Case 1: Assessing a Systemic-Naive Patient With Occupational Plaque Psoriasis

Dr. Bunick introduces the panel's first case: a 39-year-old roofing contractor with an 8-year history of chronic plaque psoriasis affecting 15% of his body surface area, primarily his trunk and arms. His disease worsens with sun exposure and sweating, and his work gear causes occasional friction irritation. His medical history includes obesity with a BMI around 33, hypertension, and a family history of premature coronary artery disease. His only treatment to date has been inconsistent topical corticosteroid use, and he has never tried a systemic or biologic therapy.

Dr. Armstrong calls this a classic presentation: a busy, undertreated patient with extensive disease and substantial cardiometabolic risk layered on top of occupational friction. She is optimistic about his prognosis specifically because he is systemic-naive, noting that biologics tend to perform even better in patients without prior systemic exposure. Dr. Bunick raises the question of future compliance, describing his own approach through what he calls his "Hitch analogy," borrowed from the movie of the same name, about helping patients get out of their own way to build a workable relationship with their medication.

Armstrong agrees that treating 15% body surface area with topicals alone is burdensome and unlikely to achieve consistent control, so she would move to discuss systemic options while reserving topicals for isolated breakthrough plaques. She adds that a thorough physical exam matters here, particularly given his occupation: she would carefully check palms and soles, ask about genital involvement, and examine his nails closely, since nail disease often responds better to systemic therapy than to topical treatment alone. Both physicians agree this patient represents an ideal candidate for early systemic intervention.

Up next, in "Choosing First-Line Biologics for Treatment-Naive Plaque Psoriasis Patients," Dr. Armstrong walks through how she narrows down among IL-23 inhibitors, IL-17 inhibitors, and oral agents for a treatment-naive patient.