expert roundtables

Therapeutic Advancements for Patients With Moderate to Severe Plaque Psoriasis

by Steven R. Feldman, MD, PhD; Joel M. Gelfand, MD, MSCE; and Alice B. Gottlieb, MD, PhD

Overview

Today, classes of biologics for moderate to severe plaque psoriasis include the tumor necrosis factor (TNF) inhibitors, interleukin-17 (IL-17) inhibitors, therapies that target the IL-12/23 pathway, and specific IL-23p19 inhibitors. In addition to high rates of skin clearance, some of the newer therapies also offer a reduced dosing burden.

Q:

How has the treatment of plaque psoriasis advanced in recent years, and what are some persisting barriers?

Steven R. Feldman, MD, PhD

Professor of Dermatology, Pathology, and Social Sciences & Health Policy
Wake Forest School of Medicine
Winston-Salem, NC 

Over the past 30 years, I have witnessed dramatic improvements in treatments for patients with plaque psoriasis.”

Steven R. Feldman, MD, PhD

There had been a quantum leap forward in the early 2000s with TNF inhibitor therapy that I thought would never be matched. However, we have had yet another quantum leap, with the emergence of therapies that have greater efficacy and more precision in targeting psoriasis, potentially translating to greater safety. Some of these agents also offer less frequent dosing, with fewer injections. Today, classes of biologics include the TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, and the specific IL-23p19 inhibitors. So, over the past 30 years, I have witnessed dramatic improvements in treatments for patients with plaque psoriasis.

One barrier to treatment is that some patients are worried about the risks of the medicine in general, even when the benefit to risk ratio is exceptionally good. And, in recent months, some patients have been worried about their treatments in relation to their risk for COVID-19. Another barrier is that many patients are afraid of needles. Still, other patients may be afraid of the newer agents, not because of an aversion to needles but rather because of a misconception that therapies with greater efficacy must come at the cost of decreased safety.  

Joel M. Gelfand, MD, MSCE

Professor of Dermatology and Epidemiology
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA

“At all levels of disease, we have newer tools and agents that allow us to achieve better outcomes for our patients like never before.”

Joel M. Gelfand, MD, MSCE

The newer therapies that target IL-17 and the IL-12/23 pathway have major advantages in terms of absolute efficacy compared with the TNF inhibitors. More broadly, patients still prefer oral therapies, and we have seen some advances in that area as well, but not with the same efficacy of the biologics. However, the oral agents are certainly well tolerated. 

We have also seen major advances in the use of phototherapy, including the ability to provide targeted laser phototherapy and home-based phototherapy treatment. Finally, we have seen advances in topical combination products that are more convenient to use and more acceptable to patients, including modifications in the types of vehicles we can give patients, whether it be sprays or foams, which may increase compliance. At all levels of disease, we have newer tools and agents that allow us to achieve better outcomes for our patients like never before.

A challenge that many of our colleagues face, especially those in small practice settings, is that they may not have the support staff that is needed to manage biologics; not for safety reasons, but rather for access reasons, to deal with the administrative burden of a myriad of forms, to appeal to insurance companies, and things of that nature. Further, every January, smaller practices may be inundated because insurance companies often opt to change their policies, putting patients at jeopardy of losing access to their therapy. I practice in an academic medical center, and we are fortunate to have the resources to maintain that access, but it can become overwhelming for practices that do not have the personnel to manage this.

Alice B. Gottlieb, MD, PhD

Clinical Professor and Medical Director
Department of Dermatology
Mount Sinai Beth Israel
Kimberly and Eric J. Waldman Department of Dermatology
Icahn School of Medicine at Mount Sinai
New York, NY 

“For many patients, the greatest barrier to effective treatment is having limited access to newer therapies because of their high cost.

Alice B. Gottlieb, MD, PhD

I often tell my patients that we can aim to treat their psoriasis with the goal of them being able to “run around naked without anyone even knowing that they have psoriasis.” So, with respect to psoriasis, we can have very high expectations, and we can aim for high rates of skin clearance. Further, some of our biologics now are also effective in psoriatic arthritis, inhibiting radiographic progression, controlling the signs and symptoms, and improving quality of life. Regarding the question of treating plaque psoriasis to an appropriate target, the National Psoriasis Foundation says that an involved body surface area of 1% or less in 12 weeks is the target. This is a double-edged sword. Psoriasis is undertreated, and perhaps that was the motivation for this push, in terms of the target; however, I do not like the absolute nature of this target. If you consider narrow band UVB phototherapy, for instance, I would argue that very few patients would meet that target in 12 weeks. So, I think that this target may set up some of our treatments for failure.

For many patients, the greatest barrier to effective treatment is having limited access to newer therapies because of their high cost. For the first few years of our experience with a newer therapy, the pharmaceutical companies essentially give the drug away with the help of co-pay cards and co-pay assistance. However, Medicare, Medicaid, and other public insurance payors now forbid that. So, for this population, access is a huge issue. And the biggest problem, in my experience, is with Medicare, particularly with co-insurance and the donut hole. A second barrier to treatment with the newer therapies is that some dermatologists are unwilling to prescribe these drugs for many of their patients who could stand to benefit. They will reserve these newer drugs for only the most challenging cases, in part because it is untenable for them because they would have to have a full-time employee to manage prior authorizations and similar hurdles.

References

Armstrong AW, Read C. Pathophysiology, clinical presentation, and treatment of psoriasis: a review. JAMA. 2020;323(19):1945-1960. doi:10.1001/jama.2020.4006

Armstrong AW, Siegel MP, Bagel J, et al. From the Medical Board of the National Psoriasis Foundation: treatment targets for plaque psoriasis. J Am Acad Dermatol. 2017;76(2):290-298. doi:10.1016/j.jaad.2016.10.017

Gunter NV, Yap BJM, Chua CLL, Yap WH. Combining understanding of immunological mechanisms and genetic variants toward development of personalized medicine for psoriasis patients. Front Genet. 2019;10:395. doi:10.3389/fgene.2019.00395

Hawkes JE, Chan TC, Krueger JG. Psoriasis pathogenesis and the development of novel targeted immune therapies. J Allergy Clin Immunol. 2017;140(3):645-653. doi:10.1016/j.jaci.2017.07.004

Menter A, Gelfand JM, Connor C, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol. 2020;82(6):1445-1486. doi:10.1016/j.jaad.2020.02.044

Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029-1072. doi:10.1016/j.jaad.2018.11.057

Torres AE, Lyons AB, Hamzavi IH, Lim HW. Role of phototherapy in the era of biologics. J Am Acad Dermatol. 2020;S0190-9622(20)30711-8. doi:10.1016/j.jaad.2020.04.095

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