EP. 1: Individualizing Systemic Therapy in Psoriasis

In this Expert Perspectives video, Michael Payette, MD, discusses systemic treatment selection in psoriasis, including when to switch therapies, the role of special-site involvement, and how shared decision-making can guide the choice between oral and injectable options.

Psoriasis management has expanded considerably with the availability of biologics and newer oral therapies, giving clinicians more opportunities to individualize treatment according to disease characteristics and patient preferences. In this Dermatology Times Expert Perspectives video, Michael Payette, MD, a dermatologist at Central Connecticut Dermatology, discusses practical considerations for selecting systemic therapy and optimizing treatment for patients with psoriasis.

Navigating Treatment Changes and Patient Preferences

As additional oral therapies enter the psoriasis treatment landscape, Payette noted that some patients who are already well controlled with biologic therapy have expressed interest in switching to an oral option, sometimes because they perceive oral medications as safer.

For patients who are responding well without access or safety concerns, however, Payette generally favors maintaining the effective therapy rather than risking a loss of disease control. At the same time, he emphasized the importance of informed consent and shared decision-making when patients have strong preferences regarding treatment.

When to Switch vs Add to Therapy

Payette described psoriasis as a systemic inflammatory disease and stressed the importance of systemic treatment when appropriate. For patients experiencing an inadequate response to a systemic therapy, he generally favors switching to another systemic option rather than relying on the addition of topical treatment.

Topical therapies may still have a role when a patient has achieved an otherwise strong response but has limited residual disease. In these cases, topical treatment can help patients move closer to complete or near-complete clearance without abandoning an otherwise successful systemic regimen.

Looking Beyond Body Surface Area

Treatment decisions should also account for where psoriasis occurs, rather than relying solely on body surface area. Payette highlighted involvement of special sites—including the scalp, palms and soles, genital area, and nails—as an important consideration when determining whether a patient may benefit from systemic therapy.

Clinical trial data examining efficacy within these difficult-to-treat areas can also help clinicians select therapies according to an individual patient's disease presentation.

Early Systemic Treatment and Shared Decision-Making

For patients who are systemic therapy–naive, Payette emphasized the potential value of intervening earlier. Patients may achieve stronger responses to their first systemic agent than after cycling through multiple therapies, making initial treatment selection particularly important.

Ultimately, Payette said he presents patients with the available topical, oral, and injectable approaches and discusses the benefits and limitations of each. Patient preferences surrounding route of administration can then become part of the decision, provided the selected therapy is clinically appropriate and accessible.

Looking Ahead in Psoriasis Treatment

Payette expressed enthusiasm about continued innovation in psoriasis, including emerging biologics, small molecules, and therapies targeting intracellular pathways. However, he also raised a broader question about research priorities within dermatology as the psoriasis treatment armamentarium continues to grow.

With numerous effective therapies already available for psoriasis, he suggested that future research investment should also consider dermatologic diseases for which patients still have few or no effective treatment options.