Welcome to ReachMD. This medical industry feature titled, Rethinking Psoriasis: Why It’s Time to Elevate Treatment Expectations and Outlooks, is sponsored by AbbVie US Medical Affairs.
The US Medical Affairs department of AbbVie Incorporated is the sole author and copyright owner of this presentation and has paid ReachMD to host this presentation. AbbVie is solely responsible for all written content within this presentation. Copyright 2021 AbbVie Incorporated. All rights reserved.
Personal opinions and thoughts are Dr. Armstrong’s own. Dr. Armstrong serves as a paid consultant for AbbVie.
We are at an interesting turning point in dermatology, where we're starting to re-evaluate how we think about psoriasis treatments, and for which patients systemic therapies are more appropriate.
Let's consider a patient with extensive scalp psoriasis. I see these patients frequently in my practice, and their condition causes significant burden both physically and psychosocially. As you can see in this patient, even though the body surface area affected is likely less than 7% with the scalp and facial involvement alone, we can imagine this can cause significant emotional distress.
But according to traditional clinical severity assessment criteria, based on affected body surface area alone, many patients with scalp or palmoplantar psoriasis don't meet the criteria for systemic treatments, even though we may be dealing with difficult-to-treat areas or degrees of severity for which topicals may not be as effective. In fact, this traditional approach of assessing psoriasis severity as mild, moderate, and severe based on affected body surface area alone can be inadequate.
This is because the clinical severity of psoriasis and the eligibility for advanced therapies do not rely just on body surface area, but also additional factors such as plaque location and the emotional impact of the disease.
Remember that these patients may not only be dealing with skin inflammation, they're also at an increased risk of developing psoriatic arthritis, cardiometabolic comorbidities, and mental health impacts just to name a few, and these lead to increased risk of morbidity and mortality.
It's our growing acknowledgement of these potential comorbidities that have led to a recent IPC consensus statement reclassifying psoriasis severity based on two categories of patients — those who are candidates for topical therapies and those who should receive systemic therapies. The guidance towards systemic therapies depends on meeting one or more of three key factors. First, affected body surface area greater than 10%; second, involvement of more impactful sites such as the face, palms, soles, genitalia, scalp, or nails; and three, history of failed topical therapy. It's important to know that meeting just one of these criteria is sufficient for initiating systemic therapy, but overall, these factors provide a fuller context for making treatment decisions that prioritize both the physical and emotional well-being for our patients.
Let's touch upon the psychosocial impact of psoriasis, which, as many of us who treat these patients know, are often characterized by feelings of stigmatization, depression, and social isolation. Many psoriasis patients can only cope with their respective burdens of disease for so long, after which they'll be at much higher risk for experiencing depression, and other mental health issues. This means we need to intervene earlier and more assertively when managing patients with psoriasis.
So, applying this new way of thinking about cases such as this patient with scalp psoriasis whose quality of life can be severely impacted by this condition, I lean more towards a systemic therapy early on to make a substantial positive impact in this patient.
Practically, there are a few things dermatologists should keep in mind. First, let's make sure our patients have a primary care physician who can monitor and address cardiometabolic risk factors.
For mental health concerns, I use an individualized approach since psoriasis patients can experience that quite differently. I found the Patient Health Questionnaire 2, or PHQ-2, to be helpful, but even just asking whether patients have lost interest in any of their activities can be an important indicator.
Finally, checking in with our patients to see how satisfied they are with their current therapy is essential. We need to keep an open line of communication, so that our treatment plans are aligned with their changing needs. This is a key part of elevating treatment expectations on both sides of the relationship.
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