PsOmething Extra: Managing Psoriasis with Concomitant Conditions

What happens when patients with psoriasis present with comorbidities and concomitant medical concerns? The availability of numerous treatments with differing mechanisms of action means that prescribers have more opportunity than ever before to help patients manage their disease safely, says April Armstrong, MD, MPH. Plus, Biologic Coordinator Neo Cuellar discusses therapeutic access and Hilary Baldwin, MD discusses skin care for patients with acne and rosacea.

Like what you're hearing? Want to learn more about the Dermatology Education Foundation? Explore assets and resources on our website.

Transcript

This transcript is provided as a courtesy and has not been edited for accuracy.

Welcome to the Dermalorian Podcast from the Dermatology Education Foundation. Psoriasis can be a troubling disease in its own right, but management can get complicated for patients dealing with comorbidities and particularly challenging presentations. The availability of numerous treatments with differing mechanisms of action means that prescribers have more opportunity than ever before to help patients manage their disease safely. Dermatologist and psoriasis expert Dr. April Armstrong offers insights.

Dr. April Armstrong:

So we're going to talk about a few different things here. We're going to talk about six things here. Latent TB, oral candidiasis, what to do with patients undergoing surgery. What if they have a history of malignancy? Now you see more patients who with psoriasis may be on GLP-I receptor agonists. And then finally, addressing the issue of sexual dysfunction and patient's quality of life in our patients with psoriasis. We'll start with a case of a psoriasis patient with positive IGRA test. So a positive interferon gamma release assay test. And the common ones in the United States include QuantiFERON test or T-SPOT test. Okay, so here's a case. Before starting a biologic, you check the baseline labs and you notice, gosh, this patient turned out to have positive QuantiFERON Gold test, but in most cases they're actually asymptomatic. And the subsequent chest X-ray was negative for active TB. So how do you approach this patient?

So you're faced with different choices here. So one of the key things is actually think about the patient's risk factor for TB. And understanding the risk factor is really important because it can increase the pre-test probability or decrease that. So the risk factor for TB and reactivation of latent TB include those who, for example, travel very often to the endemic areas or those who are in close contact with those who have had active TB. Also, those who are immunocompromised, who maybe have undergone transplantation, kidney dialysis are at risk. And those who are on TNF-alpha inhibitors are at increased risk for reactivation of latent TB. So understanding these factors are very important. In fact, when no risk factors are present and you get a positive QuantiFERON test, what I oftentimes do is that I will actually re-test the patient because sometimes you may get a different result.

So there are various different regimens and we've now gone away from the nine months regimen to the shorter three to four months. So there's three main regimens that's listed, recommended by CDC. The ones that are my favorite, you can do monotherapy with rifampin, which is you do have to do four months. That's a trade-off. You do have to tell patients their tears or their urine, maybe have this orange tint so that they're not surprised or scared when they see that. Rifampin typically have lower rates of hepatotoxicity compared to isoniazid. So it's monotherapy, you can do four months or you can do combination of isoniazid and rifampin together for three months. The key thing is that if you do have a patient who have baseline, for example, risk factors for hepatotoxicity, do check their LFTs beforehand. You can start these regimens a month into it, check their LFTs again, and then if it's okay or remain the same, you can finish their course.

Okay. So you can be a superhero here, especially if it takes a long time, for example, to get into the ID. Few things, few other tips is that number one is that the reactivation of TB risk is much lower with IL-17 and IL-23 inhibitors compared to TNF inhibitors. So if you do have a patient with a history of latent TB that's treated, done with, and if you have the option of choosing different biologics, I would recommend going with a non-TNF inhibitor in this case. You can typically, if it's a new patient you found de novo latent TB, then you can start IL-17 and IL-23 inhibitors concurrently with your treatment for latent TB. So what I would do is that I will start them on the latent TB treatment while getting their prior authorization for their biologic. And then if the patient has active TB, I think that's definitely is the place where you want to work with your ID colleagues to manage those patients.

We're going to pivot a little bit. We're going to talk about oral candidiasis. So psoriasis patients, especially those who have a history of diabetes, who may have also poor oral hygiene may be at baseline regardless of therapy, may be more predisposed to developing oral candidiasis. But we also know that with our IL-17 agents, there's also a low risk of oral candidiasis as well. So if you do come across a patient who is treated with an IL-17 agent who develop oral candidiasis, what do you do? So usually if the diagnosis is not in question, it's typically a clinical diagnosis and you typically do not have to scrape the lesion. But if you're not sure, you can scrape the lesion with a tongue blade to look at it under microscope.

Usually the oral candidiasis associated with this tend to be mild, and you have two options. You can treat it topically, which is the usual recommendation, or you can treat it orally. Oral treatment is typically associated with a bit more involved oral candidiasis. I personally like to treat it orally because it's a little bit easier for patients to take a pill rather than do these troches, suspensions like four times a day, right? So because that can be very just disruptive to a person's daily life. So in most people, an oral fluconazole 200 milligrams QD for seven days is sufficient to help clear this. Usually this is not a reason for discontinuing IL-17 inhibitors. Most patients, if they were to get this, typically get about one episode a year in the beginning.

So all right, we're going to pivot to the next scenario, which is thinking about patients undergoing surgery. So this question probably comes up not infrequently. So let's think about undergoing surgery and whether to hold a biologic or an oral therapy for surgery.

So you may have a few different scenarios and I'll propose one of the most common scenarios. So you have a patient who says, I'm about to undergo knee replacement surgery, should I hold a biologic? So we typically divide the different surgeries into two categories. One is low-risk surgery, and we define low-risk surgery as surgeries where your respiratory tract, your GI tract, and your genitourinary tract are not penetrated. So the epithelium of these tracts are not stabbed through by some surgical instrument. Okay, it sounds a little graphic, but that's how we separate. So those are considered low-risk. So your endoscopic procedures, for example, derm procedures, all of your orthopedic surgeries, [inaudible 00:07:44] procedures, which is most of your procedures and surgeries. In those cases we recommend, we meaning the National Psoriasis Foundation, recommend all biologists can be continued through these low-risk surgical procedures.

What about moderate to severe surgery? So if you have a patient where you anticipate a colectomy that these different tracts are penetrated, then you want to approach this at case-by-case basis. So this here is where some of the uncertainty comes and some of the variability in terms of the recommendation comes as well. Some surgeons will require that you stop the biologic, but most data up to date have not shown that biologics even used in those settings increase the risk of infection. However, this does have to be a collaborative approach with the surgeons and if necessary, the biologic agent could be a discontinued for about three to four half-lives, which can be actually a long time before the surgery and about one to two weeks after. So if we think most our biologics, their half-life is between two to three weeks, three or four half-lives can be two months. And then if you don't do that, then you also need to have up to two weeks of following the surgery so they can be without biologic for a while.

So if you have a patient whose psoriasis is not quite stable, they still have residual lesions despite of their biologic, you may expect a flare of their psoriasis during that time. So definitely approach this a little bit more carefully. I've continued many patients in those situations with their biologic because their psoriasis tend to be more severe and I'd explain the reason to the surgeons and usually we have come together on an agreement on this. So it really depends on the patient, the degree by which their psoriasis is controlled.

Speaker 1:

Next up, Dr. Armstrong addresses management of psoriasis in patients with a history of malignancy. But first, here's this episode's Dermalorian clinical clip. November is healthy skin month and there's no better time to address the influence of social media on skincare trends. Dermatologist, Dr. Hillary Baldwin weighs in.

Dr. Hilary Baldwin:

Our patients these days come in with bags of stuff that they've purchased as well as an absolute firm belief that what they've seen on the internet, especially on TikTok, is absolute dogma. And so it's a difficult job to convince them otherwise, and I usually don't try to convince them otherwise. I think it's a very interesting switch from the way that we used to take care of our acne patients when I was in training and my entire career up until maybe the last five or six years, the rule for treating acne has always been kiss. Keep it simple, stupid, right? The fewer products you use, the better. The more products you add, the less they're going to use anything that you've suggested. Now, my teenagers and my twenty-something patients come in with a regimen of 6, 7, 8 things that they use every single day religiously, and they believe in all of them.

I'm not sure where this is all going to lead. I'm not a hundred percent sure it's a great idea other than for the people who are manufacturing these very expensive products. But as far as I'm concerned, as long as they're using their acne medication, I'm okay with the rest of this and I don't try to reteach them. If they come in with a piece of information which is really wrong and potentially harmful to them, I don't know. It's okay to use a particular medication during pregnancy, for example. I'm making something up, but if there's something that's actually harmful, I'm going to mention it. But otherwise I don't try to fight with the TikTok-ers because not going to win. Nor do I have the time to win. So as long as it's doing no harm, that's the oath I took, I'm okay with it.

Speaker 1:

In the spirit of do no harm, let's rejoin Dr. Armstrong as she discusses psoriasis management for patients with a history of malignancy.

Dr. April Armstrong:

All right. So few things. Most commonly we see lots of patients who may have keratinocyte carcinomas. So BCCs, SCCs in general, almost everything that we do will be okay and you can continue for those. So the use of biologics is permissible, use of oral medications, oral medications also permissible. If you have a patient who have extensive history of basal cell carcinoma or squamous cell carcinoma, you want to consider even potentially use something like acitretin to either add that on, which can be helpful for their psoriasis and also be somewhat chemopreventive for their skin cancer. So the dose typically one that's used for chemoprevention for skin cancer is 10 milligrams of acitretin. Usually the starting dose of acitretin, if used as a model therapy in a patient with moderate psoriasis is around 25 milligrams. So if you are using 25 milligrams of acitretin, you'll know that you'll likely have a beneficial effect in terms of chemoprevention of their squamous cell carcinoma or basal cell carcinoma.

Okay. Now let's pivot to harder questions. Let's imagine you have history of solid organ malignancy now in remission for greater than five years. And you may say why five years? Five years is what in psoriasis clinical trials later on is the cutoff point for entry for most of the recently developed medications. So five years. So if they've been in remission, deemed a remission from oncologists for greater than five years from their solid organ malignancy. In general, to date, our data is very good for IL-12/23 inhibitor ustekinumab. All of our IL-17 inhibitors, our IL-23 inhibitors all appear to have very good safety data. So in majority of the cases you can continue those medications. TNF inhibitor data historically are a little bit mixed, but I think as we come along further, they are generally considered safe as well. Apremilast also appear to be safe. I think for the other oral medications, we're still gathering data in this area. So if you have patients with history of solid organ malignancy in remission for greater than five years, as you can see, all of these different medications can be considered.

And now let's talk about history of solid organ malignancy in remission within five years. So you're more likely to encounter those patients who said, well, I had breast cancer, I get that resected, I'm in remission for two years. What do you do? I think with all these patients, you need to have a good conversation with them because their cancer can recur and they need to understand that their cancer, there's a natural baseline of recurrence. And what we understand is that our biologics may or may not improve that chance or lower that chance. So for those within five years, typically the ustekinumab, IL-17, IL-23 inhibitors, apremilast, the benefits of treating is greater than the risks. But again, it's very important to talk to them about how every cancer have a natural recurrence rate. And then to our understanding currently our systemic medications doesn't seem to affect that.

All right, how about lymphoproliferative malignancies? So this is a little bit different of a beast. So these are your liquid tumors like lymphomas and leukemias, and we know that patients with psoriasis actually have a higher risk of lymphoma. And that's reasonable because when you think about psoriasis, their T-cells are getting constantly stimulated. So it's rational that they have increased risk of lymphoma because perhaps one of those aberrant stimulations lead to this malignant clonal expansion. Okay. So those you definitely want to do a case-by-case basis. And if they really have a terrible quality of life from their psoriasis, you want to work with a patient and the oncologist to determine what to do. In general, in those patients. We probably want to avoid systemics, think about phototherapy, think about acitretin, think about apremilast, and also intensify topical therapy.

We're going to switch gear a little bit. So this will transition us to GLP-I receptor agonists and their role in psoriasis. So these days when we see people, and if you haven't seen someone for a long time and you see them and then gosh, they look awfully good. And then in the old days we used to say, hey, did you go to the gym? And these days we're like, hey, did you go to the gym or did you take that? So I think the prevalence of the use of GLP-I agonists in the US has really increased. And for some of our psoriasis patients, they may be on both. So you may have the question, does GLP-I agonists also decrease their psoriasis severity?

So first of all, as you may know that GLP-I agonists work by few things. They decrease our gastric emptying, they decrease our appetite, they decrease their glucagon secretion, increase insulin. That's why no one eats anything while on this, right? But did you know that very interestingly that GLP-I receptor expression is increased in the psoriasis plaques versus the non-lesional skin in the same psoriasis person. And also it's increased in much greater levels in patients with psoriasis compared to patients with non-psoriasis.

So I'll show you some preliminary really case reports that show perhaps the GLP-I agonist may have an immunomodulatory effect on our psoriasis lesions. So there are very few really randomized control large studies out there. One study that's quite small, but it's comparing, they randomized patients into placebo versus being on liraglutide and they're looking at their changes in these psoriasis patients. So there is a placebo effect changing PASI about one. And then if you look at liraglutide group in this study, 56 days, the decrease is around 2.5 points in PASI.

So this is a very small study, so it did not achieve statistical significance. It's very small, but try to hand-tap, perhaps GLP-I agonist may contribute to the improvement of psoriasis. So if your patients ask you, do you think it can potentially help with psoriasis? The answer is likely it possibly may. And then the reason is because the likely the psoriasis patients may not secrete that much adipokines that are really contributing to this feed-forward mechanism.

In my remaining few minutes, I'm going to talk about genital psoriasis and sexual health in psoriasis patients because this is very important, I think. We may not talk about it as often, but it really impact our patients, especially our younger patients who may be in their prime of their life in terms of socialization and in terms of wanting to meet someone or have a family.

So let's get started. So dermatology is like location, location, location. So this is really, really important. And I think this strip mall has the whole concept down. So when we think about location, location, location in psoriasis, we oftentimes think about these special areas, our scalp, our neck, arms, hands, genital area. So they are key locations that really can impart a significantly increased decrement in patient's quality of life. So when we see psoriasis in the genital areas, they can look very different from the plaque psoriasis we see on the extensor areas, for example. So what you see is that you see a lack of scaling in these areas because these are moist areas. So any scaling that's there, you see as maceration.

Also, it's very important to distinguish them from STDs. Your patients probably think they have some kind of STDs. And so it's very important to also know how to distinguish that from that. And sometimes especially the scary thing is that if their psoriasis, their first manifestation is in the genital areas, that can really alarm the patients because they haven't seen it before. And most people automatically think it's STDs, especially if they are seeing people and are sexually active.

Okay, I did want to talk about a little bit of candida and psoriasis because the two can be confused a bit. So candida colonization is actually not uncommon, and it's also not uncommon in patients who concurrently have intertriginous psoriasis. And the symptoms can be essentially identical. You get pruritus, lots of itching, redness. Now if you see a pre-pubescent girl and you see erythema and pruritus in that area, you try to distinguish is this psoriasis? Is this vulva-vaginal candidiasis? In pre-pubescent girls, I encourage you to really think about intertriginous psoriasis because chronic vulva-vaginal candidiasis is very uncommon in that patient population. So if they're a pre-pubescent girl, the likelihood of them having intertriginous psoriasis in that area is higher than vulva-vaginal candidiasis.

Okay. So as we know patients with psoriasis, intertriginous psoriasis, genital psoriasis can really affect their quality of life. So how can we help these patients with genital psoriasis? First, we want to normalize it because when they come to you, they think it's something that's really embarrassing. So I typically say a lot of patients with psoriasis can have psoriasis affecting their genital areas or their private areas. Do you have that? And so they say, oh, a lot of people have that. Well, okay, it doesn't make me feel like, oh, I'm so strange or different. So I think I invite them to share with me if they have that. And then we examine the area and where appropriate, consider non-steroidal topical medications for these areas because they may use it for a very long period of time. So we have our different options. We have our TCI's and we have our roflumilast [inaudible 00:23:08]. And of course, for moderate to severe cases, we want to consider oral or biologic medications to treat those areas.

Okay. So here are some of the take-home points. Number one is that you can treat latent TB concurrently oftentimes with systemic medications. Number two, oral candidiasis can be managed. Number three, for those undergoing surgery, the majority of the cases, you can continue biologics and you may need to educate your surgical colleagues about that. History of malignancy, you definitely want to evaluate the type of malignancy and also how long they've been in remission. And in many cases, you do have to collaborate with oncology. Patients on GLP-I receptor agonists, likely those will have a positive effect on decreasing their psoriasis severity. And then for those who have genital psoriasis, you want to normalize that, ask about it, and manage it appropriately.

Speaker 1:

Choosing the best treatment for each patient is a crucial step, but making sure they actually get on treatment can be a challenge. That's where access coordinators come in. Earlier this month, the US observed National Biologic Coordinators Day. In this month's Dermalorian Derm Decoder Neo Cuellar, a biologic coordinator from Phoenix talks about the role of the biologic coordinator.

Neo Cuellar:

It's not just about getting a prior auth approved. There are so many privileges to do what I do. As a biologic coordinator, we don't get to choose the therapy for the patient. Essentially, we fight for whatever drug that our providers decide could best help the patient improve whatever condition that they're there for. The skills, the attention to detail, whether it's from the biologic coordinator or it's from the support staff, that's really what dictates the pull through, the difficulty for that approval of the prior authorization. Us BCs, again, we have such an honor of the major role that we play in the patient getting the therapy that can ultimately improve not just their quality of life physically, but also mentally. And honestly, I have a hand in giving my provider back the power just to practice medicine and just to prescribe.

Speaker 1:

That's it for this episode of the Dermalorian podcast from the Dermatology Education Foundation. If you like the Dermalorian podcast, tell a friend about it. Thanks for listening.