Experts in dermatology review a case of a patient with plaque psoriasis concentrated on her hands and discuss taking the patient’s preferences into consideration when selecting treatment.
Alexa Hetzel, MS, PA-C: We’re going to dive into our case presentations. Our first case is a 50-year-old woman who has had with plaque psoriasis for the past 5 years. She has no joint involvement, but it’s covering 18% BSA [body surface area] with numerous plaques, especially located on her hands. She has tried different topical therapies. She doesn’t like them because they feel greasy, especially on your hands. You can only imagine how she feels. She hasn’t tried anything else. Jennifer, what’s your initial impression?
Jennifer Conner, MPAS, PA-C: My first thought is that this is someone who needs systemic therapy based on her BSA and the involvement of her hands. Even if she didn’t have 18% BSA, I’d be thinking about being more aggressive with her simply based on her quality of life. When your hands are involved with psoriasis or any type of dermatologic disease, it can be impactful occupationally or on hobbies—she’s also a mother—or whatever she likes to do.
Alexa Hetzel, MS, PA-C: Laura, how important is shared decision-making? Lakshi talked about that already, but in making sure she understands what’s happening, how do you perceive that message and what she feels is the best option for her?
Laura Bush, DMSc, PA-C: I understand her because she’s 50, and I’m in my 50s. I would say that 18% would be way too much psoriasis for me. I’d sit down and explain that this is a whole-body disease, that it’s an inflammatory cascade in her immune system, and that treating her systemically will help all areas in her body more than just putting something on the skin. I can also correlate with her on the fact that I wouldn’t have time to put creams on 18% of my body.
She has already said she’s noncompliant because she doesn’t like it. It’s important to get her buy-in. Give her options for something she might want, not what we think she needs. That’s what I’d do with this patient. Explain the different options and the potential adverse effects and risks, then help her decide what she wants to try because she has already said she doesn’t want certain things.
Alexa Hetzel, MS, PA-C: She’s crossed stuff off already.
Laura Bush, DMSc, PA-C: She said it’s important for her to be involved in deciding.
Alexa Hetzel, MS, PA-C: Absolutely. Lakshi, in your experience do patients have to fail certain therapies before you utilize a step-up therapy practice in treatment approach?
Lakshi Aldredge, MSN, ANP-BC: Yes, unfortunately in the world we live in, to get some of the more effective biologic therapies or even some of the newer oral therapies, our insurance companies require us to go through step therapy. Fortunately, we can do some workarounds. I find it easier to get first-line treatments now than I did even 5 years ago. If I want to put a patient on a medication right away, I’m able to do that. Oftentimes, if I can’t, I’ll use a bridge therapy that’s available, whether it’s cyclosporine or another immunosuppressive medication, perhaps like methotrexate or something I wouldn’t normally want to start right away or keep them on.
The bottom line is, for this woman, it’s important that we understand what her hesitancy is with some medications so we can clarify misconceptions. What is their feasibility? What is the practicality of putting them on some of the medications that may not be available? Is she commercially insured? What’s her housing situation? These are things that we need to consider when we’re thinking about therapies.
For us as providers, nurse practitioners, and PAs [physician assistants], we’re fortunate that we have a lot of regimens that we can start this woman on to get her clear, and we can do so in a relatively quick manner. Sometimes that may involve using a sample while we’re waiting for an approval or even a super-potent topical steroid to help get them clear sooner before systemic treatment can kick in.
Alexa Hetzel, MS, PA-C: Our documentation helps us too. As Laura mentioned, put in your BSA and IgA, making sure that we know it’s affecting her hands or her quality of life. Terry, are there things that you will go to as a primary if you can get that? If it’s not the right option for patients who will usually go secondary, will it vary because everybody varies?
Terry Faleye, MPAS, PA-C: It varies [depending on] who’s in the room. A lot of times it’s all about buy-in. I can sit back and tell a patient [about a] medication. I can tell them about the efficacy of it. But the minute I say they might have to inject themselves, they might look at me and say, “I’m not injecting myself.” All of a sudden, the trajectory of that conversation changes.
In a lot of ways, I’ll start with any medication because a majority of the medications that we have, regardless of whether they’re systemic biologics that we have in play, work relatively really well. I don’t feel like I’m jeopardizing anyone. I feel like I can get efficacy here, and I honestly can get good efficacy using this drug too, sometimes even utilizing a topical. For me it’s all a matter of what they feel comfortable doing and if they’re willing to. At the end of the day, we’ve all had those patients who come in and you say, “How is everything going?” And they say, “I haven’t used it. I just had a couple of questions.” In your mind, we just wasted a month.
Alexa Hetzel, MS, PA-C: Restart.
Terry Faleye, MPAS, PA-C: Yes, restart. It’s listening to our patients and finding out exactly what [works]. I can make a recommendation, but at the end of the day, it has to be a collaboration. They have buy-in by saying, “Let’s go this route.” At no point are we held hostage to it, we can truly pivot at any point. That’s how I approach it.
Alexa Hetzel, MS, PA-C: I have my favorites in each class. I have my favorite TNF [tumor necrosis factor] that I like to use. I have my favorite IL-17 and IL-23. Depending on how the conversation is going, in my head, I’m checking off the boxes, thinking about what I like to use. Depending on how the patient is answering their comorbidities and their family history, I’m whittling away at it in my head. Individuals always think it’s going to take all this time, but you’re knocking things off as you go, checking the boxes. The reason I have my favorites is because some thingsfailed for me in the past, and I don’t want patients to fail on therapy. I want them to do well.
Terry Faleye, MPAS, PA-C: Correct.
Laura Bush, DMSc, PA-C: It’s funny that you say that because I was thinking about how I used to go through things. It used to be we have methotrexate and we’d go down the list, but the list was only 3 things. Now, if we go through the list, we have a buffet.
Alexa Hetzel, MS, PA-C: It’s a buffet.
Laura Bush, DMSc, PA-C: We can’t go through the whole list. When you were saying that, I was thinking I do the same thing because if we go through the whole list, we’ll be there forever going through the options. Then at the end they’ll say, “What do you think?” I present things, but I think this 1 or that 1 won’t be good for them. We check the boxes by what they have, their comorbidities, and their whole body.
Alexa Hetzel, MS, PA-C: That’s why they came to us. You can hear the commercials on the news and see the individuals in their bathing suits showing their clear elbows and they’re at the beach. But if that’s not the right treatment option for them, they came to us to know that. We’ve got to make sure we tell them that because that’s the marketing part that we have to fight.
Jennifer Conner, MPAS, PA-C: The beauty of it, because we have so many options, is that we’re looking at what the right option is for this patient. The other conversation I always have with them is about access. I say, “Your insurance may come back and say you have to be on this other medicine first,” and I’m OK with that. I don’t hang my hat on any 1 of these drugs. As Terry said, they’re all good, they all work well, and they’re all safe. I’m not going to be upset if they come back and we have to try another 1. We’ll try it. If not, I’ve got a portfolio of other things that we can try, so don’t be discouraged. We’re not done.
Transcript edited for clarity