Learn more about what treatments are on the rise for plaque psoriasis, the latest management advice and what trends are shaping the future of the disease. 

The changing treatment landscape of plaque psoriasis

In case you missed it, some of this week’s featured content includes stories on IL-17 and IL-23 inhibitors for moderate-to-severe psoriasis, how microbiota may impact rosacea, the future role of telehealth after the pandemic, navigating COVID-19-related practice challenges, new National Psoriasis Foundation (NPF) COVID-19 Task Force guidance statements, plus more.

POLL: Do you think social media trends influence your patients' skin-related concerns?

This week’s edition of The Mainstream Patient features stories on the benefits of lactic acid, itchy skin during the winter, tretinoin, 2021’s biggest beauty trend, plus more.

What Role Will Telehealth Play After COVID-19?

A recent study finds that payer sway in a region hurts not only patient care, but also physician pay.

Phase 3 trials initiated for topical roflumilast cream in AD

Arcutis Biotherapeutics announces the commencement of two identical phase 3 clinical trials evaluating topical PDE4 inhibitor roflumilast cream in patients with mild-to-moderate atopic dermatitis.

One expert says the action of demodex folliculorum and the composition of the symbiotic microbiota in the skin of patients with rosacea may provide valuable insights into the pathogenesis and pathophysiology of this widespread skin disease.

MJH Life Sciences COVID-19 Coalition webinar on Jan. 26 will focus on COVID-19 variants emerging around the globe.

IL-17, IL-23 Inhibitors May Outperform Older Biologics, Oral Therapies

Several systemic therapies are currently available for the treatment of patients with moderate-to-severe psoriasis. Biologics changed the game for treatment. Continued study of and innovation in IL-17 and IL-23 inhibitors promise even better results, but clinicians need to understand each biologic in detail.

Tips for Navigating Practice Challenges During COVID-19

George Martin, MD, program director of the 2021 Maui Derm Live and Maui Derm Connect annual conferences being held January 25-29 in Maui, Hawaii, shares his checklist of essential advice for optimizing practice management during the COVID-19 pandemic.

NPF Issues New Guidance Regarding COVID-19 Vaccines

New guidance statements related to COVID-19 vaccines and psoriatic disease patients have been published by the National Psoriasis Foundation (NPF) COVID-19 Task Force.

Articles

ICYMI, some of the content featured this week includes stories on rosacea pathogens, IL-17 and IL-23 inhibitors for psoriasis, navigating practice challenges during a pandemic, and more.

Weekly Roundup: January 18-22, 2021

The National Psoriasis Foundation (NPF) COVID-19 Task Force announces new guidance

 statements regarding the COVID-19 vaccines and psoriatic disease patients.

"The approval of the first COVID-19 vaccine has provided a light at the end of a tunnel and hope worldwide,” said Stacie Bell, PhD, chief scientific and medical officer of NPF, in a press release. “Vaccination is a critical step in the fight against this life-changing pandemic. We are so fortunate to have an amazing group of providers and researchers to offer guidance to our community as we navigate this unprecedented time."

The new guidance statements urge psoriatic disease patients to get the vaccine as soon as possible based on federal, state and local guidance.

The NPF COVID-19 Task Force also says systemic therapies for psoriasis and psoriatic arthritis do not contradict the COVID-19 vaccine and patients should continue their biologic or oral therapies in most cases.

“The new mRNA vaccines are an astonishingly 95% effective in preventing COVID19 [sic] and are extremely safe. We recommend that patients with psoriatic disease get the vaccine as soon as it is available to them. Patients may continue their oral or biologic psoriasis or psoriatic arthritis treatment without interruption when receiving these immunizations,” said Joel Gelfand, MD, MSCE, professor of dermatology and epidemiology at the University of Pennsylvania Perelman School of Medicine and co-chair of the NPF COVID-19 Task Force.

The complete list of NPF COVIF-19 Task Force guidance statements can be found 

1. Npf covid-19 task force vaccines statement. Accessed January 22, 2021. https://www.psoriasis.org/covid-19-task-force-vaccine-statement/

New guidance statements related to COVID-19 vaccines and psoriatic disease patients have been published by the National Psoriasis Foundation (NPF) COVID-19 Task Force. 

NPF Issues New Guidance Regarding COVID-19 Vaccines 

When the COVID-19 pandemic initially hit and restrictions were subsequently imposed, physicians had to think on their feet as to how to best protect their patients, as well as themselves and their staff. From increased use of masks to sanitizing stations and the implementation of telemedicine, the pandemic has turned the world of dermatology on its head.

Some physicians, such as George Martin, MD, dermatologist, Kihei, Hawaii, have used the pandemic’s challenges to develop innovative protocols for seeing patients in-office and virtually while keeping everyone safe and healthy.

Martin, who is also program director of the 2021 Maui Derm Live and Maui Derm Connect annual conferences being held January 25-29 in Maui, Hawaii, shares his checklist of essential advice for optimizing practice management during COVID-19:

responding creatively to the environment presented to you.

being nimble in your thinking and finding new solutions.

creating new protocols or adapting existing ones.

: listening to employees for their different perspectives and ideas.

Though adaptability, flexibility and innovation are critical to creating opportunities and limiting downside, tapping into the team is also essential to success, he says. “There’s no I in team. You hire talented people. Sit down with them and listen. Your employees are exceptionally bright creative. They can offer a fresh point of view.”

Martin says that his office followed Center of Disease Control and Prevention (CDC) guidelines, screened patients outside of the office, took temperatures, socially distanced and wore N95 masks in order to keep the practice running safely and efficiently during the pandemic.

The office also allotted 15 minutes for every patient instead of the typical 10 minutes to allow for extra time for room sterilization. The extra time also meant that no one would feel rushed and patient contact in the corridors with staff and other patients could be minimized.

Martin says because of this due diligence, his practice had no staff shortages due to the pandemic and both team members and patients remained healthy and safe.

While COVID-19 remains a concern in Maui, Hawaii, where he practices, Martin says the virus is not as prevalent in Hawaii as it is in states such as New York and South Dakota.

Despite this, he reports a 10% to 15% decrease in patient volume when the practice only saw life- threatening emergencies. Soon after, his practice implemented telemedicine as a modality to see patients, but that came with its own learning curve, according to Martin.

“COVID-19 slowed us down initially for about 6-8 weeks,” says Martin. “Coming out of that, we realized that telemedicine for dermatology was really just a screening tool for us, like triage. But it allowed patients to connect so that they didn’t feel like they were left out there stranded,” says Martin.

He adds that most of his telemedicine appointments ended with patients having to come into the office for in-person exams. Most follow-ups were conducted via phone rather than telemedicine.

Tips for Navigating Practice Challenges During COVID-19 

Biologics represent a huge step forward in psoriasis treatment, but their proliferation over the past few years makes it critical for clinicians to become familiar with each drug’s properties. Making the right decision for each patient means looking at more than one measure of efficacy or safety.

Beyond its cutaneous manifestations, psoriasis is recognized as a systemic disease that is associated with comorbidities including psoriatic arthritis, Crohn’s disease, uveitis, obesity, type 2 diabetes mellitus, dyslipidemia, hypertension, cardiovascular conditions, anxiety and depression. Finding an effective regimen that can achieve and maintain a high clearance of psoriatic lesions, as well as address the potential mosaic of comorbidities with minimal adverse effects, is the ideal treatment goal.

For patients with mild psoriasis, topical agents form the mainstay of treatment and include corticosteroids, vitamin D analogues, calcineurin inhibitors and keratolytics.

Patients experiencing moderate-to-severe psoriasis and psoriatic arthritis might receive systemic therapies including cyclosporine, methotrexate, apremilast (Otezla, Amgen) and retinoids, traditionally used to suppress the immune system and keratinocyte proliferation. However, the dermatologist’s growing armamentarium has generated much interest among clinicians and their patients with psoriasis; among the new tools: biologic agents, including inhibitors to tumor necrosis factor α (TNF-α) such as etanercept, infliximab, and adalimumab; IL-12 and IL-23 inhibitor ustekinumab (Stelara, Janssen Pharmaceuticals) ; IL-17A inhibitors secukinumab (Cosentyx, Novartis) and ixekizumab (Taltz, Eli Lilly and Co); IL-17RA inhibitor brodalumab; and IL-23 inhibitors guselkumab (Tremfya, Janssen Pharmaceuticals), risankizumab (Skyrizi, Boehringer Ingelheim/AbbVie Inc), and tildrakizumab.

 Two agents in the pipeline,Mirikizumab (Eli Lilly and Company) and bimekizumab (UCB), show strong results in phase 3 clinical trials.

Investigators in the immunopathogenesis of psoriasis have identified IL-23 and IL-17 as fundamental contributors in the disease’s immune pathways. The discovery of the IL-23/T17 signaling pathway and significant therapeutic advances, including novel biologic therapy, have led to better treatment and management of psoriatic disease, according to a recent review paper.

“The discovery of the roles for [IL-17] and IL-23 on the development of psoriatic disease has led to substantial increases in our understanding of the pathogenic immune events in psoriasis and has led to a paradigm shift in the treatment of this condition,” wrote Jim G. Krueger, MD, PhD, professor, senior attending physician and head of the Laboratory of Investigative Dermatology at The Rockefeller University in New York, New York, and fellow authors.

The FDA recently approved several inhibitors of the IL-23/IL-17 signaling axis for the treatment of psoriasis, which, according to the investigators, have proved very effective and result in significant improvements in 80% to 90% of patients with psoriasis.

“The unprecedented success of selective IL-17 and IL-23 antagonists for the treatment of psoriasis underscores the essential nature of these cytokines in the pathogenesis of this chronic inflammatory condition,” Krueger wrote.

Ellis et al appraised two network meta-analyses that assessed systemic therapies for patients with moderate to severe psoriasis and found that the newer biologic therapies targeting the IL-12/23 and IL-17 axes appear to be more effective than older biologics and oral agents, according to their recent paper.

The results of several clinical trials have shown novel biologic agents such as ixekizumaband guselkumab to be highly effective for patients with moderate to severe psoriasis.

 Recently approved by the FDA as the first selective IL-23 inhibitor for the treatment of psoriatic arthritis, guselkumab is a human immunoglobulin G1λ monoclonal antibody targeting the p19 subunit of IL-23, whereas ixekizumab is a human monoclonal antibody targeting IL-17A.

In a recent head-to-head study comparing the efficacy, safety and speed of response of the two biologics, 1027 patients with moderate to severe psoriasis were randomized to receive the approved dose of either subcutaneous ixekizumab or guselkumab. The primary end point was 100% improvement in the Psoriasis Area and Severity Index (PASI) 100 score at 12 weeks’ follow-up. Results showed that ixekizumab was superior to guselkumab for quickly improving signs and symptoms of moderate to severe psoriasis, meeting the primary end point (215 of 520, ixekizumab group [41%]; 126 of 507, guselkumab group (25%)]. According to the investigators, ixekizumab can completely clear moderate to severe psoriasis more rapidly than guselkumab, the IL-23 inhibitor.

Other head-to-head clinical trials of secukinumab versus ustekinumab, ixekizumab versus etanercept and brodalumab versus ustekinumab have demonstrated the IL-17 antagonists’ superior efficacy.

In another network meta-analysis study including 77 trials (34,816 patients), investigators assessed the relative efficacy of IL-17– and IL-23–targeted treatments for moderate to severe psoriasis, comparing the short-term efficacy of available (or imminently available) biologic and nonbiologic systemic therapies, reflected in the PASI response. Results showed that brodalumab, ixekizumab, secukinumab, guselkumab, and risankizumab were more efficacious than tildrakizumab, ustekinumab, all the TNF-α inhibitors, and nonbiologic systemic treatments for psoriasis. In terms of PASI 90 and PASI 100 response, data showed that brodalumab, ixekizumab, guselkumab and risankizumab demonstrated the greatest therapeutic benefits.

Clinicians have an increasing number of selectively targeted biologic agents to better treat and manage patients with moderate to severe psoriasis. However, characteristics such as rapidity of onset, long-term efficacy, safety profile and effects on comorbidities vary among these therapies. Differentiating among the many novel biologic agents to find the ideal regimen can be daunting. Having a better understanding of each drug can help guide clinicians toward the best choice for each patient, minimizing the disease’s impact and boosting patient satisfaction and quality of life.

 Krueger reports no relevant disclosures or financial interests.

1. Armstrong AW, Read C. Pathophysiology, clinical presentation, and treatment of psoriasis: a review. 

. 2020;323(19):1945-1960. doi:10.1001/jama.2020.4006

2. Keown A. Eli Lilly’s mirikizumab hits the mark in phase III study, bests Cosentyx. BioSpace. July 17, 2020. Accessed January 14, 2021. https://www.biospace.com/article/eli-lilly-s-mirikizumab-bests-novartis-cosentyx-in-plaque-psoriasis-study-company-says

3. First presentations of bimekizumab phase 3 data demonstrate superior skin clearance over placebo and Stelara at week 16 in adults with moderate-to-severe plaque psoriasis. News release. UCB. June 12, 2020. Accessed January 14, 2021. https://www.ucb.com/stories-media/Press-Releases/article/First-Presentations-of-Bimekizumab-Phase-3-Data-Demonstrate-Superior-Skin-Clearance-Over-Placebo-and-Stelara-at-Week-16-in-Adults-with-Moderate-to-Severe-Plaque-Psoriasi

4. Hawkes JE, Yan BY, Chan TC, Krueger JG. Discovery of the IL-23/IL-17 signaling pathway and the treatment of psoriasis. 

 2018;201(6):1605-1613. doi:10.4049/jimmunol.1800013

5. Ellis AG, Flohr C, Drucker AM. Network meta-analyses of systemic treatments for psoriasis: a critical appraisal. 

 2019;180(2):282-288. doi:10.1111/bjd.17335

6. Griffiths CE, Reich K, Lebwohl M, et al; UNCOVER-2 and UNCOVER-3 investigators. Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (UNCOVER-2 and UNCOVER-3): results from two phase 3 randomised trials. 

 2015;386(9993):541-551. doi:10.1016/S0140-6736(15)60125-8

7. Paul C, Griffiths CEM, van de Kerkhof PCM, et al. Ixekizumab provides superior efficacy compared with ustekinumab over 52 weeks of treatment: results from IXORA-S, a phase 3 study. 

2019;80(1): 70-79.e3. doi:10.1016/j.jaad.2018.06.039

8. Reich K, Griffiths CEM, Gordon KB, et al. Maintenance of clinical response and consistent safety profile with up to 3 years of continuous treatment with guselkumab: results from the VOYAGE 1 and VOYAGE 2 trials. 

 2020;82(4)936-945. doi:10.1016/j.jaad.2019.11.040

9. Blauvelt A, Papp KA, Griffiths CE, et al. Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: results from the phase III, double-blinded, placebo- and active comparator-controlled VOYAGE 1 trial. 

 2017;76(3):405-417. doi:10.1016/j.jaad.2016.11.041

10. Blauvelt A, Papp K, Gottlieb A, et al. A head-to-head comparison of ixekizumab vs. guselkumab in patients with moderate-to-severe plaque psoriasis: 12-week efficacy, safety and speed of response from a randomized, double-blinded trial. 

 2020;182(6):1348-1358. doi:10.1111/bjd.18851

11. Blauvelt A, Reich K, Tsai TF, et al. Secukinumab is superior to ustekinumab in clearing skin of subjects with moderate-to-severe plaque psoriasis up to 1 year: results from the CLEAR study. 

 2017;76(1):60-69.e9. doi:10.1016/j.jaad.2016.08.008

12. Gordon KB, Blauvelt A, Papp KA, et al; UNCOVER-1 Study Group, UNCOVER-2 Study Group, UNCOVER-3 Study Group. Phase 3 trials of ixekizumab in moderate-to-severe plaque psoriasis. 

 2016;375(4):345-356. doi:10.1056/NEJMoa1512711

13. Lebwohl M, Strober B, Menter A, et al. Phase 3 studies comparing brodalumab with ustekinumab in psoriasis. 

 2015;373(14):1318-1328. doi:10.1056/NEJMoa1503824

14. Sawyer LM, Malottki K, Sabry-Grant C, et al. Assessing the relative efficacy of interleukin-17 and interleukin-23 targeted treatments for moderate-to-severe plaque psoriasis: a systematic review and network meta-analysis of PASI response. 

 2019;14(8):e0220868-10. doi:10.1371/journal.pone.0220868

Several systemic therapies are currently available for the treatment of patients with moderate-to-severe psoriasis. Biologics changed the game for treatment. Continued study of and innovation in IL-17 and IL-23 inhibitors promise even better results, but clinicians need to understand each biologic in detail. 

MJH Life Sciences COVID-19 Coalition announces a free webinar focused on everything you need to know about new COVID-19 variants emerging both around the globe, and close to home in the United States.

The webinar will include top thought leaders across a variety of key medical specialties.

The coalition generates up-to-date and accurate information on the pandemic’s ever-evolving impact on healthcare professionals and patients.

 to watch the webinar live at 6 p.m. ET on Jan. 26.

More details on the Emerging SARS-CoV-2 Variants: What you need to know webinar can be found at “

MJH Life Sciences COVID-19 Coalition webinar to discuss virus variants

Emerging SARS-CoV-2 Variants Webinar

New data on the action of demodex folliculorum and the composition of the symbiotic microbiota in the skin of patients with rosacea may provide valuable insights into the pathogenesis and pathophysiology of this widespread skin disease, said Elena Araviiskaia, MD, PhD, professor, Department of Dermatology, First Pavlov Medical State University of Petersburg, St. Petersburg, Russia, in her presentation

 at the European Academy of Dermatology and Venereology 2020 Virtual Congress October 28–November 1.

Various factors have been implicated in the development of rosacea including genetics, the innate immune system, vascular hypersensitivity, ultraviolet radiation, skin barrier dysfunctions as well as the patient’s skin and gastrointestinal (GI) microbiome status.

The composition of the skin’s microbiome is crucial for normal skin immune functions. The imbalance of the skin’s microbiota and/or perturbation of its microbial populations have long been thought to play a key role in rosacea, she adds. Continued research has shed some light on the role of the microbiome in rosacea, in particular the impact of demodex folliculorum. In patients with rosacea, some potentially pathogenic bacteria include 

, which are sometimes found within the demodex mite itself, and 

Recent studies also implicate imbalances in the gastrointestinal flora in the development of rosacea symptoms. It has become clearer that rosacea is associated with systemic inflammation and with a number of GI comorbidities including celiac disease, ulcerative colitis, Crohn’s disease, irritable bowel syndrome, gastroesophageal reflux disease, and 

colonization, according to Araviiskaia. Other comorbidities linking rosacea to systemic inflammation include cardiovascular comorbidities, myocardial infarction, diabetes mellitus, and hyperlipidemia.

“Of the comorbidities seen in patients with rosacea, most are associated with GI diseases,” says Araviiskaia. “Whether these are due to the breakages of the barrier of the gut or indirect via innate immunity still needs to be clarified." She recommends that future research and studies in rosacea focus on symbiotic microbiota and the potentially pathogenic bacteria, as well as the still incompletely known impact of 

“Continued research will offer new medications and open the door for novel therapeutics including probiotics and dermocosmetics, both of which have shown good efficacy in modulating the microbiome and improving the symptoms of rosacea,” says Araviiskaia.

Araviiskaia reports no relevant disclosures.

1 Araviiskaia E. Role of the microbiome in rosacea. Oral presentation at: European Academy of Dermatology and Venereology 2020 Virtual Annual Congress, October 28–Nov. 1, 2020

Pathogens, Microbiota May Impact Rosacea 

Arcutis Biotherapeutics announces it has initiated a phase 3 clinical trial evaluating topical roflumilast cream (ARQ-151, Arcutis Biotherapeutics) for the treatments of atopic dermatitis (AD).

Roflumilast cream is a once-daily topical phosphodiesterase type 4 inhibitor (PDE4) defined as an intracellular enzyme that increases production of pro-inflammatory mediators while decreasing production of anti-inflammatory mediators.

The enzyme has been linked to a variety of inflammatory diseases including AD, psoriasis and chronic obstructive pulmonary disease (COPD). Roflumilast cream has the potential to be a “Best in Class” topical PDE4 inhibitor, according to a company press release.

“More than 19 million people in the U.S. suffer from AD, of which at least 60 percent [sic] are young children, thereby making safety and tolerability particularly important in this disease,” says Patrick Burnett, MD, PhD, FAAD, Arcutis’ chief medical officer. “Atopic dermatitis is characterized by a defect in the skin barrier, which results in a red, itchy rash that in many cases can cover significant areas of the body. Current treatments often fall short, resulting in patients, parents and physicians having to make trade-offs between efficacy, safety and tolerability.”

The INTEGUMENT 1 and 2 (INterventional Trial EvaluatinG roflUMilast cream for the treatmENt of aTopic dermatitis) studies are identical, parallel group, double blind and vehicle-controlled phase 3 clinical trials. Each trial will evaluate roflumilast cream 0.15% or vehicle once-daily for 4 weeks in 650 patients ages six years and older with mild-to-moderate AD involving ≥3% body surface area.

The primary endpoint of the studies is Investigator Global Assessment (IGA) Success, which is defined as a Validated Investigator Global Assessment - Atopic Dermatitis (vIGA-AD) score of clear or almost clear, as well as a 2-grade improvement from baseline at Week 4. Various secondary endpoints will also be assessed, including itch, measured by the Worst Itch-Numerical Rating Scale (WI-NRS), and proportion of participants who achieve at least a 75% reduction in the Eczema Area and Severity Index (EASI-75) at Week 4.

Following the completion of INTEGUMENT 1 or 2, patients will have the option to enroll in a 12-month, open label extension study (INTEGUMENT-OLE). Additionally, the company has plans to commence a third phase 3 study (INTEGUMENT-PED), evaluating roflumilast cream in pediatric patients two to five years of age with mild-to-moderate AD, according to Arcutis.

“We are excited to begin our pivotal Phase 3 trials in patients with atopic dermatitis,” says Burnett. “If approved, roflumilast cream would be the first once-a-day topical nonsteroidal treatment for AD, and would also offer patients a cosmetically elegant, non-greasy formulation. In clinical trials, roflumilast cream has demonstrated a benign safety and tolerability profile, without the local tolerability or safety issues associated with many other topical AD treatments, and importantly, unlike steroids, it can safely be used chronically. We believe topical roflumilast has the potential to eliminate the need to compromise between safety, efficacy, and tolerability, and we look forward to reporting topline data in the second half of 2022.”

1. Arcutis initiates pivotal phase 3 clinical trials evaluating topical roflumilast cream (ARQ-151) as a potential treatment for atopic dermatitis - 

https://investors.arcutis.com/news-releases/news-release-details/arcutis-initiates-pivotal-phase-3-clinical-trials-evaluating/

Arcutis Biotherapeutics announces the commencement of two identical phase 3 clinical trials evaluating topical PDE4 inhibitor roflumilast cream in patients with mild-to-moderate atopic dermatitis. 

When the COVID-19 pandemic started to sweep through the United States, primary care physicians saw the number of office visits either dramatically drop or cease all together. Between lockdowns that encouraged people to stay home and fearful patients who didn’t want to risk potentially exposing themselves to the virus, many doctors saw their livelihoods threatened as appointment cancellations piled up.

As a result, the Centers for Medicare & Medicaid Services (CMS) changed Medicare payment policies to reimburse telehealth visits for a wider range of care, and some Health Insurance Portability and Accountability Act (HIPAA) restrictions were temporarily loosened to make it easier for doctors to communicate with their patients through whatever devices they chose. Prior to the pandemic, telehealth would only be reimbursed by Medicare for limited circumstances, such as patients living in rural areas with little access to care. The communication
changes removed requirements for patients to only use often clunky HIPAA-compliant platforms, opening up the ability to use smartphones and increasing consumer convenience. Most private payers also followed Medicare’s lead and changed their reimbursement policies.

“The fear from patients and the change in payment policies really drove and facilitated an incredibly high spike in demand for telehealth,” says Anders Gilberg, senior vice president, government affairs, for Medical Group Management Association (MGMA).

Practices with telehealth capabilities quickly ramped up their capacity, while others installed the technology needed to conduct remote visits. According to the Medical Economics® 2020 Telehealth-EHR survey, more than 77% of doctors surveyed used telehealth for the first time because of COVID-19.

“It was a lifeline [for] medical practices,” Gilberg says. Patients and doctors alike embraced the technology and the convenience, and practices began to collect income again.

Gabe Charbonneau, MD, a family physician in Stevensville, Montana, saw the number of in-office visits plummet early in the pandemic. “We really quickly ramped up doing telemedicine, and about half of our visits were on Zoom,” he says. “Because it was such a financial hit, there was a lot of pressure for us to figure out how to get people back in for visits.”

The pandemic quickly proved that telehealth could be a lifeline for practices.

“If there’s a silver lining to this pandemic, it’s the advances made in telehealth,” says Thomas Ely, DO, president of the American Osteopathic Association.

But as the intensity of the pandemic wanes and people are becoming more comfortable returning for office visits, the future of telehealth is in question. “We had practices at one point that were almost doing 100% telehealth visits, but that has come down considerably, even though the payment policies from Medicare are still in place,” Gilberg says.

Charbonneau saw his practice’s telehealth visits drop as patients shifted back to in-office visits. “Some days, we might have two or three telehealth visits, if that,” he says.

When the public health emergency ends, so will the changes that have made telehealth viable, Gilberg says. “In order to make telehealth permanent, it needs to have a viable reimbursement structure behind it, and it’s only going to be permanent if Congress steps in at the federal level.”

While there is interest from both Democrats and Republicans in making such changes, there are unanswered questions about telehealth in the long term.

IS CONGRESS REALLY COMMITTED TO TELEHEALTH?

Despite telehealth being a great solution to some challenges the pandemic created early on, there are still questions that Congress will want answered before making any permanent changes to reimbursement for telehealth.

“I think Congress may not necessarily be looking at full, permanent telehealth coverage, but perhaps an effort to cover it beyond the public health emergency, and then [Congress can] study what its impact is on utilization, cost and quality,” Gilberg says. “It still remains to be seen whether you can provide the same quality of service without a hands-on approach with the patient.”

In some areas, such as behavioral health, where a physical 

 may not be needed and a patient might be more comfortable not being in a doctor’s office, it might be an easier sell to Congress to allow for more telehealth. The same goes for chronic care management, where a simple check-in may be all that’s required.

But will telehealth still have the same appeal if it’s more difficult to use once the public health emergency is over?

“It’s likely to be limited to HIPAA-compliant platforms, so no more just dialing up your physician on FaceTime or Zoom or something like that,” Gilberg says. “Consumers today, they demand a certain degree of convenience, so there’s that aspect. Then there’s also, especially among the Medicare population, I think they trust that when they go to the doctor they prefer a hands-on examination,” he says.

Congressional leaders, who have already expressed concerns about rising health care costs, also have to wrestle with the idea that a more convenient telehealth service might be unaffordable.

“One of the reasons that telehealth expansion in Medicare hasn’t really become a reality yet is because there has been a concern that if you have broad coverage, that it would increase volume and potentially increase unnecessary care, because it’s just too convenient,” Gilberg says. “The Congressional Budget Office believes it would increase Medicare volume on the physician side and therefore potentially drive up costs of the program to the government. The other side of that is, if you can do some of the preventive things more conveniently and keep patients out of the hospital, that will, in the long run, save money from expensive in-patient types of utilization.”

Even if Congress makes telehealth policy changes permanent, reimbursement rates would likely be lower for virtual visits than they are now. “CMS determined that physicians would largely [have lower] overhead costs and fewer practice expenses when they utilize telehealth, even though I don’t think most medical practices would agree with that,” says Gilberg, who added that the reimplementation of all HIPAA requirements would necessitate using a compliant platform, which entails vendor costs to the practice. “And prior to the pandemic, telehealth visits were reimbursed less than in-person visits, at least in Medicare.”

WHAT PRIVATE PAYERS THINK ABOUT TELEHEALTH

Most private payers tend to follow whatever Medicare does when it comes to reimbursement, so when Medicare boosted telehealth, most of them did the same. While private insurers remain interested in telehealth, it may not be a boon for private practices, even if they decide to continue reimbursement after the public health emergency ends.

“There are different types of deals and relationships, not necessarily among physician practices and health plans, but instead, they are associating themselves with telehealth vendor platforms that they might have a financial interest in,” Gilberg says. “If you’re a patient, you would call in and maybe get a doctor or maybe talk to a physician assistant or nurse practitioner you haven’t seen before. That raises concerns about continuity of care and other issues if telehealth isn’t covered in the future with an existing physician practice contract and patients are steered to a platform that is either owned or managed by a health plan.”

Telehealth may not be a boon for doctors, even though it provides a way to easily monitor the health of patients with chronic conditions. “It doesn’t necessarily mean that every one of those telehealth visits is going to be compensated on a fee-for-service basis,” Gilberg says. A practice is more likely to receive some form of capitated payment for each patient, so while the technology makes it easier to check in with patients, that telehealth time won’t necessarily be compensated.

Kishlay Anand, MD, MS, founder and CEO of Akos, a telehealth technology company, sees telehealth playing a vital role in managing chronic conditions and reducing medical spending on hospitalizations. “It will become part of the care continuum where, basically, care will start at home,” Anand says. “You will still be able to see your provider and still go to the hospital, but for that high-risk chronic care group, using telehealth and virtual care management is going to be mainstream going forward, and that’s critical to bending the cost curve in health care.”

Advocates for telehealth point to banking as the model health care is following, albeit at a much slower pace. A decade ago, almost all banking was done in person at branches. Today, the simplest transactions are mostly done online with the branches handling more complex needs.

Anand estimates that one-third of visits eventually will be virtual. “Basically, what you are doing is incorporating telehealth as a methodology in the complete care management, and it becomes another access point for patients,” he says.

Ely agrees that 25% to 30% of primary care patients can be evaluated using telehealth with satisfactory outcomes, but work remains to be done. “Physicians are going to have to develop best practices for using this technology, and the use of the technology must be incorporated into medical education,” Ely says. “What is still needed, however, is to ensure compensation is commensurate with the type of service provided.”

Anand adds that telehealth parity laws that many states have passed will help ensure physicians are compensated for virtual visits at the same rate as in-office visits. Telehealth also may be necessary to help with the pending shortage of primary care physicians. “We all know that primary care as a gatekeeper concept works very well,” Anand says. “As health care moves from a churn-and-burn, fee-for-service model to a more value-based model, I think primary care will need to use technology and a virtual high-touch approach to manage the population more efficiently and cost effectively.”

IS TELEHEALTH A WORTHY LONG-TERM INVESTMENT?

COVID-19 has boosted the acceptance of telehealth for both patients and physicians, but the unknowns about reimbursement and long-term patient enthusiasm make it a challenging bet for cash-strapped practices. Will the investment pay off ?

“It’s definitely going to decline some from where it is right now,” says Jeremy Gabrysch, MD, founder of Remedy, a virtual care provider based in Austin, Texas. “Providers are going to be...more eager to see patients back in the clinic, and patients might even gravitate toward that a little bit. But I don’t think that we’re going to go back to where we were.”

And moving back to only in-person visits might hurt a practice’s long-term outlook, he adds. “We should be careful about swinging too far back to the old status quo, because there are these younger patient groups who are wanting this kind of virtual care,” Gabrysch says. “And actually, people across all generations have found that telehealth is very convenient and that they still are very connected to their doctor, even when they connect to them by video. We don’t want to lose this opportunity.”

Anand sees a future where physicians can’t ignore telehealth as an option, because it will play a vital role in doing well in value-based care. “Telehealth is going to be critical, and any primary care physician [who] wants to provide better access to care and move toward value-based initiatives needs to look at and invest in telehealth as part of moving from the fee-for-service model,” he says.

Gilberg sees potential, but he believes a lot rides on reimbursement for general acceptance.

“I expect longer term that you might see greater take up again, especially for something [such as] behavioral health, as opposed to other services where you really need to see a patient to maybe do some diagnostic testing,” Gilberg says. “If the patient demand isn’t there, and the payers are not supporting it, it is highly unlikely that physicians and medical practices will be able to supply it because their margins are already small. Once we emerge from the pandemic, telehealth is going to be largely contingent on payer coverage as well as patient demand.”

This article was originally published by our sister publication 

A recent study finds that payer sway in a region hurts not only patient care, but also physician pay. 

What Role Will Telehealth Play After COVID-19

explains why itchy skin is so common during winter and details everything there is to know about tretinoin. Meanwhile, 

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dives into how long it takes for skincare ingredients to work and reveals why “skinimalism” will be 2021’s biggest beauty trend.

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The Mainstream Patient: January 18, 2021

Poll

The latest content from our January issue;

A brand new edition of the Mainstream Patient;

Breaking coverage from the Orlando Dermatology, Aesthetic & Surgical Conference (ODAC);

Check back with our website frequently so you don’t miss any of the latest dermatology news.

A glimpse at what to expect from Dermatology Times this week.

What’s new on Dermatology Times: January 18-22

In case you missed it, some of this week’s featured content includes a new podcast episode about building a COVID-19 dermatology registry, as well as stories on finasteride risks for younger males, how COVID-19 telehealth helps broaden patient population, updates in acne research, plans for Allergan Aesthetics to acquire a medical device company, plus more.

POLL: When do you expect in-person conferences to resume?

This week’s edition of The Mainstream Patient features stories on acne treatment alternatives, dermal fillers, skincare regimens for psoriasis, wet hair care, laser treatments, plus more.

Study Examines Finasteride Risks for Younger Males

A recent study shows an association between finasteride use and psychological adverse events (AEs) including suicidality. Dermatologists should weigh benefits and risks carefully when considering finasteride for certain patients with hair loss, according to one expert

COVID-19-related Telehealth Broadens Patient Population

A retrospective study shows significant differences in the characteristics of patients seen by telehealth during the COVID-19 pandemic versus those seen during in-office visits 1 year earlier.

Next-Generation Therapies and Approaches Will Advance Acne Treatment

Topicals and oral antibiotics, as well as research on the skin microbiome, are paving the way for the future of acne treatment, according to a recent presentation at the 2020 ODAC Pre-Conference Inflammatory Diseases Symposium.

Allergan Aesthetics to Acquire Cypris Medical in Warrant Agreement

Allergan Aesthetics has entered into a warrant agreement that will give the company an option to acquire Cypris Medical following the completion of a clinical trial evaluating Cypris’ Xact device.

The Cutaneous Connection- Episode 15: Building a COVID-19 Dermatology Database

Esther Freeman, MD, PhD, details how her and her fellow colleagues banded together to create a COVID-19 dermatology registry in just eight days. The registry has since seen over 1,000 submissions from frontline clinicians located in 40 countries, helping to identify and diagnose active COVID-19 through submitted skin findings.

Immunity Induction Therapy with Antibodies, Wound-Healing Therapies Show Potential

Acne research delineating molecular and cellular pathogenic pathways gives insight into new therapeutic targets. According to a recent review, biologics and other therapies that modulate scar formation and wound healing will have value for treating severe acne.

ICYMI, some of the content featured this week includes a new podcast episode and stories on finasteride, telehealth, medical device company acquisitions, updates in acne research, plus more. 

Weekly Roundup: January 11-15, 2021

Continuing research on the pathogenesis of acne has yielded a new understanding of underlying molecular and cellular pathways, suggesting new targets for therapeutic intervention, says Ichiro Kurokawa, MD, director, Department of Dermatology, Meiwa Hospital, and clinical educational professor, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan, in collaboration with Keisuke Nakase, PhD, assistant professor, Department of Microbiology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan.

The information on these advances is summarized in a recent article1 written by Kurokawa and Nakase. The authors review recent findings on the pathogenesis of acne, discuss novel treatments, and propose future therapeutic strategies. With the need for additional treatments for severe acne, Kurokawa tells 

that findings from immunological studies are of interest as they suggest the potential to use immunity induction therapy with antibodies.

“The future treatment for severe acne will involve biologic therapies targeting interleukin (IL)-1α, IL-1β, IL-6, tumor necrosis factor (TNF)-α, and transforming growth factor (TGF)-β,” he says. In particular, these pro-inflammatory cytokines are involved in the development of scar formation, which is the most refractory complication of severe acne. In addition, TNF-α promotes lipogenesis in human sebocytes,” says Kurokawa.

“Treatments that enable wound healing are also of interest as a therapeutic intervention to prevent permanent scarring in patients who suffer from severe acne,” he adds.

The discussion of recent findings on acne pathogenesis is divided into sections reviewing research pertaining to sebaceous gland biology, sebum, genetics, keratinization, hair cycles, immunology, bacteriology, and wound healing. Findings from these studies suggest numerous novel potential treatments.