PracticalDermatology

With a full toolbox of treatments, multiple new targets, plus a packed pipeline, psoriasis care has entered the realm of personalized medicine. George Han, MD, PhD, associate professor of dermatology and director of clinical trials and teledermatology at Zucker School of Medicine at Hofstra/Northwell in New Hyde Park, NY, discusses the current psoriasis treatment landscape.

What is the most exciting thing happening in psoriasis today?

George Han, MD: I’m especially enthused to see that since we have so many treatment options for psoriasis available and in development, we are starting to enter an era where not only excellent treatment outcomes are attainable, but we can start to fine-tune our approach to deliver more personalized medicine. This may mean choosing a medicine that considers comorbidities, is sensitive to patient preferences for dosing regimen or familiarity with self-injection, or family planning. We’re now beyond a simple “drug X works better than drug Y” paradigm and thinking more about which treatment approach works better for each individual.

With so many treatment options, how do you choose a therapy?

Dr. Han: Choosing a treatment is challenging, but it is really important to be familiar with the data. I find that overall, the average treatment responses are looking very similar across the newer targeted therapeutics, i.e., IL-17 and IL-23 inhibitors. So, we take factors, such as durability of treatment, speed of onset, comorbidities, and presence of psoriatic arthritis into account to guide our decision-making. I hope that as more studies and potentially comparator studies come out about treatment in special sites, we’ll be able to use that to help guide treatment.

What’s in the pipeline for the treatment of psoriatic disease?

Dr. Han: There’s still a lot of innovation going on in psoriasis. In the topical realm, it’s been quite some time since we’ve seen a truly novel mechanism of action approved for psoriasis, and we’re expecting potentially two to come to market in 2022 in the form of tapinarof, an aryl hydrocarbon agonist, and roflumilast, a phosphodiesterase inhibitor. These medications have the potential to truly simplify our topical treatment approach to psoriasis, solving the often-confusing grab-bag of treatments that our patients are facing: one medication for the body, another for the scalp, another for the face, all with varying time frames, including some that can only be used for two weeks. It’s no wonder that people come in with shopping bags full of topicals and are confused by what to use where and when.

In the oral treatment arena, deucravacitinib looks like it has the potential to be a game-changer, with efficacy responses much higher than any other oral we have available. It also looks good for special sites, such as the scalp, as well as for psoriatic arthritis. This TYK2 inhibitor seems to have a favorable safety profile, and other drugs targeting this pathway are further along in the pipeline. Last but not least, we will have a new entry in the IL-17 inhibitor family that expands our ability to target this pathway, blocking both IL-17A and F, the latter of which has been elucidated as an important contributor to the inflammatory cascade of psoriasis. With this more “complete” blockade of IL-17, bimekizumab is showing the highest-ever reported PASI 100 clearance rates, as well as potentially setting the gold standard for psoriatic arthritis treatment down the line.

Other medications, such as a nanobody targeting IL-17A and F, are in the works also. Even with all the treatments we have available for psoriasis today, the pipeline remains rich and thankfully, it does seem that all of these new entries will genuinely provide something novel and useful for our patients.

Are there obstacles related to getting these drugs to patients?

Dr. Han: Unfortunately, there are often challenges with getting appropriate treatments in the hands of our patients. This is not only with medications, but also treatments such as home phototherapy, which I think is very much underutilized. We’re up against confusing prior authorization policies, formularies that change seemingly on a whim, and now insurers directly reaching out to patients to incentivize them to switch their biologics (non-medical switching). It is no wonder that the majority of practices don’t bother fighting a denial with an appeal, and many just feel unequipped to handle prescribing biologics. We need a more transparent system where medical decision-making is what drives the coverage process and not obscure formularies dictated by back-room financial deals. I understand that insurance plans want to save money, but that principle should be secondary to our medical decisions, not vice-versa.

We need to continue working on advocacy, bringing attention to this subject, and emulating step therapy and prescriber prevails laws in some states that have been helpful in our fight to bring appropriate treatments to our patients.

Are biosimilars being used yet for the treatment of psoriasis?

Dr. Han: Biosimilars haven’t had a significant impact on the US market yet, due to litigation and various agreements. While biosimilar infliximab is available, its utilization in dermatology is not terribly high, so as of yet, we’re not really talking much about it. We should start thinking about this, though, as biosimilars for adalimumab will be available as soon as next year. The cost savings for insurers will almost certainly ensure that eventually we will have to also consider utilization of biosimilars. In thinking about the effect on the sustainability of our healthcare system, it’s not necessarily a bad thing that biosimilars may be used when appropriate. However, it’s important to note that some of these biosimilars may even possess a feature known as interchangeability, meaning that our prescriptions for adalimumab can be automatically converted to a biosimilar by a pharmacist.

We should all become a bit more familiar with biosimilars, so we’re not taken by surprise when they come to market.

Are dermatologists taking ownership of comorbidities in psoriasis patients?

Dr. Han: I think we all could do a bit better on recognizing and counseling patients on comorbidities. In our practices, we have competing interests ourselves and are often judged on metrics revolving around patient volume and revenue. Practically speaking, visit times are becoming shorter, and we have to be as efficient as possible in our patient encounters. However, a few words at the end of the visit—taking maybe a minute or two—could really help remind our patients that we’re not the only doctors they should be seeing. For psoriasis patients, I would prioritize asking a few quick screening questions about psoriatic arthritis.

We should also make sure they have a primary care doctor who is monitoring for diabetes/prediabetes, heart disease, and hypertension. Taking a moment to ask how a patient’s psoriasis makes them feel is important, as we can connect the patient to a psychiatrist to help manage mental health issues that may be affected by psoriasis. Patients also often ask about diet, so it pays to have a little familiarity with the topic or at least a good resource to direct patients to.

Will treating psoriasis early and hard reduce its downstream consequences and comorbidities?

Dr. Han: This, along with the idea of finding a cure for psoriasis, is basically the holy grail of psoriasis treatment and research. We have been seeing more attention being devoted to metabolic syndrome and other systemic comorbidities of psoriasis, which is a positive step. We have plenty of data implying a direct link between psoriasis and these comorbidities, including data showing that the inflammatory cytokines that are elevated in psoriatic skin are also elevated in the bloodstream and that these very same mediators underlie development of atherosclerotic plaques. But as of yet, we haven’t had convincing data that modulating this, such as with a systemic treatment, will actually have an impact. Most of this is because both the numbers and time needed for such a study are high, but I am optimistic that we will eventually be able to answer this question convincingly.