Welcome to ReachMD.
This medical industry feature, titled “Reaching a Deeper Understanding of Our Patients With Moderate Psoriasis,” is sponsored by Amgen. This program is intended for dermatology healthcare practitioners, or HCPs.
Here’s your host, Dr. Jennifer Caudle.
This is ReachMD, and I'm your host, Dr. Jennifer Caudle. And joining me to discuss the impact of moderate psoriasis on patients is Melodie Young, a nurse practitioner with more than 20 years’ experience in dermatology and an expert in psoriasis.
Melodie, welcome to the program.
Thank you for having me.
Well, we're excited that you're here. So to start off, Melodie, can you provide us with a scope and overview of moderate psoriasis in the United States?
Absolutely, Psoriasis is one of the most common immune-mediated diseases, and affects more than 7.5 million adults in the U.S.1 It is a systemic inflammatory condition, the most common form of which is plaque psoriasis.2 This chronic disease is typically characterized by red, raised, well-circumscribed, silvery, scaly plaques that may cover any part of the skin.3-4 Psoriasis can have a large impact on patients, even for those with less extensive skin involvement, such as patients classified as having moderate psoriasis.5
The moderate patient population is an important group to talk about, because unlike patients with severe disease and extensive skin involvement, it is not as straightforward to identify and classify them.1-3
Classically guidelines from the American Academy of Dermatology, or AAD, and the National Psoriasis Foundation, or NPF, consider patients with moderate psoriasis to be those with disease affecting between 3% and 10% of their body surface area, or BSA.1 But there are more nuances in identifying which patients with varied levels of skin involvement are more affected by their disease.1,3
I see patients with moderate disease in my practice all the time. In fact, in the U.S., up to 39% of patients with psoriasis may have moderate levels of skin involvement.2,4,5 To optimize care for this important population, we have to look more closely at individual patients and the entire disease, because the extent of skin involvement alone may not accurately reflect a patient's experienced severity.2,3
Now thinking about psoriasis in its entirety, you mentioned that psoriasis is characterized by manifestations on the skin, but is a systemic inflammatory disease. Can you elaborate on the systemic nature of psoriasis?
Yes. Patients with psoriasis are dealing with more than a cosmetic skin disease. They are dealing with a chronic systemic inflammatory disease.1,2
In psoriasis, inflammation arises from dysregulation of the immune response.1 The resultant elevated levels of circulating pro-inflammatory cytokines drive both the development of the characteristic skin plaques and systemic inflammation.2
As I mentioned earlier, this systemic disease can have a large impact on patients, even for those with more limited skin involvement.3 In fact, the 2020 Understanding Psoriasis Leveraging Insight for Treatment Survey, or UPLIFT, a population-based survey that includes 1,006 patients from the U.S. found that 52% of patients with moderate psoriasis skin involvement perceived their disease to be severe at the time of the survey.3
Similarly, I had a young adult patient with psoriasis who came to see me recently, he only had psoriasis on his scalp, with 10% total BSA affected, but he was profoundly impacted by his disease.
These examples show there is potential for underestimating disease severity by using common severity assessment, such as BSA alone.1
Now considering the inconsistency between the extent of skin involvement and patient-perceived severity, what other factors might contribute to a patient's perception of their psoriasis severity?
All patients with psoriasis have unique needs and perceptions of disease.1,2 These may be impacted by factors such as skin lesions in special areas and/or certain symptoms of psoriasis.1,3,4
Special areas of psoriasis are defined by the International Psoriasis Council, or IPC, as the scalp, nails, face, palms, soles, or genitalia.1 Psoriasis in these special areas can have a disproportionately large impact on patients3 and may feel severe irrespective of the extent of skin involvement.1,3
Patients with moderate skin involvement are frequently affected in special areas.4 For example, in the UPLIFT U.S. subpopulation of 247 patients with moderate psoriasis skin involvement, about 82% were affected in special areas, with more than 50% of patients affected on the scalp, and about 25% affected on the nails.4
Symptoms such as pruritus or itch can also contribute to perceived disease severity.1,2 Itch has been indicated by patients to be the most common symptom of psoriasis and the most important factor contributing to disease severity.1 In fact, the multinational Growth from Knowledge survey found that about 60% of patients with moderate psoriasis reported itch at the time of the survey.3
I'm your host, Dr. Jennifer Caudle, and today I'm speaking with Melodie Young about moderate psoriasis.
Now that we've taken a look at the potential impact of moderate psoriasis on patients and common drivers of perceived disease severity, let's shift our attention to specific clinical considerations for patients with moderate psoriasis.
So, Melodie, for healthcare professionals who see patients with moderate psoriasis, are there any important considerations that might impact patient management?
Yes, Dr. Caudle. One important consideration for HCPs, or healthcare providers, in managing patients with psoriasis is comorbidities.1
Comorbidities such as psoriatic arthritis and cardiometabolic disorders are common in patients with psoriasis, even those with moderate skin involvement.1,2 For instance, data from real-world patients in the U.S. CorEvitas Psoriasis Registry, formerly known as the Corrona Registry, showed that among 316 patients with moderate psoriasis, 40% had hypertension, 38% had psoriatic arthritis, 31% had hyperlipidemia, 16% had diabetes, and 11% had cardiovascular disease.1
Because of the prevalence of comorbidities in this population, appropriate management of these patients calls for multidisciplinary care, and dermatology HCPs and primary care physicians are poised to facilitate the necessary referrals. 1,2
We can see that comorbidities are an important consideration for patients with moderate psoriasis. Another important consideration you mentioned earlier is that factors beyond skin involvement may drive increased perceived severity. And with that in mind, how would a healthcare provider ensure a comprehensive assessment of a patient's psoriasis severity?
As I described earlier, there are several conventional clinical measures that are commonly used to describe the severity of psoriasis such as BSA, the Psoriasis Area and Severity Index, or PASI, and the static Physician’s Global Assessment, sPGA.1-3 BSA describes the total BSA affected by psoriasis, while PASI accounts for the area affected, as well as the intensity of redness, scaling, and plaque thickness.1,4 The sPGA is also a measure of the physician’s impression of the disease at a single point in time.4
However, these clinical measures do not take into account the disproportionately large impact of special areas or symptoms, such as itch, nor do they consider patient-reported outcomes or perspectives.2,4,5 Since these factors may contribute to patients perceived severity, BSA, PASI, and sPGA used by themselves may not be sufficient for capturing the severity of disease.2,3
Recent psoriasis guidelines from the AAD and NPF and the International Psoriasis Council, or IPC, recognize the limitations of defining disease severity by the extent of skin involvement alone.1,2 The IPC in particular challenged the classic definitions of psoriasis severity, because of the potential for mis-categorization of patients based on conventional measures alone.2 Moreover, recent guidelines recommend looking beyond skin involvement, and taking other factors into account when assessing disease severity, such as involvement of special areas, the patient's treatment history, the patient's perspectives, and the impact of disease on quality of life.1-3
Knowing the guidelines recommend considering other factors beyond skin involvement, how can we gain a deeper understanding of our patients with moderate psoriasis in an effort to provide optimal care?
Looking beyond clearer skin and considering all aspects of psoriasis may uncover unique, unmet needs and foster patient-centered care for patients with moderate psoriasis and limited skin involvement.1-3
For example, let's look back to my young adult patient with scalp psoriasis and 10% BSA from earlier. After assessing the extent of skin involvement, it was important for me to recognize the impact of the plaque locations. When I asked him what bothered him about his disease, he mentioned how his scalp was constantly itchy. He also explained that he was conscious of the visible plaques and flakes due to his scalp psoriasis. I think it is important to have a discussion with patients to reach a deeper understanding of their psoriasis and to better tailor and optimize their care.1,2
Those critical considerations can help us better understand and provide optimal care for patients with moderate psoriasis.
I'd like to thank my guest, Melodie Young, for helping us better understand the potential impact of moderate psoriasis.
Melodie, it was great speaking with you today.
You as well. Thank you.
Thank you. I'm Dr. Jennifer Caudle, and thanks for listening.
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