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Approaches to Plaque Psoriasis Treatment Selection


Expert dermatologists discuss approaches to treatment selection for patients with plaque psoriasis, taking into account the impact of the therapy on quality of life.

Alexandra K. Golant, MD: Yes. I agree. I often try to get a sense of [what] the impact of the disease on their quality of life or what is bothering them the most. Because that can sometimes help you[ focus on]…what are our priorities here? And also what is your goal, especially when you see new patients, but particularly your established patients. And psoriasis patients are a unique [group] because we’ve had psoriasis treatments for so long. And many of these patients have been through the wringer with multiple topicals for decades that were of the same type. That they think these are the patients that I consider my veteran psoriasis patients [who say:] “I’ve had everything, I’ve tried everything. There’s nothing new that you can even tell me about.” And what can be exciting about those moments, and then that dialogue in the exam room is saying, “There’s something that I can introduce to you that might be different that actually might change your experience for the better.” But it’s all rooted in that shared decision-making? Are you a patient that will apply a topical? Are you a patient that will never apply a topical? And understanding what motivates them, and what are barriers to that particular patient’s compliance. Are there any tips or tricks that you’d like to incorporate into those conversations?

Mona Shahriari, MD: No, you hit the nail on the head. And when I’m thinking about, how do I treat these patients? In addition to getting some more insight on those quality-of-life metrics that a patient may be impacted by virtue of their psoriasis, I’m thinking about do I treat this patient as a candidate for topical therapy? Or as a candidate for systemic? Because historically, let’s face it, the FDA likes nice objective metrics, puts people into mild, moderate, severe categories based on body surface area [BSA] data, physician global assessment [PGA] data, but the reality is, there’s so many other parameters that you have to keep in mind for a patient. So when I’m thinking about my patients, yes, is a topical feasible for them? Does the body surface area warrant that? But also, if somebody has a high body surface area, I’m going to consider a systemic agent 10% or higher. But also do they have psoriasis in a sensitive area, like the face, like the scalp, like the intertriginous regions? Because that’s someone who has a huge impact from a quality of life standpoint, who may be someone you want to consider a systemic for, or somebody who uses a topical, it works while they use it. But as soon as they stop, the disease comes right back. So these are all the things that I have to keep in mind when I’m managing my patients with plaque psoriasis, to determine what is going to be best for that individual patient that’s sitting in front of me.

Alexandra K. Golant, MD: I could not agree more fully. And that conversation in that shared decision-making process plays out when you’re selecting a treatment. And I agree, this mild, moderate, and severe, [that] those categories are changing because as we get more effective treatments, how do we define a moderate patient really has changed, the body surface area requirements have changed. And we all, or at least I, encourage when [teaching] residents to approach a patient thinking about quality of life. Is this disease having an impact on this patient’s quality of life? That alone can qualify you for a more advanced or stepped-up therapy. That shared decision-making conversation too, plays out when you’re talking about adverse events or potential complications. As you said, trying to understand what is acceptable to the patient based on family values, cultural values, risk tolerance is super important as well. Are they comfortable with you explaining a box warning? Are they not comfortable with that? Will they put on a treatment that you have to apply twice a day? Does that not work with their lifestyle, or job, or work schedule? So understanding those types of things can be super critical as well to selecting a treatment that your patient will eventually use.

Transcript edited for clarity.

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