An overview of current treatments used as initial therapy to treat plaque psoriasis and factors that affect treatment selection.
Andrew F. Alexis, MD, MPH: We’re going to shift gears. We’ve set the stage for pathogenesis and clinical presentation. Now let’s talk about treatment. We’re going to go back to the West Coast, and we’ll turn to Dr April Armstrong. April, could you take a moment and bring us up to speed: What is the standard of care for initial therapy for plaque psoriasis in 2020?
April W. Armstrong, MD, MPH: Yeah. Thank you for that question, Dr Alexis, when we think about standards of care for plaque psoriasis, 1 of the key things we think about is body surface area of involvement or severity of psoriasis. In general, when we think about those with mild psoriasis—those with psoriasis less than 5%, for example—we really think about topical therapies or target phototherapy. For those with more moderate to severe psoriasis, those patients with more extensive body surface area involvement, now we’re thinking about systemic therapy, which include biologics as well as oral therapies.
In addition to that, phototherapy. One thing to note is that, for example, you may have patients who have psoriasis involving critical areas, such as the face or palms and soles. If they have genital psoriasis that’s not well controlled with topicals, then for those patients, we may also consider systemic therapies. Traditionally, we have—I would say, for the last decade—the old paradigm going from phototherapy to oral systemic therapy to biologics. In the last 3 to 5 years, that paradigm has really shifted in terms of thinking about biologics, oral therapies, and phototherapies concurrently. In fact, these days, 1 of the key recommendations that has been put forth is that for most patients, we do want to consider biologics as 1 of the first-line treatments for patients with moderate to severe plaque psoriasis. One thing to also note is that the presence of psoriatic arthritis really drives our selection of therapies as well.
If a patient has psoriasis but also psoriatic arthritis, then we really want to think about systemic treatments that can target both psoriasis and psoriatic arthritis. When we think about our psoriasis therapies, we have TNF [tumor necrosis factor] inhibitors, which are etanercept, adalimumab, certolizumab, and infliximab. They are FDA approved for both psoriasis and psoriatic arthritis, which Dr Blauvelt will talk about in more detail a little later. Then IL-17 inhibitors, which as a class came on after the TNF inhibitors, including secukinumab, ixekizumab, and brodalumab.
The 2 of them, secukinumab and ixekizumab, are approved for psoriasis and PSA [psoriatic arthritis]. Brodalumab, while approved for psoriasis in the United States, is also approved for psoriatic arthritis in other parts of the world. Following that class is IL-23 inhibitors, which include guselkumab, tildrakizumab, and risankizumab. They’re really known for their infrequent dosing and robust efficacy in psoriasis. Recently 1 of the IL-23 inhibitors, guselkumab, also gained approval for psoriatic arthritis.
Andrew F. Alexis, MD, MPH: Thank you, April. Excellent overview, and it really sets the stage for the rest of our conversation today.