Adherence Challenges Take Center Stage in Psoriasis Management

At a recent Dermatology Times Case-Based Roundtable in Miami Beach, Florida, Mark D. Kaufmann, MD, an associate clinical professor of dermatology at Icahn School of Medicine at Mount Sinai in New York City, New York, guided a candid discussion among dermatology clinicians on how patient realities—cognitive decline, global travel, and lifestyle stress—reshape treatment choices for psoriasis. The session emphasized 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% BSA) and comorbid hypertension, obesity, and mild cognitive impairment presented the first challenge. He had abandoned both topicals and apremilast (Otezla; Amgen) due to poor adherence and was untreated at the time of discussion.

Panelists agreed that the central issue was not efficacy but logistics. “Compliance is an issue,” one clinician said. “With his cognitive impairment, you have to take it out of his hands.” The group discussed Medicare Part B–covered biologics delivered in-office as a way to ensure continuity, while acknowledging the infrastructure required.

Kaufmann highlighted the buy-and-bill burden: “You need a sophisticated infrastructure. These are very expensive drugs, and you have to orchestrate delivery and scheduling down to the day.” For this patient, the in-office model aligned with both his adherence struggles and his Medicare coverage pathway.

In the end, the panel agreed that tildrakizumab (Ilumya; Sun Pharma), administered in-office every 12 weeks, was the most appropriate option. This choice overcame the patient’s adherence challenges, fit within Medicare Part B coverage, and relieved both the patient and spouse from the burden of self-injection at home.

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

The second case featured a 64-year-old man, newly retired, with 10% BSA involvement primarily on his back. Diagnosed only 4 years earlier, he and his spouse travel internationally. Forgetting medications was routine, and topicals were impractical.

Panelists quickly recognized that treatment frequency was the hinge point. “You’ve got to do it for him—and as infrequently as possible,” one participant said. Long-interval dosing biologics, particularly those every 12 weeks, were considered the most viable path.

Another layer was his proximity to Medicare eligibility. Kaufmann asked, “What happens when he turns 65? You want something that can cross over seamlessly without restarting a new medicine.” This sparked broader discussion about aligning biologic choice with insurance transitions, not just clinical need.

The roundtable also devoted time to ergonomic considerations: would psoriatic arthritis make self-injectors impractical? Several panelists noted that many patients, even those who technically qualify for home injections, prefer returning to the office so staff can assist with administration.

For the traveler, clinicians selected a long-interval dosing IL-23 inhibitor such as tildrakizumab, administered every 12 weeks. The infrequent schedule allowed the patient to maintain his international travel lifestyle while setting up a smooth transition to Medicare in the coming year, eliminating the need to restart therapy or renegotiate access once he aged into Medicare coverage.

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

The final case was that of a 48-year-old retail manager with psoriasis since age 24, now with scalp and nail involvement, embodied the psychosocial complexity of psoriasis. She had a history of anxiety, inconsistent use of biologics (ustekinumab (Stelara; Johnson and Johnson) and secukinumab (Cosentyx; Novartis), and difficulty self-injecting.

Her case spurred conversation around motivation and risk communication. One participant said, “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.” Another emphasized referral: “Sending her to a psychiatrist could go a long way.”

From a therapeutic standpoint, high-impact sites drove the group toward agents with published scalp and nail data, but no consensus drug emerged. Panelists agreed that even with strong biologic efficacy, nails remain stubborn: “Nails are tough. Doesn’t matter what you do.”

Shared decision-making was considered critical. Because anxiety had already undermined adherence, participants supported moving administration into the clinic, with longer dosing intervals to minimize burden. Adjunctive scalp foams or nail-directed topicals were mentioned as ways to give the patient a sense of agency without overwhelming her.

System-Level Themes: Buy-and-Bill, Medicare Navigation, and Access

All 3 cases circled back to the practicalities of in-office biologic delivery. While it solves adherence problems, it requires investment. “It’s a whole dance routine—you need staff who can choreograph ordering, shipment, and patient arrival,” Kaufmann explained. The rheumatology and oncology fields were cited as models, with their infusion center infrastructure enabling revenue streams dermatology has yet to fully adopt.

Insurance challenges also dominated. Participants contrasted Medicare Part B vs Part D structures, noting how Part B can simplify billing and shift costs into predictable office-visit models, but only if the clinic is equipped for buy-and-bill.

Ultimately, clinicians acknowledged that while drug mechanisms are important, patient realities dictate the winning therapy. Cognitive decline, frequent travel, and work stress all demand different solutions, even when psoriasis severity appears similar on paper.

Closing Perspective

The Miami Beach roundtable reinforced that psoriasis treatment is as much about workflow engineering and lifestyle adaptation as it is about PASI scores or molecular targets. Kaufmann summed up the approach: “We see our patients for just a small snapshot. If we consider what’s happening in their lives outside the office, we might make very different decisions.”