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Research shows that less than half of patients with severe psoriasis in the United States receive aggressive treatment - systemic drugs, biologic drugs or phototherapy - for their disease. The total number of severely psoriatic patients has been estimated at 120,000 to 450,000 or more.
To find out why so many severely psoriatic patients are not being treated with any of these therapies, Dermatology Times interviewed four dermatologists who specialize in treating psoriasis, representatives of two manufacturers of biologic medications for psoriasis and the president and CEO of the National Psoriasis Foundation (NPF). The NPF defines severe psoriasis as having more than 10 percent of the body surface involved with disease.
A hidden disease For too long, psoriasis has been a disease that people don't confront, says Alan Menter, M.D.
Frustrating to patients, physicians Treating psoriasis has always been frustrating to both patients and physicians, according to Ivor Caro, M.D., medical director of dermatology, Genentech, South San Francisco. Genentech manufactures efalizumab (Raptiva), a biologic medication cleared by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe chronic plaque psoriasis. The total number of patients with moderate to severe plaque psoriasis is 1.5 million, says Dr. Caro.
In addition, methotrexate and cyclosporine require close follow-up with blood tests, and systemic retinoids are slow in onset and have nuisance side effects such as dry skin or dry lips, he adds.
"As dermatologists, we are in part to blame because it's much easier to give patients a topical cream and tell them to come back in six weeks than it is to sit down with them and discuss the lab-oratory monitoring and significant side effects of traditional systemic therapies such as methotrexate and cyclosporine," says Dr. Caro. "As we enter a new era in psoriasis therapy, it will become more obvious that the new biologic treatment alternatives are much more palatable than some of the older therapies."
Patients in, patients out According to Gerald G. Krueger, M.D., the first reason that many severely psoriatic patients are not being aggressively treated is that busy dermatologists like to get patients in and out of their offices quickly.
"People with severe psoriasis need coaching that takes more than five to 10 minutes face-to-face time," says Dr. Krueger. "After a couple of sessions, patients sense this and assume that nothing can be done, so their severe psoriasis is not treated effectively.
Dermatologists should change their general practice habits." Dr. Krueger is chair and professor of dermatology, University of Utah School of Medicine, Salt Lake City.