Case 3: Redefining How We Classify Psoriasis Severity

In the third case, Dr. Tina Bhutani-Jacques introduces a 34-year-old man with longstanding plaque psoriasis involving approximately 2% body surface area who remains frustrated by recurrent flares and visible plaques despite previous treatment with topical corticosteroids. Although his disease is limited in extent, the patient is reluctant to continue topical corticosteroids because of concerns about long-term adverse effects, including skin thinning, and expresses a preference for nonsteroidal treatment options. This case highlights the importance of incorporating patient preferences and quality-of-life considerations into treatment decisions.

Dr. Bhutani-Jacques reviews the evolving approach to assessing disease severity in plaque psoriasis, emphasizing that body surface area alone is no longer sufficient to guide management. She explains that clinicians should also consider factors such as symptom burden, involvement of high-impact or special sites, effects on quality of life, and previous treatment response when determining the most appropriate therapeutic approach. Using this patient as an example, she demonstrates how even limited disease can significantly affect daily functioning and warrant a more individualized treatment strategy.

The discussion also highlights the International Psoriasis Council's updated framework, which classifies patients as candidates for either topical or systemic therapy rather than relying solely on traditional mild, moderate, or severe disease categories. Dr. Bhutani-Jacques explains that patients with more than 10% body surface area involvement, disease affecting high-impact locations such as the scalp, palms, soles, genital, or intertriginous areas, or those who have experienced inadequate response to topical therapies should be considered for systemic treatment. She also reviews guidance from the National Psoriasis Foundation, emphasizing that failure of two appropriate four-week courses of topical therapy should prompt clinicians to discuss advancing treatment beyond topical management.

In the next episode, "Setting Realistic Treatment Goals for Localized Plaque Psoriasis," Dr. Bhutani-Jacques sets concrete treatment goals for this patient and explains how formulation choice and steroid hesitancy shape her plan for a case involving visible, hard-to-cover areas.