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Escalating Treatment From Topical to Systemic in Plaque Psoriasis


Jennifer Conner, MPAS, PA-C, and Lakshi Aldredge, MSN, ANP-BC, comment on approaches to escalating treatment of plaque psoriasis from topical therapy to systemic therapy and initiating that conversation with the patient.

Alexa Hetzel, MS, PA-C: Obviously, we can tell that none of us saw this patient beforehand. We wouldn’t have just thrown topical steroids on her for greasy hands and 18% BSA [body surface area]. Jennifer, when might a treatment be escalated, maybe separate from our female patient, from a topical to a systemic?

Jennifer Conner, MPAS, PA-C: So I think, obviously, when a patient is not satisfied. I always ask them about joint pain, even if they have a low body BSA. If they are talking to me about joint pain then I start having that conversation with them very early. They might have 1%% BSA but I’m asking them about joint pain. The interesting thing I find about psoriatic arthritis and joint pain is, especially with men, they’re like that’s just an old football injury. But is it really? Let’s talk about this.

Alexa Hetzel, MS, PA-C: From your peewee football days?

Jennifer Conner, MPAS, PA-C: Right, they always try to write it off as something else, like age. That’s just my plantar fasciitis, but actually that’s probably psoriatic arthritis. You really sit down and dive into this and you find out that these people have psoriatic arthritis and we get them on a biologic and their life is changed. That’s what I love about these medications.

Alexa Hetzel, MS, PA-C: Amazing,. So Lakshi how would you initiate a conversation with our female patient about a systemic treatment option?

Lakshi Aldredge, MSN, ANP-BC: I think that that’s the million-dollar question. For patients, it’s a big transition in their minds to go from a topical treatment to something systemically because the worry about what the side effects are, just as any of us would. One of the things that I reassure them about and sometimes they find reassuring, I say when I look at you I think about me sitting where you are living in the skin that you’re living in and what I would do for myself. Here’s what I would do for myself and then I go on to explain about systemic therapy and why it’s important.

Just as with high blood pressure, you’re going to take a high blood-pressure pill because this is something that is going to affect not only your heart, but also your veins, vascular system, even your brain. Psoriasis is very similar. We’re giving you therapy that is going to affect your entire body because psoriasis is a condition that affects every organ in your body. So when I frame it [as] this is no different than hypertension or diabetes so taking something internally to calm down the inflammation, to normalize your body, it’s not anything that’s going to be necessarily harmful.

We’re normalizing things. If I frame it that way ahead of time and set that stage, I think it’s a little bit more reassuring to them to see what’s coming. We’re not immunosuppressing them, we’re not making their body vulnerable necessarily, we’re normalizing a state of higher inflammation. I think that that sets the tone. I think, again, referencing it in the terms of there are tons of people that are taking high blood pressure medicines, diabetic medications, it kind of reassures them that what they’re taking is not something that’s really far out there or new and crazy.

The other thing that is really nice is a lot of our other treatments [have] been approved to 6 months of age, if not young children. So when I tell them that there are young children, even babies, who are taking biologic or systemic therapy for these conditions, that can also be reassuring for them and set the stage to getting them to accept taking systemic therapy. So I kind of set that framework and then much like you all have mentioned, talk about the different agents and how they affect psoriasis, efficacy, their safety profile and then we come to a decision together.

Transcript edited for clarity.

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