The impact of psoriasis on those it affects extends well beyond the disease itself. Patients with psoriatic disease get less sleep per night and are more likely to experience anxiety and depression, among other things. These facts signal the importance of new therapies and heightened public awareness, to encourage those with psoriasis to seek and receive optimal treatment. As National Psoriasis Awareness Month (August) approaches, efforts continue both in the clinic and in advocacy to boost awareness and education and to increase access to treatment.
A Serious Disease
Despite mounting evidence showing the sweeping impact of psoriasis on patients, questions abound regarding the seriousness with which clinicians should approach the disease, according to Alan Menter, MD. “Much of the buzz regarding psoriasis therapy, whether for biologic agents or otherwise, has been geared toward moderate to severe disease,” says Dr. Menter, which is generally disease of 10 percent Body Surface Area (BSA) or more. By extension, there seems to be a prevalent misguided notion that topical monotherapy constitutes an appropriate approach for the majority of patients with mild to moderate disease. However, Dr. Menter observes that the extent to which psoriasis affects an individual does not often cut along the lines of BSA. “For example, scalp psoriasis, which does not cover a large area, is known to cause patients quite a bit of personal turmoil,” he says. Additionally, patients with less disease may have their personal lives inhibited by time spent itching and clothing choices, he adds. “For many of these patients, it gets tiring to apply a topical cream twice daily, ad nauseum,” observes Dr. Menter. Therefore, he continues, clinicians should perhaps consider the use of systemic and biologic therapy more seriously.
Efforts to understand and treat the disease should be geared toward understanding the systemic nature of the disease, which has been tied to various inflammatory conditions and cardiac issues. “We are now beginning to better understand the systemic nature of the disease, which extends beyond just the severe end of the spectrum,” says Dr. Menter. Several recent and ongoing studies are helping to elucidate the complicated picture regarding comorbidities. For example, a recent poster found that young patients with psoriasis are more likely to be obese than their non-psoriatic counterparts, notes Dr. Menter. With issues such as obesity, metabolic syndrome, diabetes, and cardiovascular disease being tied so closely to psoriasis, the consensus appears to be growing that psoriasis is an independent risk factor for many of these conditions. In addition, compelling new data highlight the potential role of TNF inhibitors in decreasing the risk for cardiac issues.
Given the greater focus on psoriasis as a systemic disease and comorbidities, Dr. Menter suggests that dermatologists should play an integral role to ensure that the full scope of the patient's condition—comorbidities and general well-being—is being addressed. “Many patients may not want to share information regarding their day-to-day lives or their mental status, but it is important that clinicians maintain a comprehensive medical perspective,” says Dr. Menter. These efforts will include interaction with colleagues in family medicine and internal medicine.
Awareness Efforts and Advocacy
At the forefront of many efforts to raise awareness and increase education is the National Psoriasis Foundation (NPF), the world's largest organization serving individuals with psoriatic disease. According to Sheila Rittenberg, Director of Advocacy for the NPF, a variety of ongoing and upcoming efforts allow both physicians and patients to get involved. “Current initiatives include expanding on research to find a cure by funding cutting-edge projects through research grants and medical dermatology fellowships, as well as hosting the world's largest psoriasis and psoriatic arthritis DNA Bank,” notes Ms. Rittenberg. The NPF also organizes Outreach initiatives, which include the Walk to Cure Psoriasis in more than 20 cities around the US, educational webcasts, affiliated support networks, a One to One peer mentoring program and social media sites (Facebook and TalkPsoriasis.org).
The NPF also plays a strong role in organizing and funding research. On the recent links discovered between psoriasis and other serious diseases, Ms. Rittenberg notes that that the NPF, “works with the medical community to educate people about these associated diseases and what they can do to minimize their risks. We fund several research grants that focus just on trying to learn more about psoriasis and these associated health concerns.”
There is also advocacy to increase federal support of psoriasis research and to improve access to care, says Ms. Rittenberg. A bill recently introduced in Congress sheds light on the seriousness of psoriasis and psoriatic arthritis and advances the national efforts to find cures. “If passed, The Psoriasis and Psoriatic Arthritis Research, Cure, and Care Act of 2011 (PPARCCA) will secure $1.5 million a year (2012- 2017) to continue the psoriasis data collection project,” says Ms. Rittenberg. It calls for a six-year investment toward understanding the public health impacts of psoriatic disease.
The NPF continues to pursue solutions to soaring copays for phototherapy treatment for psoriasis, according to Ms. Rittenberg. “Having piloted an initiative in the state of Illinois, the Foundation is working with a national phototherapy task force to turn around high copays for this safe and reliable treatment modality,” she says. There are also efforts to eliminate specialty tiering, through which patients are charged 20 percent for expensive complex medications such as biologics.
Ms. Rittenberg observes that, “Physicians can work with the National Psoriasis Foundation on providing their patients with the most current information through our patient literature and booklets, attending our medical events, such as Chief Residents Meeting, which trains the next generation of psoriasis experts on the disease,” says Ms. Rittenberg.
On the Horizon
With great strides having been made recently in clinical studies, Dr. Menter predicts that upcoming data in various streams will help clinicians to better understand and treat psoriasis. “Several reports are due out this year examining a range of issues, such as cardiac issues in IL-12/23 agents and more work looking at how particular therapies impact or fail to impact comorbidities,” he says.
A number of promising agents in development may play a role in the future of psoriasis therapy. This is particularly encouraging, given the great need for new molecules, notes Dr. Menter. “The most potent topical agent we have today, clobetasol (Clobex, Galderma), was approved in 1972, so we are certainly in need of a significant number of new topical therapies,” he explains. Exciting new developments regarding the discovery of new genes and potential pathways to mitigate inflammation offer great potential for the innovation of new agents, according to Dr. Menter.
Briakinumab (Abbott), is still completing phase III trials after Abbott withdrew its marketing application in January. Ustekinumab (Stelara, Janssen Biotech) is in phase III clinical trials for the treatment of psoriasis in adolescents and the treatment of psoriatic arthritis.
A Bright Future
While there is more work to be done to boost education and research new therapies, the number of promising developments in research may signal a brighter future for those with psoriasis.
For more information on the National Psoriasis Foundation and its advocacy efforts, visit www.psoriasis.org. For additional resources on psoriasis management and awareness, visit www.practicaldermatology.com on July 21 or after. Click “Skin Disease Awareness.”