When to Consider Oral Therapy for Plaque Psoriasis

Mark Lebwohl, MD, dermatologist, dean for clinical therapeutics at the Icahn School of Medicine at Mount Sinai, and chairman emeritus of the department of dermatology at Mount Sinai, outlined how he weighs oral therapy against other options in moderate-to-severe plaque psoriasis in a recent Dermatology Times Expert Perspectives custom video series. Lebwohl began by explaining how patient preference, lesion location, and prior treatment history guide his decision.

Phototherapy and Patient Preference

Lebwohl said phototherapy is used far less often because of its time burden. Treatment requires 3 sessions a week for months. Localized options such as the excimer laser remain in use for difficult-to-treat areas, including the palms and soles.

“Phototherapy has largely gone by the wayside because it is so time-consuming,” Lebwohl said.

For patients new to systemic therapy, he discusses the advantages and disadvantages of oral therapies. For Lebwohl, the patient makes the final decision.

“Many patients don’t want to start with an injection, so they’d sooner or more readily accept an oral therapy,” Lebwohl said.

Oral Therapy for Palm and Sole Psoriasis

In unique areas such as the palms and soles, Lebwohl said molecule size may influence response. A JAK inhibitor is one of the most effective therapies he has used for palm and sole disease.

TYK2 inhibitors are similar in size and very small. Icotrokinra, an IL-23 receptor blocker, is only slightly bigger.

“For palm and sole, I often will go to one of those oral therapies,” Lebwohl said.

Prior Treatment History

Many of the newer oral therapies are more effective than apremilast, Lebwohl said, so patients previously treated with apremilast are easier to treat. A prior biologic does not rule out an oral therapy. According to Lebwohl, those patients are more difficult, however.

“You’re now dealing with a tougher patient,” he said.

Stronger Biologics and Combination Therapy

Patients who have not done well on a biologic often receive a stronger one, according to Lebwohl. All the IL-17 and IL-23 blockers used today are more effective than older TNF blockers. He may switch patients to bimekizumab, the newest approved biologic.

“Probably, in terms of PASI 100, it has the highest rates of any drug we’ve ever used,” Lebwohl said.

Lebwohl also uses combination therapy not infrequently. He adds an oral therapy for a patient on a biologic who is not doing well enough, and he described this as a common use for oral therapies.