Adherence, Anxiety, and Access: Psoriasis Care Gets Personal

At a recent Dermatology Times Community Case Forum in Hollywood, Florida, Mark D. Kaufmann, MD, associate clinical professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York, New York, guided a candid discussion on how patient realities—cognitive decline, global travel, and lifestyle stress—reshape treatment choices for psoriasis. The evening highlighted adherence, infrastructure, and payer constraints as much as drug efficacy, offering a pragmatic look at what it takes to match therapy to patients’ lives.

Case 1: Balancing Cognitive Decline, Polypharmacy, and Medicare

A 74-year-old man with chronic plaque psoriasis (10% body surface area [BSA]) and comorbid hypertension, obesity, and mild cognitive impairment presented the first challenge. He had abandoned both topicals and apremilast (Otezla; Amgen Inc) due to poor adherence and was untreated at the time of discussion.

“Compliance,” one clinician statedimmediately. “With his cognitive impairment, you have to take it out of his hands.” Kaufmann agreed, adding, “Adherence is definitely an issue that we deal with…. Whatever you tell them to do 3 times a day gets done twice a day, [and] twice a day gets done once a day.”

The panel acknowledged that logistics often outweigh pharmacologic nuances in older patients. Cognitive impairment, dexterity limitations, and comorbidities all complicate self-administered therapies. “Getting the treatment plan implemented is the rate-limiting step here,” Kaufmann said. “Sometimes looking at simpler regimens can be very meaningful to them.”

When the group considered biologics that are covered by Medicare Part B and administered in the office, the discussion turned to infrastructure. “You need a sophisticated infrastructure,” Kaufmann said. “These are very expensive drugs, and you have to orchestrate delivery and scheduling down to the day.”

Still, the model made sense for this patient population. As one participant noted, “You make sure they’re taking it—adherence, absolutely.”

In the end, the panel agreed that tildrakizumab (Ilumya; Sun Pharmaceutical Industries Ltd), administered in the office every 12 weeks, was the most appropriate option. This choice overcame the patient’s adherence challenges, aligned with Medicare Part B coverage, and removed the burden of self-injection from both the patient and spouse.

Case 2: Designing Therapy for the Jet-Setting, Soon-to-Be Medicare Patient

The second case involved a 64-year-old man, newly retired, with 10% BSA involvement primarily on his back. He received his diagnosis only 4 years earlier, and he and his spouse traveled internationally, so forgetting medications was routine, and topicals were impractical.

Panelists immediately recognized that frequency was the hinge point. “You’ve got to do it for him, and as infrequently as possible,” one participant said. Kaufmann replied, “Wouldn’t it be nice if you could get [him] on something at [age] 64 and work through 65?” He pointed out that biologics like tildrakizumab “cross over seamlessly” between commercial and Medicare plans, eliminating disruption during the insurance transition.

Ultimately, the panel emphasized aligning therapy not only with disease but also with coverage continuity. “If you treat it the same as Medicare,” Kaufmann said, “and you’ve got the infrastructure, you should be able to do it.”

For this traveler, tildrakizumab given every 12 weeks offered the best fit, preserving his mobility, ensuring consistent access, and avoiding the need to restart treatment upon entering Medicare.

Case 3: High-Impact Disease in a Time-Strapped Professional

The final case, that of a 48-year-old nursing manager with long-standing psoriasis involving the scalp and nails, brought the psychosocial weight of the disease into sharp relief. She had cycled through ustekinumab (Stelara; Johnson & Johnson) and secukinumab (Cosentyx; Novartis AG) but missed doses due to anxiety and schedule overload.

Kaufmann summarized her challenge: “She just doesn’t continue to do what she’s supposed to. [Adherence] is the big one.” A participant added, “Once you explain that she may be debilitated in the future if she doesn’t treat her scalp and nails, it may make it more important to her.”

The discussion turned to the burden of self-injection and high-impact sites. “Every drug that we use for psoriasis has met its match when it comes to scalp and nails,” Kaufmann said. “Nails are tough—doesn’t matter what you do.” Another clinician agreed, adding, “If you can clear their nails and scalp, they’re very appreciative, and whatever you’re doing, they want more.”

The group weighed retraining for self-injection vs office-based administration. “If she’s that anxious, bring her in,” one clinician said. “It’s 4 times a year—it’s like getting your teeth cleaned.” Kaufmann added that, for many, “it’s not a lot. Most of my patients are so grateful, they’ll do whatever it takes.”

Given her anxiety, nonadherence, and high-impact presentation, the group endorsed in-office therapy. Tildrakizumab every 12 weeks was selected for its quarterly dosing, reliable scalp and nail data, and ability to simplify care within her stressful lifestyle.

Buy and Bill, Medicare Navigation, and Access

Across all 3 cases, the conversation repeatedly returned to infrastructure and access. “It’s a whole dance routine,” Kaufmann said. “You need staff who can choreograph ordering, shipment, and patient arrival.” One clinician described their office’s process: “We get the product a day before the patient is there, so we’re not holding on to it.”

Kaufmann noted the major advantage of buy and bill: “When you buy and bill tildrakizumab, it takes a Part D problem and pushes it into Part B—bravo.” By managing the medication as part of office care, clinicians can improve adherence and reduce coverage denials, particularly for Medicare beneficiaries.

Still, the model isn’t without challenges. “Your practice has to lay out a lot of money,” Kaufmann reminded the group. “Over $10,000 per dose. If you lose one, that’s a lot of money.” The message: Efficiency and precision matter as much as clinical skill.

Closing Perspective

The Hollywood roundtable underscored that psoriasis treatment is as much about workflow design and patient context as it is about Psoriasis Area and Severity Index scores. “We see our patients for just a small snapshot,” Kaufmann said. “If we consider what’s happening in their lives outside the office, we might make very different decisions.”