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Plaque Psoriasis Treatment Guidelines


Expert dermatologists discuss the treatment guidelines for plaque psoriasis, and how the decision about treatment is ultimately in the hands of the clinician.

Benjamin Lockshin, MD, FAAD: I’d like to talk about the difference between interpreting the clinical trial data that many of us read about in the journals and applying it to our clinical practice. We’d mentioned a couple times throughout this discussion that we use these drugs in combination therapy or we use some of these newer topical medications in conjunction with biologic agents. Real-world evidence is complementing what we’re doing and giving us a better understanding of how to mix and match and get patients to that clear or almost-clear status where the psoriasis isn’t something they think about. Instead it’s something that they used to have, that we effectively suppress. That is what I’d like to see in the next 5 years.

James Q. Del Rosso, DO: It’s taken away. So it’s not an everyday part of their life. It’s not dominating their life anymore.

Benjamin Lockshin, MD, FAAD: That’s our goal. We talked about the impact and quality of life and asking about if they’re depressed or how they interact with their partners and their career.

James Q. Del Rosso, DO: As I’m thinking about it, one of the things that I see that happens a lot is that we keep hearing about guidelines and groups, and everybody is waiting for the guidelines. We’re sort of forced by managed care now because managed care wants to see what you’re doing is in the guidelines, which I think clearly works against us. And that really wasn’t the purpose of guidelines. Guidelines were to give us people who are spending a lot of time putting information together to sort of be a guide to help us. It’s not a Bible, it’s not a law, it’s just a guideline. Ultimately, the person who has to make the decision is the clinician. They’re the one who is with the patient. But it’s sort of gotten turned around. I think it’s actually something where we have to start thinking that the guidelines are there to try to help us and support us, just like any other reference. But they’re not there to tell us what to do. I see a lot of our clinicians, especially some who are lesser experienced, waiting to see what the guidelines are going to say so they know how to make a decision, as if this is a vending machine and you put in a coin and you get the answer of what to do.

Benjamin Lockshin, MD, FAAD: Cookbook medicine.

James Q. Del Rosso, DO: Ultimately, that really falls on us.But I’ve seen situations where I’ve wanted to use a certain therapy and went through the thought process, and I’ve had an insurance company come back and say, “The guidelines say that you can do this. We want you to do this first.” And it sort of circumvents. It’s in the guise of so-called evidence-based medicine to improve care. Actually, there’s no data to show that evidence-based medicine improves the outcome of patient care, but good clinicians do. That’s me on my soapbox. I want to know what other people think about.

Brad Glick, DO, FAOCD: We talk a lot…about algorithms, and I kind of align that with guidelines. But my algorithm is my room-to-room algorithm. Truly, every patient is a little bit different. That’s how I like to follow circumstance. I think we’re in an absolutely fantastic time, as Dawn was saying. We would think that as we got more unique therapies—let’s pick the biologics, the more highly targeted treatments—we would expect that we would get more adverse effects. If we don’t, though more highly targeted, we can clear our patients now, as Ben was saying. Or if we don’t clear them, we have new agents, like these nonsteroidals, that can get them to clear. So, it’s very hard to follow those guidelines. And I don’t think that we should be forced into the so-called steps of therapy. We have to start here. Then you go to the next step and then the next step because our patients deserve the most leading-edge therapy. Although some of it is evidence-based, not all of it is necessarily evidence-based because in the clinic, some of the therapeutic responses that our patients get are from our clinical experiences. I think it was said today that collaborative and combination therapies are really crucial. Because none of the therapies, whether we’re talking topicals or whether we’re talking systemics, are in and of themselves getting patients completely clear.

James Q. Del Rosso, DO: In many of the cases. I also think about the fact that the literature is there to support us, but, ultimately, we have to decide what we think is best for the patient regardless of what it is they’re using. We hear this term “first line”—so is this a first-line therapy or is this a second-line therapy? To me, first line is what that patient needs on that day. That’s the most important thing. And that goes back to what you said, going from room to room, what that patient needs is really what’s first line. Sometimes we get forced into saying these things because of external forces, and it’s to get medicines covered and some of those battles that we fight. But it’s ultimately up to us to decide what’s best for the patient.

Brad Glick, DO, FAOCD: Jim, you asked the question, what’s new and what’s coming? There are some things, but I think that we’ve really had an amazing wave of psoriasis therapies. We have one more biologic that’s going to probably come before the end of this year. There are some topicals in the pipeline. But as our colleague, Andrew Blauvelt, likes to say, we have gotten pretty close to PsO [psoriasis]-solved psoriasis because we have some incredible therapies right now. And we always need new therapies, and I hope we get even newer topical therapies like these 2 nonsteroidals. We have a nice toolbox. I think as Dawn was saying before, our patients are very fortunate that while psoriasis is awful and it really impairs their quality of life, we have a pretty quick way to turn a lot of them around.

James Q. Del Rosso, DO: You’re not having to see a lot of the patients as often, like we had to before [when] we had to bring them back, see what the corticosteroid was doing, see what the cyclosporine or the methotrexate was doing. These people often have quite a long time before they have to come back in.

Benjamin Lockshin, MD, FAAD: I think we feel comfortable giving them a longer leash because these medications are safer. You’re not going to run into the headaches and concerns of using the steroids in the wrong location or using overusing a systemic therapy and running into unwanted adverse events.

Transcript edited for clarity

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