First-ever U.S. psoriasis treatment goals

Following belatedly in the steps of Europe and parts of Asia, the United States has established its first treatment targets for plaque psoriasis.

Published by the medical board of the National Psoriasis Foundation (NPF) in the Journal of the American Academy of Dermatology, the goals for acceptable and target responses are equated to body surface area (BSA), which is a common gauge to access psoriasis severity.

“These treatment goals are long overdue,” says lead author April Armstrong, M.D., MPH, an associate dean of clinical research at the Keck School of Medicine, University of Southern California, Los Angeles. “By having treatment targets, we are better able to know where we want to direct psoriasis treatment.”

In an interview with Dermatology Times, Dr. Armstrong says treatment targets enable clinicians and patients to actively engage through dialogue about their goals.

“Without these goals, it becomes difficult to determine what treatment route to take and how it will be accomplished,” she says. “Also, setting consensus goals helps to set expectations of what patients can achieve for their psoriasis disease activity.”

However, a patient may have certain comorbidities that will potentially lessen the likelihood that goals will be met.

“At least, though, these goals serve as a starting point for the patient to think about reassessing his present treatment regimen,” says Dr. Armstrong, who is a NPF board member.

The published treatment targets deliberately avoid recommending specific therapies because “each patient may warrant different types of therapy to achieve his goal,” Dr. Armstrong says. “These goals, in effective, allow patients and clinicians to think about what is possible and what therapies should be used.”

For example, one patient may attain his goal by using an oral agent, whereas another patient might rely on an injectable agent. “That choice will be dependent on the patient’s baseline disease severity, as well as any other concurrent medical conditions, side effects and combination therapies,” Dr. Armstrong says.

The goals allow for flexibility in how treatment targets are achieved.

“There should be an individualized discussion between the clinician and the patient, after a full evaluation of the patient’s comorbid conditions, and preferences,” says Dr. Armstrong, adding that the NPF does not endorse one therapy over another.

Patients can be on the same therapy for months and years, without clinicians and patients pausing in their tracks to discuss treatment goals.

“Our treatment targets allow a ‘time out’ for both parties to seriously contemplate the current regimen and whether that regimen can be optimized in order to achieve the specified goals,” Dr. Armstrong says. “The journey and the conversation are paramount.”

When the authors queried patients and clinicians if they preferred instituting multiple targets or a single target like BSA, the consensus was one target.

Treatment targets using BSA were drafted based on a validated consensus achievement method, called the Delphi method, consisting of a literature review and a group of psoriasis experts (including the medical board of the NPF), plus input from both general dermatologists and patients.

The two major target categories are the targets established after a new therapy is started (three months postinitiation) and the maintenance targets.

“The timing and the goals are related, because if you assess the patient too early, the patient is not going to achieve a particular endpoint,” Dr. Armstrong says. “At three months, the acceptable response is either a static BSA of 3% or less, or BSA improvement of 75% or more from the baseline.”

The target response at three months is more stringent: BSA of 1% or less.

“Clinicians and patients should be satisfied with the acceptable response, but try to aim for the target response,” Dr. Armstrong says.

Treatment targets are also meant to broaden treatment options, not to restrict options.

Maintenance targets are measured every six months, with a recommendation of BSA 1% or less at every visit.

As new treatments become available, treatment goals may be adjusted.

Dr. Armstrong emphasizes that psoriasis treatment should be tailored to the individual patient, based on factors ranging from convenience to side effects; in other words, a risk/benefit evaluation.

“The goal is to achieve better outcomes for our patients overall by heightening the engagement between clinician and patient through meaningful dialogue and distinct conversations,” Dr. Armstrong said.