We are now in an age of treatments for psoriasis that some patients perceive as very expensive or risky, and yet, these patients have a skin disease that can be incredibly debilitating and significantly impacts their quality of life.
More than ever, especially in more severe cases of psoriasis (based on total body surface area or on visible areas affected such as the face, scalp and hands), treatment decisions need to be in concert with your patients. This means that they need to be as informed as possible since there have been significant advances in treatment options in the last decade. In addition to educational materials and counseling, I encourage people to go the National Psoriasis Foundation Web site at https://www.psoriasis.org, perhaps join with a minimal contribution, so they can be part of the decision-making process and educate themselves so that we can have a really good discussion on what things might help them balancing benefits and risks.
Clearly, the “biologics” like etanercept, adalimumab, and ustekinumab have been true game changers with respect to treatment options since I was a resident 20-plus years ago. The benefits are significant and the risks certainly are no more significant (and likely less) than the methotrexate we prescribed for years. While there is also a fair amount of direct-to-consumer advertising with these products, which I think is not unhelpful, when you start listening to these commercials and they really quickly list all of the potential side effects at the end, including death, it becomes tricky to counsel a patient who is nervous about starting one of these medications. Personally, I like direct-to-consumer advertisements because they stimulate discussions with patients.
In the beginning, part of patients learning more is trying to wrap their heads around whether they have time or willingness do what is necessary for a given treatment. For example, can they get to UVB treatments two times a week? Are they willing to put on lotions and moisturizers? Is their disease so extensive that lotions and creams are really not going to be able to address their extent of disease? And if that’s the case, then they may need or want some form of systemic therapy; but they have to be willing to assume some risks as with any systemic medication. So I counsel patients that there is a ladder of treatment options that we follow, starting with topical therapy for limited area involvement, but advancing to systemic treatments. I generally outline the benefits and risks of methotrexate, cyclosporine, etanercept, adalimumab, and ustekinumab, as well as narrowband UVB (both as laser and full-body treatments). It doesn’t take long to present the patient with a general review, and while patients may be a bit overwhelmed at times, they usually have a sense of what they are willing to do and are interested in trying.
These days, we’re very lucky. In addition to the older systemic treatments, such as methotrexate or retinoids, we have these so-called “biologic” drugs as an option. These agents interact with certain inflammatory mediators that drive this disease. So they mimic or are natural molecules in the body (hence the term “biologics”). All of these things work on inflammatory cascades, so they're immunosuppressant to some extent. Any immunosuppressant can, at least potentially, increase risk of infection, and potentially, malignancy.
We've known for years, for example, that patients who are on systemic treatment for psoriasis with light therapy have increased risk of getting skin cancers. However, it was generally felt that the risk of getting a skin cancer was worthwhile in that the patient would be monitored on a regular basis and we could catch those lesions in an early and easily treatable phase while clearing the psoriasis that was otherwise debilitating. When I trained, patients were admitted to an inpatient unit for intensive topical and UV phototherapy! Hence, their quality of life would improve significantly. But you’d have to explain to the patients that it is one of the risks.
So now with the biologics, we know that we have to follow these people a little more closely for skin cancer issues, but it’s the same logic really. We’re going to follow them, help them while their psoriasis is getting better, and watch for signs of skin cancer.
The end of the story is one of a willingness to work with the patient to achieve a treatment outcome that is both satisfying to them and also medically sensible, balancing risks and benefits. I also share the data with patients regarding cardiovascular risks associated with the diagnosis of psoriasis and what I consider as early data suggesting that some of these risks might be minimized with systemic therapies. I often use Dr. Steve Feldman’s work on compliance in psoriasis patients, especially those who are telling me that “nothing works”, but having them try just one week of treatment with a given topical therapy and then see them back at that point. Invariably, the treatment works if they use it. We can then both agree that it’s not that the medication doesn’t work, but that it has to be used. Then they realize that they have more control, and it’s that sort of control and involvement that I strive for in my interactions with patients, especially those with a chronic and recurrent disease like psoriasis.
Eliot N Mostow