Physician Spotlight: Lawrence Green, MD

Multiple new psoriasis treatments aimed at various targets in the immune cascade have been developed over the past few years. These medications are changing the way that physicians treat psoriasis, but cost and prior authorization remain significant barriers for many patients. Lawrence Green, MD, a clinical professor of dermatology at the George Washington University School of Medicine in Washington, DC, provides an update to Practical Dermatology® magazine and offers a sneak peek into the psoriasis treatment pipeline. An active clinical trialist, Dr. Green also serves on the National Psoriasis Foundation’s Board of Directors and is the chair of the foundation’s Research Committee.

What is the most exciting thing happening in psoriasis care today?

Lawrence Green, MD: We have had many innovations in treating severe psoriasis in the past 20 years with biologics and new oral medications. Now, we are seeing innovation with topicals that can be used as monotherapy or adjunctive therapy with systemic medications. The introduction of two new nonsteroidal topicals—tapinarof cream 1% (Vtama, Dermavant Sciences, Inc) and roflumilast cream 0.3% (Zoryve, Arcutis Biotherapeutics)—is revolutionary because there has been little innovation in topical therapy for psoriasis since the 1950s.

Topicals introduced in the 1990s, such as calcipotriene and tazarotene, either were not effective or were too irritating for prolonged use on some parts of the body, so they were never embraced as monotherapy. The new creams can and will be used as monotherapy. They can be used on any place on the body once daily no matter how thick or thin the spots are. In my opinion, there is no reason to use topical steroids to treat mild to moderate psoriasis anymore. These new topicals are much safer and just as, if not more, effective. They are also much easier to use. You can’t use steroids on the face, scalp, groin, or underarms, but these creams can be used anywhere on your body once a day until you are clear. There is no risk of thinning of the skin, erythema, or steroid-induced rosacea on the face. I believe we will see a paradigm change in mild to moderate psoriasis care due to these new creams just like biologics changed care for severe psoriasis.

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

Dr. Green: There are a lot of exciting things in the pipeline for psoriasis. Topical roflumilast foam is the foam formulation of a highly potent and selective phosphodiesterase-4 inhibitor that Arcutis Biotherapeutics is developing for the treatment of inflammatory dermatoses, particularly in hair-bearing areas such as the scalp. The first approval will likely be for seborrheic dermatitis, but an approval for scalp psoriasis won’t be far behind. The foam is versatile and elegant, and patients really like it. We will also see more selective tyrosine kinase 2 (TYK2) inhibitors in the future. Bristol Myers Squibb brought the first TYK2 inhibitor, Sotyktu (deucravacitinib), for plaque psoriasis to market in 2022. Takeda Pharmaceutical Company is starting a phase 3 study of its TYK2 inhibitor, NDI-034858. (Takeda bought Nimbus Therapeutics in December 2022.)

Bimekizumab (UCB), the first human monoclonal antibody to exert simultaneous specific inhibition of interleukin (IL)-17A and IL-17F, is finally coming. It should be available in the second quarter of 2023. Bimekizumab is possibly more effective than other IL-17 blockers because it inhibits both IL-17A and IL-17F. Biosimilars are also coming, but the currently available agents target tumor necrosis factor-alpha, not IL-17 and IL-23. Tumor necrosis factor inhibitors are not as widely used in psoriasis anymore, so these biosimilars may not have a profound effect on patient care.

Has access to newer systemic psoriasis medications improved?

Dr. Green: No, prior authorization requirements remain a barrier for patients. I would estimate that half of my patients are getting medications from the manufacturer directly for free because insurance companies won’t cover the cost of these medications. It is a huge problem. Many patients experience flares as they wait to be denied and then get the medication for free from its manufacturer. Many of these biologic medications are not even on insurance company formularies, so we can’t even do step therapy because the medication does not exist on their formularies to step to.

Are dermatologists taking ownership of comorbidities in patients with psoriasis?

Dr. Green: It’s very important to see psoriasis as a systemic inflammation process that affects the whole body, not just the skin and joints. It leads to and exists with a host of comorbidities. I am hoping that dermatologists will treat comorbidities or refer these patients out for treatment. There’s a lot of evidence that says, yes, treating psoriasis early and aggressively with biologics will reduce comorbidities. It makes sense that, if we reduce inflammation, we will have positive effects on comorbidities, but we don’t have absolute proof yet.