The psoriasis landscape has changed dramatically in recent years, and breakthrough discoveries in epidemiology, diagnosis, and treatment keep on coming. It’s an exciting time, to say the least, and Professor Peter van de Kerkhof, MD, PhD, Chief Medical Officer of the International Psoriasis Council in the Netherlands, has had a front row seat. Here, Dr. van de Kerkhof discusses some of the most exciting research in the field and shares insights on how COVID-19 affects the care of psoriasis patients.
What is the most exciting area in psoriasis research today?
Peter van de Kerkhof, MD, PhD: The most exciting step in psoriasis research today is the development of biomarkers, which hopefully will permit a personalized approach in the treatment of psoriasis. Research on pustular psoriasis has taught us that loss-of-function mutations of the IL-36 RN gene, encoding for IL-36 receptor antagonist, are associated with generalized pustular psoriasis and inhibition of the IL-36 pathway by BI 655130 monoclonal antibody against the IL-36 receptor. HLA-Cw6 is one of the most strongly associated psoriasis susceptibility alleles. The allele is associated with type I early-onset psoriasis. We have learned that HLA Cw6 positive patients show better responses to ustekinumab and worse responses to anti-TNF treatments.
There are so many biologics to treat psoriasis. How do you choose?
Prof. van de Kerkhof: The key is that we need the entire spectrum of biologics to have a personalized approach in the treatment of psoriasis. Based on psoriasis’ clinical phenotypes (for example, a patient with episodes of erythroderma) or based on severe symptoms, such as unbearable itch, we may decide to prioritize a fast-acting treatment. Some biologics are more or less active in psoriatic arthritis. The risk for tuberculosis prioritized anti-IL17 and anti-IL23 treatments above anti-TNF treatments. Last but not least, the perspective of the patient is essential to prioritize fast-acting biologics. In some patients, it is likely that they have to interrupt biological treatments for various medical reasons. If this is expected, treatment with an outstanding remission following discontinuation may be prioritized.
The major message: we need the full spectrum of available biologics.
What barriers to care remain?
Prof. van de Kerkhof: Access to systemic treatments is still not optimal. Patients with severe disease are still undertreated. Partly, patients are reluctant to try systemic treatments, and partly, dermatologists are reluctant to prescribe systemic treatments. Recently introduced treatments are more expensive, and these drugs are not available in all countries. In many countries, there are restrictions to the more expensive recently introduced biologics and access to the traditional systemics may also be limited.
Are we close(r) to a psoriasis cure?
Prof. van de Kerkhof: We are close to deep remission. We know that anti-IL17 and anti-IL23 biologics realize complete clearing of the skin in about 50 percent of patients. Prolonged remissions have been seen in these patients. Tissue-resident memory T-cells may remain for prolonged periods of time in the healed skin and may be important in early relapses. Biomarkers indicating whether deep remission has been realized may permit personalized long-term management of the disease.
What is known about psoriasis and COVID-19?
Prof. van de Kerkhof: If the patient has psoriasis, the chance of acquiring COVID-19 is not increased above the normal population, and the chance to be hospitalized for COVID-19 is lower for patients on biologics. When patients have signs and symptoms of active COVID-19, the general approach is to stop treatment with immuno-suppressive drugs.
The current vaccines for COVID-19 are not live vaccines, and patients with psoriasis are not contraindicated for these vaccines. So there is no increased risk of complications with these vaccines for patients with psoriasis, including patients on immunosuppressive treatments.
For further reading:
Bachelez B, Choon SE, Marrakchi S, et al., Inhibition of the Interleukin-36 Pathway for the Treatment of Generalized Pustular Psoriasis N Engl J Med. 2019; 380:981-983
Chen L, Tsai T-F.HLA-Cw6 and psoriasis. Br J Dermatol. 2018 Apr;178(4):854-862
IPC Statement on COVID-19 and Psoriasis. Available at: https://www.psoriasiscouncil.org/blog/COVID-19-Statement.htm
IPC Statement on SARS-CoV-2 Vaccines and Psoriasis. Available at:https://www.psoriasiscouncil.org/blog/IPC-Statement-on-SARS-CoV-2-Vaccines-and-Psoriasis.htm
Recommended
Sandra Marchese Johnson, MD, FAAD
Lucas Riley Johnson
Lesley Clark-Loeser, MD
