Treating Psoriasis in 2015

At the Maui Derm for Dermatologists meeting in January, the “Psoriasis 2015” session—moderated by Bruce Strober, MD, PhD, Associate Professor and Vice Chair at the University of Connecticut School of Medicine—included discussion of topics ranging from the metabolic impact of psoriasis to new drugs in 2015 to the immunology and genetics of psoriasis.

Ahead is rundown of some of the key take-away points from each presentation.

What’s New and On The Horizon

Dr. Strober started the session by providing an overview of several new drug approvals that he said he believes could change many views on treatment options. In 2018, he explained, there might be 15 or 16 approved systemic drugs for moderate to severe psoriasis, adding that many of these—some of these newer biologics, particularly IL-17 inhibitors and IL-23 inhibitors—achieve extraordinarily high efficacy.

“One of the biggest failures of the [older] drugs for psoriasis is that they don’t keep working,” he said.

He provided a detailed report on apremilast (Otezla, Celgene), which was FDA-approved last March for the treatment of adults with active psoriatic arthritis. The drug was the first FDA-approved oral agent for the disease. In September, it was also approved for treatment of severe plaque psoriasis.

He also singled out ustekinumab (Stelara, Janssen) during his presentation as a biologic to continue to keep an eye on. “Ustekinumab is consistently superior with regard to most aspects of drug survival,” he explained.

Craig Leonardi, MD, Clinical Assistant Professor of Dermatology at St. Louis University Medical School, agreed that the way we think about psoriasis treatment will soon change. According to Dr. Leonardi, the main take-away from his look at highly effective treatments of psoriasis in the first quarter of this year is to “hold onto your hats.”

Things are moving fast with new kinds of treatments. “Be prepared,” Dr. Leonardi said of the advancements. “This is nothing short of a revolution—a renaissance.”

According to Dr. Leonardi, new biologic agents, phototherapy, and small molecules have thrown conventional wisdom of treatment out the window. He pointed out the FDA Advisory Board’s look at secukinumab (Cosentyx, Novartis) back in October, which led to the drug gaining approval in January for treatment of adults with moderate to severe plaque psoriasis. “Novartis ran a masterclass,” he said. “It had everyone falling off their chairs in shock.”

The Key to Avoiding Relapse

Linda Stein-Gold, MD Director of Dermatology Clinical Research at Henry Ford Health System in Detroit & Division Head of Dermatology at Henry Ford Health System in West Bloomfield, MI, discussed how long patients who respond to treatment should continue therapy. Can you and should you continue treatment when a patient no longer shows signs of psoriasis? According to Dr. Stein-Gold’s research the answer is yes. “I think if you want to treat with a topical,” she said. “Continue even if they’re clear.”

To avoid replapse, twice-weekly application of a topical therapy for 12 weeks is the most effective course of action, according to Dr. Stein-Gold. The continued use is associated with a lower rate of relapse (19.5 percent vs. 41.7 percent).

“If we want to keep our patients under control, we can’t stop therapy,” she explained.

Beyond the Skin:
Treating the Whole Patient

Joel M. Gelfand, MD, MSCE, Associate Professor of Dermatology and Epidemiology, University of Pennsylvania’s Perelman School of Medicine, reminded the audience that psoriasis is not just a skin disease. It’s a systemic disease that also attacks patients internally.

According to Dr. Gelfand, there’s a greater chance for cardiovascular disease associated with psoriasis than the cardiovascular risk associated with diabetes and hypertension.

“Should we aggressively treat psoriasis to lower the risk of cardiovascular disease?” he asked the audience. “We don’t know the answer for certain.” He suggested the first step is to begin educating patients about the potential risks. “I encourage you to think about disease differently, as well,” he added.

Psoriatic Arthritis: The Importance of Early Diagnosis

In addition to comorbidities like heart disease, Arthur F. Kavanaugh, MD, Professor of Medicine at the University of California, San Diego School of Medicine, warned that psoriatic arthritis goes undiagnosed in many patients. “Only half of the patients are diagnosed and only half of the diagnosed patients receive drug treatment,” he said.

Dr. Kavanaugh said he calls patients and asks them what they’re taking for their disease. He said a lot say they’re taking nothing. “There’s a lot of work we can do,” he added.

Dr. Kavanaugh said he’s optimistic that things are changing and that more patients and doctors are aware of psoriatic arthritis, adding that there’s a misconception that it’s not as serious as rheumatoid arthritis. Believing a delay in diagnosis correlates with worse outcomes for patients, Dr. Kavanaugh said, “I think we can do better. I think we will do better.” n