Perspectives on the Management of Plaque Psoriasis - Episode 6
The panel reviews therapeutic classes and their respective benefits in patients being treated for plaque psoriasis.
Christopher G. Bunick, MD, PhD: Dr Torok, I’m going to give you the last 2 questions on this case. The first question that I’m going to ask you is, what would you do to help this patient overcome the psychological aspects of their disease? We keep coming back to taking care of the patient from a psychological standpoint. This patient had tried a lot of topicals, including topical corticosteroids, topical calcineurin inhibitors, and topical calcipotriene, which is a vitamin D–based medicine. In your practice and experience, why are patients failing these topicals? What’s causing some of these topicals to not be effective enough for some of our patients with psoriasis?
Helen Torok, MD: I call it topical fatigue. People are tired of using topicals. After about a week, they fall off. It doesn’t seem to work. They get some benefit, and then it always comes back. “No matter how often I use it, it’s back.” Yes, it’s psoriasis. It will come back. There’s topical fatigue and they have bags of tubes that they’ve used, and nothing cures them. Nothing keeps them clear. That’s why they stop. They’re frustrated. They don’t want to use anything more topical. They pay a lot of co-pays for all those tubes they’re using. You get a small tube and it only covers 1 arm. That’s the patient who you’re going to tell, “Listen, you’re going to get better. We’re going to get you better. You’re going to get clear and stay clear.” That’s the important thing. “You’re going to stay clear, not just for a day or two. You’re going to have long-term clearing benefit.” After a couple of injections, some of these patients will be clear for a year, as Dr Lebwohl said. Sometimes I just give it to them every 3 to 4 months, rather than once a month.
Mark G. Lebwohl, MD: In the case of a patient with fairly bad psoriasis who has failed only topical therapies, the whole range of biologics are available to us. I will automatically go to the safest drugs, which are the IL-17 [interleukin-17] and IL-23 blockers, and I’d have a conversation with the patient. “Do you want a drug that works very quickly but requires injections more often—especially up front, and eventually once a month—or would you prefer a drug that’s somewhat slower but requires injections only every 3 months?” I’d sound them out and see what they prefer. Depending on their answer, I’d give them an IL-17 or IL-23 blocker.
Christopher G. Bunick, MD, PhD: Excellent. This was a very interesting discussion. I have 3 more thoughts in my head before we move on. No 1: Based on what you just said, Dr Lebwohl, in patients who don’t have any joint symptoms, is there a place for TNF [tumor necrosis factor]-alpha inhibitors as first-line agents? Or are the IL-17 and IL-23 blockers your first-line agents for people with plaque psoriasis with no joint involvement?
Mark G. Lebwohl, MD: Every patient is individual and different. I don’t use a lot of TNF blockers for psoriasis anymore because we have the IL-17 and IL-23 blockers. But let’s say a patient with psoriatic arthritis comes with Crohn disease, which I have. The 2 classes of drugs that work best for psoriatic arthritis are IL-17s, which of course can exacerbate Crohn disease, and TNF blockers, which are good for psoriatic arthritis and Crohn disease. I very likely would use a TNF blocker in that circumstance. But on average, I try to go for the IL-17s and IL-23s because they don’t have boxed warnings.
Helen Torok, MD: The other time you would want to use a TNF is if you have a woman who’s considering getting pregnant or nursing. That’s when I love the TNF, certolizumab.
Christopher G. Bunick, MD, PhD: To Dr Torok’s point, one of certolizumab’s strengths in pregnant women is the safety and low level of penetration into breast milk and through the placenta. That’s a very good point. With certolizumab, there are data where patients who have failed other TNF-alpha inhibitors or other IL-17 inhibitors tend to do pretty well when they switch back to certolizumab. There’s something interesting about that molecule where patients who have failed other TNF-alpha inhibitors or the IL-17s can actually respond quite well to certolizumab. That’s an interesting observation that you don’t hear too much about in the discussions of psoriasis.
Jashin Wu, MD: There’s 1 more quick point. Etanercept is actually the only biologic that’s approved for pediatric psoriasis between the ages of 4 and 6. In the rare case that you have a severe patient in that age range, etanercept could be a good option for them.
Christopher G. Bunick, MD, PhD: Excellent. Dr Torok, you mentioned something else that’s very interesting: the size of the tubes. This is the second of the 3 points that were very interesting from this case. I hear about the size of the tubes a lot. Patients come in and have too small of a tube. As dermatologists, when patients come in and say they failed a topical corticosteroid or topical agent, they’re often getting these tiny tubes, and you know there’s no way they’re even getting an adequate dose to treat their disease. What do you think about that?
Helen Torok, MD: I totally agree with you. They come in with 30 or 60 g. You’ve got 30% or 40% BSA [body surface area]. I had a patient today. He has 40% BSA and he’s got 1 little tube of cream from his previous dermatologist. I put him on a biologic obviously, but the size is ridiculous.
Christopher G. Bunick, MD, PhD: Yes. Do you think that there needs to be better education of pharmacists, so that when they realize a patient has plaque psoriasis, they’re saying, “Wait, maybe this small tube isn’t the right size?” Is there a communication problem between dermatologists and pharmacists?
Helen Torok, MD: I don’t think so. It’s all what the insurance allows size-wise. They can’t even refill it after 1 or 2 weeks. They have a time limit. They’re not allowed to get another tube for another 4 weeks. That’s mandated by insurance.
Jashin Wu, MD: Also, I’m not sure that pharmacists read our notes. I’m not sure they would say, “Oh, this patient has 50% body surface area, so this tube of 30 g isn’t going to be enough.”
Christopher G. Bunick, MD, PhD: Dr Wu, let me ask you the final question of my 3 main points from this case discussion, and it’s regarding the idea of cure, which Dr Torok or Dr Lebwohl had mentioned. When patients get better and they’re clear, I often hear patients ask, “Doctor, can I stop? Am I cured?” How do you address that question? I’m sure you get it with your patients.
Jashin Wu, MD: Yes, I do. I tell them, “Unfortunately, psoriasis is a lifelong condition. We don’t have a cure for it. Maybe that will come in the coming years and decades. But unfortunately, there’s no cure. So if they’re on a good medication that’s controlling their disease, they should be continuing on that medication. Say they’re on a biologic and they say, “I’m clear. Can I take a break?” Try to tell them that they should continue, because if they do take that break, they’ll have a flare of their psoriasis either slowly over time or quickly, depending on the agent, and then if they go back on the original agent, it might not work quite as well anymore. Maybe there are some antidrug antibodies against the drug that developed during that break.
In my career, I’ve had a few patients who actually were “cured.” These were patients who are older, maybe in their 70s and 80s. Maybe there’s a bit of senescence of the immune system, so their psoriasis cleared up on its own with the help of a biologic. Once, they said to me, “I’m tired of taking this agent. I want to take a break.” I went through my general warning that it could come back, but for a couple of patients, it didn’t come back. I don’t know if Dr Lebwohl or Dr Torok have had that experience, but I’ve seen it in a couple of patients.
Helen Torok, MD: Yes.
Mark G. Lebwohl, MD: Most commonly in patients with guttate psoriasis, we’ll clear them and it doesn’t come back for years, or at all. That would be the most common time I’ve seen that. Certainly, I agree that you occasionally get patients who are older and their psoriasis will seemingly burn out, but that’s pretty unusual.
Transcript edited for clarity.