Various pharmacologic and nonpharmacologic treatment options are available for patients with plaque psoriasis, and the treatment that patients receive is largely determined by their disease severity. Treatment options for limited and more severe psoriasis were highlighted at the Society of Dermatology Physician Associates (SDPA) 22nd Annual Fall Dermatology Conference.

Following these proceedings, featured expert Steven R. Feldman, MD, PhD, was interviewed by Conference Reporter Associate Editor-in-Chief Christopher Ontiveros, PhD. Dr Feldman’s clinical perspectives and consolidation of these highlights are presented here.

Back when I started practicing in the 1990s, we did not have medicines like we have today that can often completely clear up plaque psoriasis with few to no side effects. Instead, we had drugs such as methotrexate and cyclosporine. So, as discussed during my presentation, “Psoriasis Essentials: A Beginner’s Guide to Diagnosis and Management,” at the recent SDPA 22nd Annual Fall Dermatology Conference, the first step of caring for patients with psoriasis, especially moderate to severe psoriasis, back then was to address their psychosocial needs because they were going to have to learn to live with their disease. To address these psychosocial needs, I strongly encouraged my patients to join the National Psoriasis Foundation (NPF). Even today, I think that this is still a helpful recommendation so that patients can learn about all the treatment options, find information on managing and living with psoriasis, and feel empowered to work toward a cure for their disease.

Many patients with psoriasis develop psoriatic arthritis, so the next step in my algorithm is to make sure that I ask my patients about their joints. If they have joint stiffness, joint pain, or back pain (which they may not recognize as a form of arthritis), I might put them on an NSAID, and I would encourage them to see a rheumatologist to get their joints evaluated and managed.

Next, I address clearing the lesions, and my algorithm splits into treatments for localized psoriasis vs generalized psoriasis. If a patient has limited disease and just needs a topical agent, I work very hard to get them to use the topical. However, if they have limited disease and I prescribe topical therapy, and they do not get better, it is almost surely because they are not using their topical. During my session at the SDPA meeting, I spoke about our 1-year study of adherence to a strong topical steroid in patients with psoriasis in which we instructed patients to use the medication every day. The long-term adherence was so abysmal that the British Journal of Dermatology allowed us to use the word “abysmal” in the title of the paper. I think the main reason that patients do not use their medicines is because they often need more guidance from their doctors on how to use them effectively, and this extra guidance can help patients adequately adhere to treatment.

For those who have more than limited disease, I think about giving them phototherapy or a biologic. Some patients prefer phototherapy because they do not want to put anything in their bodies. If you do not have a light box in the office, I think that it would be reasonable to prescribe a home light unit. For patients with extensive psoriasis, a home light unit that would last a lifetime probably costs less than the first 2 or 3 months of a biologic treatment. The LITE study by Joel M. Gelfand, MD, MSCE, from the University of Pennsylvania and colleagues was enlightening. They compared home light treatment with office light treatment under pretty much real-world conditions. Ultimately, home light treatment not only was as effective as office light treatment but also gave patients greater quality-of-life improvement because there is a lot less hassle in undergoing phototherapy in your own bedroom than in a doctor’s office several times per week.

Biologics have been revolutionary for psoriasis. I did not think that I would see another quantum leap forward in psoriasis management after the development of TNF inhibitors. Now I rarely prescribe TNF inhibitors because IL-23 and IL-17 blockers are more effective and safer. IL-17 blockers are faster-acting than IL-23 blockers, and IL-23 blockers seem to be marginally safer than IL-17 blockers.

Finally, sometimes insurers want patients to try methotrexate before they cover a more costly biologic. If you do need to prescribe methotrexate, make sure to order the appropriate laboratory work at baseline and then follow up with your patient on a regular basis. I like to give the NPF brochure on methotrexate to my patients. It includes information on all the risks and benefits of methotrexate, as well as treatment alternatives, to help address the common treatment-related questions and scenarios that arise.