We can distill barriers down to 2 major categories (ie, physician-based and patient-based barriers) while acknowledging that payor-based barriers influence both. The costs of high-priced therapies are clearly a barrier for payors; if a patient does not have good commercial insurance, getting access to expensive, modern biologics or small-molecule therapies is a challenge.

Some physician-based barriers are the result of these payor barriers. Not all practices have the resources to devote to the prior authorization process—a Byzantine, time-consuming process that varies by insurance company and by drug. In my office, we have more than 1500 patients on biologic therapy, so we employ 2 individuals full-time to serve upwards of 7 providers, just to go through the prior authorizations and ensure that patients have access to these therapies. Ultimately, in practices that do not have these resources, patients may not have as much access to effective treatments. An additional potential physician-based barrier is the time it takes to learn and develop the necessary expertise to use these newer, highly effective agents; some clinicians may be reluctant to embark on that journey.

Another important physician-based barrier is having a threshold that is too high for a disease worthy of systemic therapy. In clinical trials of systemic psoriasis therapies, typical patients might have a body surface area (BSA) of more than 10% and a Psoriasis Area and Severity Index score of 12. However, in practice, the use of such criteria would exclude patients who should benefit from biologic therapy, especially those with special areas of involvement, such as the hands and feet, in whom the BSA will never reach 10%.

To help overcome this barrier, the International Psoriasis Council used a modified Delphi approach, with blind voting, to develop a more common-sense definition of disease that warrants systemic treatment. Our recommendation was that patients should be on systemic therapy if they met any 1 of the following 3 criteria: a BSA of more than 10%; failure after an earnest try of topical therapy; or special area involvement, such as the scalp, palms and souls, genitals, or nails. If any of these areas are severely affected and not responsive to topical therapy, systemic therapy is indicated. This is important because, if we do not think in these terms, access is denied and there is a barrier to appropriate care for patients in need.

Patient barriers, such as misgivings about the need for treatment, can also be important. Online information may disproportionately emphasize risks, and patients may have concerns about their immunity or the need for monitoring. Or they may have a bias against the use of a systemic medication, particularly if it is an injectable. Injectable therapies are among the safest and most effective drugs that we use.  However, some patients might find injectable therapies to be scary, or they may believe that we are using a “bigger gun” than is needed or that they are somehow less safe than oral therapies. From my perspective, the opposite is true. As relates to monitoring and safety, there are likely more challenges associated with oral therapy.