Transcript
Ted Lain:
The International Psoriasis Council put out a paper talking about the characteristics of disease that would qualify someone for a systemic agent. And historically, we've looked at the inclusion/exclusion criteria for systemic therapies in psoriasis, so BSA of 10, PASI of 12, IGA of 3, of moderate at least. But of course, we have so many patients who don't meet those criteria, but still should be on a systemic. They deserve it. Whether it's scalp involvement, genital involvement, hand/foot involvement, special site involvement, for example. But the IPC did something really interesting and they said, look, BSA 10% or more qualifies and/or special site involvement of any of the sites that I just mentioned qualifies for systemic disease. And/or if a patient has failed two four-week cycles of topicals, if they just can't get a topical that works within four weeks to control their disease and they tried another one, then they deserve a systemic.
It's a bold statement. And now with some of these newer oral therapies out, which make it much more manageable for patients, I think we're going to see a lot more on systemics, but I think we need to take a step back, especially for those low BSA involved patients. When we say a topical has failed, does that mean a topical with a skincare regimen? Because that's what this study really tells you is that the skincare regimen is the Ironman suit to a topical. It can make it work better. And so perhaps we need to do a little corollary to the IPC guidelines and say a four-week trial with good topical OTC adjuvant therapy to ensure we're doing the very best we can with these topicals. Because as we know, you move from topicals to systemics and you're talking about exponential increase in cost to the system.
And so I don't know if you guys agree with that, but it just hit me that, my goodness, these results show that a topical alone is probably not sufficient. We have to surround it just like we do with other inflammatory skin diseases. Zoe, what do you think?
Zoe Diana Draelos:
No, I fully, fully agree. And the thing is, even though those recommendations are made, that doesn't mean that payers are going to adhere to them. So just because they came out and said that, they still want you to start with triamcinolone cream, 0.1%. It is indeed unfortunate. But even with biologics,
Many people with psoriasis still have dry, scaly skin, especially over elbows and knees. And so there's still a need for good skincare. Even if your plaque is completely clear, many psoriatics still have scaling over the joints. That is quote dry skin, but it still needs treatment. And we don't know that it could be subclinical psoriasis either. So I think skincare is necessary no matter what kind of biologic you're taking, no matter what kind of topical you're making. And then the dermatologist really needs to customize skincare for the body area, for the extent and the needs of that particular patient.
Ted Lain:
Yeah. Firas, I mean, it's pretty interesting to start thinking about how we optimize the prescription topical regimen with these OTC products so that we don't get to a four-week burnout or a four-week failure. I mean, four weeks is really short, isn't it? And you mentioned this eight-week trial was pretty short for topicals. What do you think would be a good amount of time to give a prescription plus OCC topical regimen before you pull the plug on it?
Firas George Hougeir:
Well, the last thing I want to do is delay treatment that is needed. And remember, the patients in these studies were kind of skewed because they had, despite systemic treatment and topical treatment, they had to have at least a BSA of 3%. They had to have a plaque where you were looking at induration, scaling, erythema to be at least six. So you had some things that weren't exactly working for them. What this showed us is that skin treatment and skin care while treating psoriasis is extremely, extremely important throughout, by the way, topicals and non-topicals. We did have some non-topical treatments as well. I believe, yes, this will, in fact, if we do a good job at educating our patients and at a skincare regimen, it will in fact slow down and potentially prevent the path of topical systemic to biologic. I agree with that. I think four weeks of a topical, depending on which one we are using and what we're using it for is sometimes too long, sometimes too short, but I think whatever we do, we should give it the best shot at success.
And this is really a basic education and discussion to have with our patients using a skincare regimen to help with their psoriasis treatment. So adding it, I think, would be good. And then how long we keep it, what's the success depends a lot on what topical we're using, how the patients are doing, and really the extent of their psoriasis.
