Essential Truths for the Care and Management of Moderate-to-Severe Psoriasis

August 2015 | Volume 14 | Issue 8 | Original Article | 805 | Copyright © August 2015


Andrew Blauvelt MD MBA,a April W. Armstrong MD MPH,b Gerald G. Krueger MDc

aOregon Medical Research Center, Portland, OR
bUniversity of Colorado Denver School of Medicine, Aurora, CO
cUniversity of Utah, Salt Lake City, UT

Abstract
Psoriasis is a systemic inflammatory disease. Effective management requires treatment with agents targeting inflammation in skin, joints, and other tissues. Biologics for psoriasis are directed at more specific targets, have a better safety profile, are better tolerated, and are more effective than conventional systemic agents. Despite these advances, many patients with psoriasis remain undertreated, and overall patient satisfaction remains low. The dichotomy between ideal therapeutic outcomes and suboptimal outcomes (which are currently commonplace) is likely largely due to misperceptions about psoriasis and biologic treatments. This article discusses these misperceptions, including the notions that psoriasis is a benign disorder, and that conventional systemic therapies are safer than biologics and adequate for most patients with moderate-to-severe disease. We present practical and evidence-based discussions to refute these misconceptions and provide useful resources for providers and patients that support access to advanced therapies. We believe that biologics represent optimal treatment for most patients with moderate-to-severe psoriasis, and until more effective approaches are generated, these efficacious and target-specific approaches should become the standard of care.

J Drugs Dermatol. 2015;14(8):805-812.

INTRODUCTION

Since the 2000’s, an interesting dichotomy has emerged in the management of patients with moderate-to-severe psoriasis. Results from clinical trials of biologics demonstrate that clear or nearly clear skin is now a realistic and achievable treatment goal.1-3 High levels of skin clearance (defined as Psoriasis Area and Severity Index [PASI] ≥ 90 or Physician Global Assessments [PGA] of 0 [clear] or 1 [almost clear]) have led to significant improvements in health-related quality of life compared with patients who achieve PASI 75 or PGA scores of more than 1.5.4-6 Despite these advances, surveys conducted from 2003–2011 indicate that under-treatment of psoriasis remains a significant problem.7 Up to 49%, 36%, and 30% of patients with mild, moderate, and severe psoriasis, respectively, reported receiving no treatment, and 20%–30% of patients with moderate or severe psoriasis reported treatment with topical medication alone. Additionally, dissatisfaction with treatment is reported by more than half of patients.7
High levels of under-treatment and patient dissatisfaction, despite the availability of agents capable of providing clear or nearly clear skin, indicate that many dermatologists have chosen not to meet the needs of many patients with moderate-to-severe psoriasis. Although some may consider treating to clearance to be an aggressive therapeutic strategy, we believe that this is a rational therapeutic goal in the current practice environment. In particular, we note that patients treated with biologics report the highest overall satisfaction ratings.7,8 Specifically, patients treated with biologics as monotherapy or in combination with methotrexate reported median ratings of “very satisfied.”8 More importantly, therapeutic satisfaction correlated with reduced PASI scores, highlighting the importance of clear skin to patients. We posit that the “treat to clear” approach is not aggressive; rather, it is the appropriate care for the 21st century and should serve as the standard of modern care for moderate-to-severe psoriasis.
The question then becomes: why is there reluctance to use therapies that achieve these treatment goals and increase patient satisfaction? We believe that the answers lie in currently held misperceptions about treating psoriasis and, more specifically, about treating patients with biologics. To this end, we have investigated misperceptions that serve as the basis for suboptimal disease management (Table 1), and we present data to refute these beliefs. It is our hope that, after reviewing these data, dermatologists will reconsider their treatment rationale and help patients achieve “treat to clear.”

Misperception 1: Psoriasis is a cosmetic and/or trivial disease that does not require systemic therapy

It is well established that psoriasis is not a benign dermatologic condition but a systemic inflammatory disease associated with prominent skin and joint manifestations and a significant number of physical and mental comorbidities.9 In addition to skin-related symptoms,10,11 approximately 25% of patients with
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