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Approaches to Treatment of Plaque Psoriasis


Jennifer Conner, MPAS, PA-C, Terry Faleye, MPAS, PA-C, and Laura Bush, DMSc, PA-C, comment on approaches to treatment selection in managing plaque psoriasis, highlighting topical treatment in combination with other therapies.

Alexa Hetzel, MS, PA-C: I’m sure we all approach plaque psoriasis very differently because we have so many options and how we see patients and what we have experienced that really works for us, but do you feel like there has become more of a standard of care that’s commonly introduced or taught to maybe our newer APP [advanced practice provider] colleagues?

Jennifer Conner, MPAS, PA-C: I think it varies. There are so many variables; the patients’ access to therapy is huge. What have they already tried before? What are their comorbidities? What stage of life are they in? If it’s a female patient, are they childbearing? There are so many factors. What other medications are they on? I sit down with them and I present it to them, like you called it, a magic purse. I say I have a whole portfolio of options for you, and we talk through it and talk about what they’re comfortable with. It’s a joint decision-making process for sure.

Alexa Hetzel, MS, PA-C: Terry, what do you feel about topicals and the reputation they’re getting right now? I feel like we love topicals in dermatology and they still serve their purpose. How do you use topical therapy when you treat plaque psoriasis patients?

Terry Faleye, MPAS, PA-C: I’m still utilizing topicals. I think the misnomer lately has been that topicals are going away or we don’t have the usage for them. I feel like there are so many patients and people on the planet, and what that means is that there’s not a one-size-fits-all solution. There are going to be those patients who are going to utilize the topicals and benefit from them. Whether it be the newer topical agents that are on market today or our typical traditional topical steroidal medications. We just have to manage that.

At the end of the day, we obviously have a lot more targeted therapies, and a lot of times it’s not just one drug. We see it all the time, that there are times that we have to add on adjunctive therapy. So a patient may be on a biologic agent, but they may be on a topical just to spot treat through flares because that’s what’s needed. I think it gives us a lot more flexibility, and in turn I think patients like that because then they don’t feel like they’re confined. …It’s like, you know what, this is fluid. It’s a case where this is where we’re starting, but that doesn’t mean that you’re stuck there. It’s a case where we have a disease state that ebbs and flows, and so does our treatment regimen as well.

Alexa Hetzel, MS, PA-C: I feel like that “forever” word really freaks people out.

Terry Faleye MPAS, PA-C: Yes. It does.

Alexa Hetzel, MS, PA-C: It’s always such a huge question of, “Am I going to be on this forever?” Laura, with all of these treatment options available that we can treat plaque psoriasis with, can you, based on your experience, talk about the efficacy between classes? Do you feel like you’ve seen one that’s more effective vs another? I feel like everything is so variable by person, I know that’s a hard question to answer, but has there been one that you find that you like better? A combination you like better, a treatment you like to start with, things like that?

Laura Bush, DMSc, PA-C: I agree with Jennifer, every patient is really different. There may be a patient who a topical works well with, but it’s not 100%. I feel like nothing is 100%. Sometimes I use combinations a lot. I really use quite a bit of all the agents, I use biologics and systemics. I feel that we’re in a really neat time because we have 2 new topicals, tapinarof and roflumilast, that are working pretty well. We also have this newer agent, deucravacitinib, and its efficacy is very promising. When you compare it to the other systemics on the market, specifically if you look at apremilast, it’s maybe almost twice as effective, and the safety is there. It’s an exciting time because we have a lot to choose from.

Alexa Hetzel, MS, PA-C: It gives us more options.

Laura Bush, DMSc, PA-C: I may use biologics, I use oral agents, I still use topicals, but for a lot of it I use crossover. It does ebb and flow, so you do have to sometimes use combination therapy. I think the newer agents are exciting.

Alexa Hetzel, MS, PA-C: It gives us just more, and we always appreciate more because it’s like we all have said, it’s never one size fits all, where the same thing you use for one person is going to work for the next person, so it’s nice to have options.

Laura Bush, DMSc, PA-C: Yeah. Our goal is to get our patient better. We all want the same thing, we want our patients to have clear skin, and that’s really important. Treat their whole body, treat the whole patient.

Transcript edited for clarity

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