Aaron S. Farberg, MD, and Jeffrey Crowley, MD, discuss the importance of investigating the data on generalized pustular psoriasis, comorbidities of the disease, and commonly used treatments.
Aaron S. Farberg, MD: Let’s talk about the background of this study. Why is it so important to even investigate these rates? Why do you think we are doing this type of study to begin with?
Jeffrey Crowley, MD: I think we mentioned to some extent already that it’s a rare disease. What we have maybe are case series that have been published, etc, but we really don’t understand exactly how the population of patients with GPP [generalized pustular psoriasis] is presenting, how often they’re having flares, what’s associated with the flare. This study does give us some information about that. It tells us what kind of symptoms they’re having with flares. It tells us how often they’re having a flare after they have a single flare, and then it tells us the miserable state of affairs of treating the flares, which I think is all very helpful information.
Aaron S. Farberg, MD: Absolutely. Life is all about data. If you want anything done or if you want to convince anybody, you need data. You better believe when my kids try to convince me that they need to stay up later, I tell them to show me the data as to why they need to stay up. It’s important, particularly in these rare diseases, to have those numbers. Otherwise, you’re just going off of hearsay. It’s one thing for you and me to say that our patients with GPP, their disease is having a huge impact on their life and their quality of life, but now we actually have the data to go along with it. Another question; in this study patients with documented GPP flares were noted to have a higher comorbidity burden—we know—and higher all-cause inpatient admissions, which was greater than 3 times, and emergency department admissions, which is 2 times greater, compared to those without documented flares. They’re utilizing the health care system significantly. How about, in your opinion, what is the relative significance of this finding? Are there any conclusions you can draw from this?
Jeffrey Crowley, MD: Yes, I think even though this is a relatively small number of patients, they’re having high utilization of the health care system. These are patients who are trying to get better, and they’re doing that by interacting with the health care system. Unfortunately, we haven’t had the best approaches to addressing this. I hope that by having drugs that target the flares, we’ll be able to decrease their health care utilization, and maybe we’ll be able to see that in the future.
Aaron S. Farberg, MD: That would be the goal. Another question we touched on but I’d love to hear more about is, the most commonly utilized treatment in these patients with GPP flares was unfortunately corticosteroids, and we talked about that. The use of biologics and other advanced treatments was surprisingly low. Most patients, as you noted, have all these various comorbidities, and you’re thinking about where’s the risk-benefit? What are the safest treatments we could provide? We know biologics are very safe. What advice do you have to increase the utilization of these, perhaps advanced but more appropriate therapies, for patients who are experiencing GPP flares?
Jeffrey Crowley, MD: I think one of the issues here is that in a hospital setting, some of these patients are presenting to the ED [emergency department] and going into the hospital. It’s difficult to get biologic drugs. First of all, the diagnosis has to be made, and then it has to go through the formulary, etc. While at our office, it’s often very easy to get access to these drugs. I think one of the problems is just a part of the way these patients are presenting and getting access. That’s probably why we don’t see such great utilization of those in this database. That’s one reason. I think getting the patient to the right person to make the diagnosis is the most important thing, and that’s not easy to do. Dermatologists need to make themselves available to emergency departments and hospitals to help folks like this.
Aaron S. Farberg, MD: Absolutely. I plan on emailing these videos and these notes to all my colleagues within the hospital, every referral, ED, and urgent care I speak to, so they can understand this. It’s true, we as dermatologists have to be the experts and educate the public as well as our colleagues on these diseases. They may not know all the details that we are familiar with, but that is not their job. Their job is to recognize it, and then get the patient referred to a dermatologist. Now, there were some interesting data I pulled out here. It was noted that 24% of patients did not receive additional GPP treatment before, during, or immediately after the medical care for their GPP flare—24% didn’t receive any additional treatment. It was kind of shocking to me. Can you comment as to any of the potential rationale or ramifications? What impact does this have?
Jeffrey Crowley, MD: Certainly some of that could be due to data collection, to errors within the system and collecting those data. They may be getting some treatment that’s not part of the process, but some of that is probably due to the ball being dropped. The patients are treated acutely. They’re told to follow up with the dermatologist, and that just doesn’t happen until they have the next flare. Again, it’s these systemic problems in terms of being able to address these patients when we don’t have dermatologists in most hospitals in the country that are seeing patients regularly.
Transcript edited for clarity