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Enhancing Psoriasis Care
Novel Therapies, Improving Adherence, and Reducing Disparities in Psoriasis Care

Released: September 16, 2022

Expiration: September 15, 2023

Steven Feldman
Steven Feldman, MD, PhD
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Key Takeaways:

    • The landscape for treating psoriatic diseases is expanding rapidly, including several novel therapies approved in only the past few years.
  • Differences in psoriasis therapies vary greatly from route of administration, efficacy and safety considerations, and access and affordability. Collaborating with patients in shared decision-making is critical to ensure patient satisfaction, medication adherence, and improved disease and quality of life outcomes.
  • Healthcare disparities in the management of psoriasis impact underrepresented minority populations; healthcare professionals are key players in identifying and addressing disparities to provide equitable care.

This commentary summarizes key takeaways on managing patients with moderate to severe psoriasis, as presented during the 2022 Dermatology Intensive titled Taking Patient Care to the Next Level: Addressing the Clinical Challenges Impacting the Management of Dermatologic Conditions

Broadening Treatment Landscape for Psoriasis

Over the past decade, psoriasis research has produced several revolutionary treatments targeting novel mechanisms of action, including interleukin (IL)-23p19 inhibitors (guselkumab, risankizumab, and tildrakizumab), IL-17 inhibitors (brodalumab, ixekizumab, and secukinumab), and, most recently, a tyrosine kinase 2 (TYK2) inhibitor (deucravacitinib). The most recent National Psoriasis Foundation (NPF) Pocket Guide and American College of Rheumatology/NPF guidelines recommend treat-to-target strategies for psoriatic disease. In psoriasis, the goal is reduction in body surface area (BSA) to 1% or less at 3 months, with maintenance evaluations every 6 months. These newer agents have made it possible to achieve the efficacy targets and improve patients' quality of life, yet many patients with moderate to severe psoriasis remain untreated or inadequately treated.

For patients with severe psoriasis, systemic therapy may be needed. Getting patients started on appropriate medications as soon as possible can facilitate symptom and disease improvement. If rapid improvement is not achieved quickly, the patient may grow frustrated and become lost to follow-up. A thorough evaluation of psoriatic disease involvement (including genital involvement that patients may be too embarrassed to bring up) may help with therapy selection. Psoriatic arthritis (PsA) is a common comorbidity; if either the psoriasis or PsA warrants systemic treatment, an anti-psoriatic agent with efficacy for PsA may be appropriate.

Involvement of the face or genitals may represent severe psoriasis because of severe impact on quality of life. Nail psoriasis may not respond to local treatment and may need systemic treatment if it is compromising quality of life. Scalp psoriasis can be very resistant to topical treatment, often due to poor treatment adherence as it is very difficult to apply topical to hair-bearing scalp. When planning treatment, consider the subjective severity of patients' symptoms and responsiveness to other treatments.  In many cases, systemic therapy may be needed.

Engaging Patients in Shared Decision-making to Improve Satisfaction and Adherence

Despite advances in therapeutic options, patient and disease outcomes can only improve if patients are able to access and adhere to prescribed regimens. Patients may be asked to do things that they don't want to do or can't do. We should consider the costs, access, daily burden of use, adverse effects, and necessary support for patients to choose and continue a therapy that fits their goals, resources, and lifestyle. Following up with patients in a timely fashion, particularly after starting or changing a therapy, may promote better adherence. Patients often do not even fill recommended psoriasis treatments. If we send patients out with a prescription and don't have any follow-up with them for 3 months, it shouldn't be surprising if they don't fill, start, or regularly use the recommended treatment. Building a rapport with patients and creating a sense of accountability by engaging them in therapy planning through shared decision-making and following up on treatment progress can improve patient satisfaction and increase adherence to therapy.

Addressing Healthcare Disparities in Psoriasis Care

There are many barriers to accessing psoriatic care. One huge barrier is related to the lack of access to medical dermatology services. Dermatologist offices are often clustered in large cities, and many counties in the US have no dermatologists at all. Unfortunately, this lack of access is more pronounced in areas more heavily populated by racial and ethnic minorities and those in lower socio-economic brackets, compounding disparities of care for these groups. Even if clinics are within reach, they may offer more cosmetic than medical services. In addition, government funded insurances like Medicare and Medicaid impose limits on what is covered for these services. Some offices limit the volume of patients they will see who are uninsured or underinsured. Finally, patients may not realize that there are support programs that may allow them access to costly medications.

As a result, patients in need of dermatology care may not be aware of where to go or how to access care. When they do need care, they may go to centers closest to them like public hospitals, which may or may not have a dermatology department or residency program. In that case, they may see a different clinician each time and lose the opportunity to develop a consistent relationship or rapport with their healthcare professionals. As happens often throughout healthcare, underrepresented minorities may not be able to find clinicians that look like them or who fully understand their cultural background or preferences.

Recognizing disparities due to lack of healthcare access, insufficient representation of minorities in clinical studies, and representation in commercial advertising can help expand cultural awareness and aid healthcare professionals in addressing personal needs and goals on an individualized basis with each patient. Spending time to learn more about patient and population needs and educate clinician-learners, peers, patients, and community stakeholders about healthcare disparities may help expand equitable access.

Your Thoughts
What are your thoughts and questions on managing patients with moderate to severe psoriasis? Please join the conversation by posting a comment in the discussion section below.

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