Tailoring Psoriasis Care to Patients, Not Just Protocols

At a recent Dermatology Times Community Case Forum hosted by Omar Noor, MD, in New York City, psoriasis care took center stage through nuanced case discussions. With an emphasis on shared decision-making, patient-specific challenges, and systemic access issues, Noor and a panel of dermatology professionals tackled complex scenarios to determine the most effective and practical treatment paths. What followed was a wide-ranging and lively discussion that revealed both the art and science of treating psoriasis in diverse patient populations.

Case 1: 74-Year-Old With Cognitive Impairment

The discussion opened with a retired teacher aged 74 years with a 15-year psoriasis history, mild cognitive impairment, and frustration with topical therapy. His clinical profile included 10% body surface area (BSA) involvement, a body mass index (BMI) of 33, and comorbid hypertension and hyperlipidemia.

“This is a cognitive patient on their way down. But guess what? We are here to lift them up,” Noor said, emphasizing the importance of easing treatment burden for the patient and family caregivers.

Health care–administered biologics such as tildrakizumab (Ilumya; Sun Pharma) were positioned as an ideal fit. They allow in-office administration every 12 weeks, eliminating the need for caregiver-administered injections at home. One participant noted, “Tildrakizumab is a great option for this patient…he could go to an infusion center and use his Medicare benefits.”

Access challenges under Medicare were a recurring theme. “It can be hard to get biologics covered in this population, because of the loophole…a lot of patients on fixed income still can't afford to pay out of pocket for that,” another participant added.

Case 2: 64-Year-Old on the Brink of Medicare

The next case featured a man aged 64 years with psoriasis onset at age 60. He had 10% BSA involvement, comorbid metabolic syndrome, and a lifestyle defined by frequent travel. He was commercially insured but expected to transition to Medicare soon.

The key challenge? Continuity of care. “If this patient could be a good commercial patient for tildrakizumab, they could potentially go on tildrakizumab and then transition to Medicare and stay on the same medication,” Noor said, pointing out tildrakizumab’s smoother transition between commercial and Medicare plans.

Panelists also highlighted that late-onset psoriasis does not necessarily require different therapeutics, but frequent travel and medication forgetfulness make infrequent dosing a major advantage. “I care a lot [about frequency],” one participant said. “It makes you feel like you’re not on medication sometimes if you’re injecting every 3 months.”

Case 3: Scalp and Nail Psoriasis, Plus Injection Anxiety

A younger patient presented next, aged 48 years, with significant scalp and nail involvement, but burdened by anxiety surrounding self-injections. She had failed prior treatments, including ustekinumab (Stelara; Johnson & Johnson) and secukinumab (Cosentyx; Novartis), due to poor adherence and psychological stress.

Participants unanimously agreed that psychosocial stress can undermine even the best medical regimen. “When your treatment is becoming more stressful…that anxiety is probably always going to be there,” one clinician noted.

Several providers reported that nail and scalp involvement often leads them to prefer IL-17 inhibitors for their rapid onset and stronger data in hard-to-treat areas. However, Noor shared data suggesting tildrakizumab may offer comparable outcomes in the scalp and nails: “What if I told you that in 16 weeks, 60% of patients on tildrakizumab saw a 90% improvement in their scalp psoriasis?”

For nail disease, one provider added, “I sometimes will stack [biologics and orals]… like an [IL-17] inhibitor and deucravacitinib (Sotyktu; Bristol-Myers Squibb). They seem to do pretty well with nail and scalp.” Although off-label, the approach sparked a broader discussion about individualized combinations for difficult cases.

Scalp, Nail, and Weight Considerations

One consistent concern was efficacy in patients with obesity; some biologics require weight-based adjustments. Noor said, “What if I told you that tildrakizumab’s efficacy is the same in overweight patients as it is in patients with normal BMI?” Clinical trial data, he said, revealed no diminished efficacy based on weight, unlike older agents like ustekinumab, which required dose adjustments.

This was met with a mixture of surprise and relief from the group. “I didn’t realize the nail and scalp data were there. No one’s ever presented that to me before,” one participant said.

Logistics, Access, and Buy-and-Bill Models

The panel also delved into practical considerations. Noor discussed his clinic’s decision to begin buying tildrakizumab directly from a third-party distributor (McKesson) and administering it in-house under Medicare. “You get reimbursed about $800 over the cost. That’s like a Mohs patient—4 Mohs a year,” he said.

The logistical ease, he said, came down to coordination. “Once you get the basic system down…it’s so easy,” Noor added, sharing how his team tracks shipment, scheduling, and administration via a simple Excel spreadsheet.

Although not every clinic had adopted the buy-and-bill model, many noted interest, especially given the rapid access under Medicare with no prior authorizations required.

Final Takeaways

As the roundtable concluded, participants emphasized how the discussion had shifted their perception of tildrakizumab’s role in psoriasis care. “We tend to focus on agents we’re more proficient with,” one clinician admitted. “But this gave tildrakizumab a 360-degree view. It’sa viableoption.”

Noor summarized a key theme of the event: Clinical decisions are not made in a vacuum. From family caregiving burdens to insurance transitions, lifestyle preferences, and treatment phobias, personalizing psoriasis care requires clinicians to think beyond surface symptoms.

“I see a ton of genital psoriasis. I think it’s overall underdiagnosed,” Noor added, pushing for future research into underrepresented body areas. The panel agreed that more data in areas like genital and guttate psoriasis would further refine their ability to match therapies to patients.