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Importance of Quick Response to Treatment for Patients With Plaque Psoriasis


Lakshi Aldredge, MSN, ANP-BC, discusses how speed of treatment response guides treatment selection for the patient, taking patient preference into consideration. Jennifer Conner, MPAS, PA-C, comments on treatment failure in plaque psoriasis.

Alexa Hetzel, MS, PA-C: Lakshi, how does quickness of response help in terms of treatment selection for you and the patient?

Lakshi Aldredge, MSN, ANP-BC: That’s an important point. In all the patient surveys that have been done by the National Psoriasis Foundation and other organizations, patients with psoriasis want 3 things. They want something that’s going to work quickly, be very effective, and be safe. It depends on the patient in front of you. What you’ve all said is true: every patient is different and has different disease manifestations and expectations.

When you have a patient, in the eye of the provider, whether it’s a physician, a nurse practitioner, or a physician assistant, we look at their disease severity. This patient needs to be on this drug, which is going to get them clear, and they’re going to be happy with it. That’s what we are thinking in the first 5 minutes that we see that patient. But I’ve learned to just let the patient say what their expectations are. Patients have become much more savvy. They’re reaching out on the internet and listening to patient-centered advertisements, so they may come with an expectation that they want a medication because they heard about it or have a friend who’s on it.

But looking at disease severity is really important. Oftentimes we judge by body surface area. The more skin that’s affected, patients can be considered more severe. However, patients who have localized disease—for example, severe scalp psoriasis, severe palmoplantar pustular psoriasis, or even psoriasis that’s simply in the genital areas—that can be very severe disease. It can be very debilitating, and you want to get them on something that’s going to very quickly relieve their symptoms of itch or burn or clear their skin.

My expectations for treatment have changed over the years. It’s a matter of shared decision-making, which is an important subject that we talk about in health care. When I think about a quick response, I think about a biologic agent or, for severe disease, as I’m bridging them, even cyclosporine. The beautiful thing that we’re seeing is some of the newer topical medications, like roflumilast and tapinarof, have very quick efficacy and nice tolerability where patients can get lesions cleared quickly and relief of their symptoms. We haven’t seen that necessarily with a topical agent unless you put them on a super-potent steroid. It’s nice to have that option for quick relief and prolonged response.

Alexa Hetzel, MS, PA-C: Jennifer, on what timeline do you consider a treatment regimen to be a failure?

Jennifer Conner, MPAS, PA-C: Typically, especially with a systemic agent, I look at the clinical studies. Usually they go out 16 or 24 weeks. That’s where most of our data derives from. When I counsel a patient, I usually see them back for follow-up 3 to 4 months after initiating a new systemic treatment. It’s usually closer to 4 months because the reality is that it probably takes at least a month to get the drug in their hands with all the access issues that we sometimes have. That’s more of a check-in [to see] how they are tolerating it, and just to make sure that we’re trending in the right direction. But I like to give it at least 4 to 6 months before I’ll make a switch. Unless they’re having some issue with tolerability or come in super unhappy, I usually try to give it a 4- to 6-month time frame.

Transcript edited for clarity

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