. Mary Leuchars, and joining me to discuss how we can overcome barriers to psoriasis care is Dr. Nicholas Mollanazar. He's an Associate Professor of Clinical Dermatology, Vice Chair of Health Informatics and Access in the Department of Dermatology, and Co-Chair of Electronic Medical Record Governance at the University of Pennsylvania Perelman School of Medicine.
Dr. Mollanazar, thanks for joining us today.
Dr. Mollanazar:
Thanks for having me. I'm excited to be here.
Dr. Leuchars:
To get us started, Dr. Mollanazar, when a patient presents with psoriasis, what factors can lead clinicians to underestimate the severity of their disease or its impact on their daily life?
Dr. Mollanazar:
It's a good question, and I think it's one with an interesting answer, because I think the obviously severe patients are the ones that we all notice and can notice right away. Those are the people who are covered in plaques with large body surface areas. I think most clinicians look at these people, and they know that the patient has severe psoriasis.
So we can focus too much on how much skin is involved and not enough on where the psoriasis is or what it prevents someone from doing. Limited disease on the hands, feet, scalp, or genitals can be very disruptive. Inflammation can also be less obvious in darker skin. And the exam alone won't tell us how someone's sleep, work, or relationships are affected. A useful starting question is, “What is psoriasis keeping you from doing?” Then ask specifically about itch, pain, sleep, mood, and joint symptoms.
Another important thing that influences the degree or severity of the psoriasis or its impact on their daily life is to ask patients how frequently or how often every month they're using their topicals. If a patient needs to use topicals two or three weeks out of every month, that is usually a significant impairment in their quality of life and not something that they always readily think to bring up in a visit.
Dr. Leuchars:
And so once you have a fuller picture, how do you then incorporate the individual, patient-level factors into the treatment decisions that you make for that person?
Dr. Mollanazar:
I consider the disease location, joint involvement, other medical conditions, pregnancy plans, and what they've already tried. Then we discuss efficacy, safety, and what fits their life, including how treatment is given, dosing frequency, and monitoring. Importantly, low body surface area shouldn't automatically rule out systemic treatment when high-impact sites are involved or topical therapy hasn't adequately controlled the disease.
One thing we don't think about often as providers is the practicability of the treatments that we give. So for some patients, we might give them a maintenance topical or a steroid-sparing topical. And that topical, if they use it every day, might work at controlling their disease. But it is not practical for the patient to use that topical every day. So we have to consider these things. We can't just automatically say, "Well, the steroid-sparing topical, if you use it every day, controls your disease. That's enough." If you are a busy individual, you have a busy family life or a busy personal life or a busy work life, you travel a lot, or you might frequently be in front of people for work, a lot of times, those are all situations in which a topical every day or twice a day is not really practical, even though it would in theory work. So we have to think about not just the theory, but the practicability of the treatments that we're giving.
Dr. Leuchars:
For those just joining us, this is On the Frontlines of Psoriasis on ReachMD. I'm Dr. Mary Leuchars, and I'm speaking with Dr. Nicholas Mollanazar about ways to address barriers to appropriate psoriasis care.
So Dr. Mollanazar, once you've selected a treatment, what access or logistical challenges can make it difficult for patients to actually start therapy?
Dr. Mollanazar:
Prior authorization, step therapy, and out-of-pocket costs can all delay treatment. Even after approval, patients can get stuck between the insurer, our office, and the specialty pharmacy without a clear understanding of who is doing what. Sending a prescription is not the same as getting someone started on treatment, and we need to make sure that last step actually happens.
And then, of course, as always with everything we do in medicine, the patient has to be on board. If you prescribe the patient a treatment, you get them approved and the pharmacy delivers it. But if the patient isn't on board with the treatment, they are not going to get better, and they're not going to start the treatment. So it's really about that initial discussion. How severe is the disease to the patient? How much is it affecting quality of life? And how aggressive do they want to get with their treatment regimen?
Dr. Leuchars:
And once patients begin treatment, what barriers can impact their adherence?
Dr. Mollanazar:
Ongoing cost, refill problems, side effects, and complicated routines can all interfere. Topicals may be messy or time-consuming, and patients may be unclear about how to use treatments or how quickly to expect improvement. Before we label someone non-adherent, we need to ask what's getting in the way and whether we've given them a plan they can realistically follow.
Something I always tell my residents when I'm teaching them is to always remember how the patient actually gets the drug and how they actually use the drug. So many of us providers don't live on this other side of the equation. But when a patient gets a topical, frequently, those instructions are printed on the box that the topical comes in, and the first thing the patient does when they get their medicine is throw away the box. So I actually tell all my patients, when I'm giving them multiple topicals for different areas, "The instructions are going to be written out. They're going to be printed by the pharmacy, and they're almost certainly going to be put on the package box. So make sure you keep that box because it's going to have which area to apply that specific topical to."
Dr. Leuchars:
Oh, that's really helpful. Before we close for today, what can clinicians do to identify and address those barriers earlier and ensure more accessible and appropriate care for patients with psoriasis?
Dr. Mollanazar:
Ask about practical barriers and treatment concerns before prescribing. Document the disease burden, prior treatment failures, and why the selected therapy is appropriate so the clinical reasoning is clear to whoever reviews the authorization. Involve pharmacy or access staff early, confirm the patient received and started treatment, and check in before the next routine visit. Patients shouldn't have to navigate that process on their own. And importantly, perhaps most importantly, make sure that the patient is on board with the treatment plan and with the course of action. The patient has to be equally as invested as you are.
And lastly, I always ask my patients how they are doing, even if they're coming in for just follow-up, and they say they're following up for just topical refills. I always ask them how they are doing and if their disease is at the level of control that they want, and I always ask how frequently they need to use the topicals.
Dr. Leuchars:
With those insights in mind, I want to thank my guest, Dr. Nicholas Mollanazar, for joining me to discuss how we can address challenges in care for patients with psoriasis.
Dr. Mollanazar, it was really great speaking with you today.
Dr. Mollanazar:
Thank you.
Announcer:
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