Matching Psoriatic Therapy to Patient Realities

At a recent Dermatology Times Case-Based Roundtable in San Diego, California, Paul Yamauchi, MD, PhD, a board-certified dermatologist at the Dermatology Institute and Skincare Center in Santa Monica, led a discussion that moved beyond guidelines and into the lived challenges of patient care. With colleagues weighing in from across practice settings, the conversation examined how therapeutic decisions in psoriasis are influenced as much by lifestyle and comorbidities as by efficacy data.

Case 1: Cognitive Decline, Comorbidities, and the Question of Adherence

The first patient, a 71-year-old retired accountant, represented the intersection of aging, metabolic syndrome, and cognitive impairment. He had cycled through topicals, phototherapy, and apremilast without success, largely due to tolerability and adherence barriers. Participants agreed that infrequently dosed, in-office biologics may offer the best solution, ensuring both compliance and safety.

Yamauchi highlighted post-hoc analyses of the Resurface trials, which confirmed consistent efficacy of tildrakizumab regardless of metabolic status. The discussion underscored that in geriatric patients, therapeutic choice often hinges less on pharmacology than on infrastructure and monitoring.

Case 2: Travel, Insurance Transitions, and the Weight of Medicare Planning

The second case involved a 64-year-old woman with moderate disease activity and frequent international travel. Her case drew attention to biologics with longer dosing intervals, such as risankizumab or guselkumab, which align with her lifestyle. Yet the group quickly turned to the looming insurance transition: the shift from commercial coverage with copay assistance to Medicare Part D, where affordability challenges can derail even well-controlled patients.

The clinicians emphasized planning ahead for this switch, often considering biologics covered under Medicare Part B. The discussion also noted the surprising cultural shift in patient attitudes toward self-injectables, driven in part by the widespread adoption of GLP-1 receptor agonists.

Given her frequent international travel and upcoming transition to Medicare, the patient was started on tildrakizumab once every 12 weeks, which offered reliable efficacy with a convenient dosing schedule compatible with her lifestyle and future coverage needs.

Case 3: High-Impact Disease in Scalp and Nails

The third case highlighted a 43-year-old executive with psoriasis localized to her scalp and nails, sites that disproportionally burden quality of life. She reported difficulty with missed biologic doses and concerns about self-injection. The roundtable emphasized that these areas warrant escalation to systemic therapy, despite modest BSA involvement.

IL-17 and IL-23 inhibitors were reviewed for their evidence in nail and scalp psoriasis, though participants acknowledged the persistent gap in reliably effective therapies for nails. Psychosocial strain, particularly for patients in public-facing roles, remained central to the therapeutic discussion.

Because of her difficulties with self-injection and the high-impact burden of scalp and nail disease, she was also initiated on tildrakizumab to provide consistent disease control through in-office administration.

Connecting the Threads: Adherence, Coverage, and Patient Reality

Across cases, several themes surfaced. Adherence challenges were seen as pivotal, often dictating whether office-administered or self-injected biologics were feasible. Insurance structures, particularly the transition into Medicare, emerged as a key determinant of continuity and affordability. Comorbidities such as metabolic syndrome and obesity shaped both drug choice and anticipated treatment responses, with clinicians noting the future role of GLP-1 receptor agonists in potentially modulating inflammatory disease. Finally, high-impact areas such as the scalp and nails were consistently recognized as deserving of aggressive intervention, even when surface area involvement is limited.

Conclusion

Yamauchi reflected that while the therapeutic arsenal for psoriasis has never been stronger, clinical nuance lies in matching patients to the right regimen. “The challenge isn’t whether we have effective therapies—we do,” he remarked. “It’s choosing the right one for the right patient, with all of their comorbidities, habits, and constraints in mind.” The evening’s discussion illustrated how the art of psoriasis management rests on aligning efficacy with the realities of patients’ lives.