Patient-reported outcomes in psoriasis studies indicate the profound impact of the disease on health-related quality of life. New systemic treatments have levels of efficacy that may help patients achieve clear or nearly clear skin, which could change patient perceptions of treatment-related outcomes. Physicians need to proactively incorporate patient-identified treatment goals into shared decision making to optimize medication adherence and patient-reported outcomes.

Understanding patient goals and setting realistic expectations at the start of plaque psoriasis treatment are of the utmost importance. There can be a disconnect between patient and dermatologist perceptions of psoriatic disease severity and treatment efficacy, and addressing this disconnect is key to a positive patient-physician relationship.

I had a recent patient encounter that reinforced this idea. This patient expected their biologic therapy to work very quickly. However, it can often take some time to see results with many of these treatments, and just how long it takes will depend on the therapy selected and the loading dose used. As clinicians, we tend to think about assessing efficacy at the 12- or 16-week follow-up, but our patients might expect to see results within 1 or 2 weeks, or even faster. They might even stop taking the medication before they return for a follow-up visit because they perceive that it is not working. These challenges occur not only in plaque psoriasis but also in many inflammatory skin diseases. Therefore, an upfront and honest discussion with the patient before starting therapy will help set realistic expectations and will, hopefully, empower the patient to continue therapy.

It is also important to understand the patient’s perspectives regarding the effects of plaque psoriasis on their quality of life and what bothers the patient the most about their disease to help guide treatment decisions. Sometimes the sequelae of plaque psoriasis have more of an impact on the patient than the disease itself. For example, as psoriasis resolves—especially in patients with darker skin tones—it may leave either lighter or darker spots in the areas where there was active disease. The disease caused this, not the treatment. However, if we do not explain this potential effect to patients in advance before starting therapy, they could think that it is a side effect of the medication. They might feel that the agreed-upon treatment decisions actually made them worse than they were before they started medication, and they may not understand why the medication is not improving the appearance of their skin as they expected. On the other hand, setting reasonable expectations before starting therapy can positively impact the patient-physician relationship and adherence to future interventions.

Clinicians typically define clearance as a lack of active disease, but we need to explain to patients that clearance can include residual effects that are likely to be a part of their new normal. It is also beneficial to prepare patients before starting therapy for any expected potential medication-related adverse events. One example is the burning that is associated with topical calcineurin and PDE4 inhibitors. If patients are not aware of this possibility, they may think that they are having an allergic reaction to the treatment and may stop using it. The same goes for the risk of injection site reactions with injectable medications. When we prepare patients for potential adverse events, they are less concerned and are more likely to continue treatment if reactions happen.

The initial visits with patients are critical to discuss their psoriasis and why a certain treatment plan may be best for their specific presentation. Optimizing the overall care of plaque psoriasis requires collaboration and education up front from clinicians to set patient expectations, as well as ongoing communication between patients and physicians to address any challenges that may arise.