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Patient Case #3: 48-Year-Old Male With Plaque Psoriasis


Experts in dermatology review a patient case of a 48-year-old man with plaque psoriasis who is having trouble with topical therapy.

James Q. Del Rosso, DO: This is a 48-year-old man with psoriasis for 4 years, covering approximately 10% of the body surface area [BSA]. It’s on the arms, elbows, and knees. A biopsy result confirms the diagnosis of plaque psoriasis, and a laboratory work-up does not show any significant abnormalities. He does not have any joint stiffness, joint pain, or any evidence clinically of psoriatic arthritis, no dactylitis, enthesitis, etc. He finds his condition troublesome and complains of mild itching and significant embarrassment, which greatly affects his quality of life. He doesn’t want to be seen scratching inadvertently; he’s in the public a lot, he’s in front of people a lot. So that’s very bothersome. He’s not experienced any remission at any time with any of his treatment, including for the pruritus. He’s always had some persistence of the problem. He wants topical corticosteroids, but he goes to the internet, and Google has told him about the topical corticosteroid adverse effects, so he would like to stay away from those. Some of the products that he has used in the past that were topical corticosteroids were somewhat greasy, and he didn’t like the way the vehicle felt. He’s a fastidious guy; he has a lot of things that bug him. So, he’s complained about that. But he’s not very consistent. He admits, “I’m not necessarily consistent with my topical; I’ll use them for a little while, but then I’ll stop,” especially if he doesn’t like the way they feel. So how are you going to deal with this patient? That’s a lot of history.

Dawn L. Sammons, DO, FAOCD, FAAD: I would have a conversation with this patient and offer them the option of systemic therapy. Once we have a patient who’s already at 10% BSA, they’ve had some experience with topicals, albeit older topicals. It’s only appropriate to give them an option…. We have some new oral agents on the market or a biologic drug as an option.

James Q. Del Rosso, DO: So, you’d have apremilast orally, deucravacitinib orally.

Dawn L. Sammons, DO, FAOCD, FAAD: That’s right. And we have a huge array of biologic therapies. But every patient’s different. If the patient was open to that, we would go down that road. If the patient’s not, then we have to talk about topical therapy. We now have some topical therapies that have that remittive effect he says he’s never had and have some good indication for decreasing itch.

James Q. Del Rosso, DO: Let’s say you decide to talk with them, and…you decide to go with an oral treatment. Let’s say you decide to go with oral deucravacitinib. All you want to do is get that TB [tuberculosis] test and then let it go. Would you still give them a topical agent from the beginning?

Dawn L. Sammons, DO, FAOCD, FAAD: Always.

James Q. Del Rosso, DO: Would you wait and see what’s going to happen with the oral medication and see whether you need a topical?

Dawn L. Sammons, DO, FAOCD, FAAD: I always give them a topical because when they walk out of my office, even if I can send them out the door with a sample pack of deucravacitinib…they’re going to start taking it, but they often need that topical therapy because patients want to be clear as quickly as possible. And that’s my goal: to get them there.

James Q. Del Rosso, DO: And that oral medication is going to take time.

Dawn L. Sammons, DO, FAOCD, FAAD: It is.

James Q. Del Rosso, DO: A topical will help…sooner, and they see a difference sooner, which makes a difference in adherence.

Dawn L. Sammons, DO, FAOCD, FAAD: They have the option, because even with deucravacitinib, a great systemic option for our patients, there are still a lot of patients who are not going to become 100% clear. What do our patients want? They want to be 100% clear.

James Q. Del Rosso, DO: Most of them are not.

Dawn L. Sammons, DO, FAOCD, FAAD: They’re not. So, they’re always going to have residual disease or often going to have residual disease. And they need to have a topical at home that they can utilize as they need it.

James Q. Del Rosso, DO: One of the things I think is important that doesn’t come out in studies: We talk about whether patients are getting to clear or almost clear skin as if all the plaques march at the same rate of improvement. They may have elbows that are thicker, but the intertriginous area is cleared in a couple of weeks. Those other areas are going to take longer to clear. But if they’re seeing improvement in at least some of those areas, they’re going to be encouraged by that.

Benjamin Lockshin, MD, FAAD: I totally agree with you, and as you go down the body…

James Q. Del Rosso, DO: Ben Lockshin agrees with me.

Benjamin Lockshin, MD, FAAD: I do.

James Q. Del Rosso, DO: I’m very happy about that.

Benjamin Lockshin, MD, FAAD: What you said is exactly right. There are some areas that are more resistant to treatment or take a little longer to clear, such as the lower extremities, palms, and soles. Sometimes the scalp can be a little challenging as well. I agree with Dawn in the respect that this is a shared decision-making situation. I would certainly mention a systemic therapy as an option, either an oral or an injectable option, but they’re also getting topicals because topicals don’t get you 100% clear, and I use them as touch-up paint, as an adjuvant therapy along with their systemic treatments.

Transcript edited for clarity

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