PsO Now What? Case-based Treatment Selection for Psoriasis

With so many options available to treat psoriasis and psoriatic arthritis across age groups, treatment selection must be made on an individualized basis. DEF Biologic & Small Molecule CME Bootcamp faculty members Joe Gorelick, MSN, FNP-C, Kara Gooding, MMS, PA-C, and Andrea Nguyen, DMSc, MPAS, PA-C discuss case presentations. Plus, an update on PRP from Gilly Munivalli, MD and rosacea tips from Wendy Cantrell, DNP, CRNP.

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

Transcript

Transcript provided as a courtesy. It has not been edited for accuracy.

Welcome to the Dermalorian Podcast from the Dermatology Education Foundation. Case-based learning is a time honored tradition in medicine, and it's a key feature of DEF programs. For this episode of the Dermalorian podcast, we present case challenges in psoriasis. We start with excerpts from a recent healthy debate session at the DEF Biologic and Small Molecule CME Bootcamp. DEF president, Nurse Practitioner Joe Gorelick presented the case of a woman seeking rapid clearance of longstanding psoriasis. Bootcamp faculty members, physician assistants, Kara Gooding, and Andrea Nguyen made the case for treatment based on audience input.

Joe Gorelick:

So this patient is a 36-year-old female with a 16 year of psoriasis. She has it affecting her scalp, face, elbows, knees, trunk, and nails. She has tried numerous topicals. She's tried oral DMARD such as methotrexate. She's been on an oral TNF inhibitor inhibitor, certolizumab. None of these are effective for her anymore, even in combination with topicals, light, and the TNF inhibitor. So she shows up in the office and she's totally distraught. She's seen all the TV commercials. She's like, "I've seen so many people and I keep getting creams. Or I get these anti-cancer pills. I just want to have normal skin like they have on TV. That's what I'm looking for. I need you to help me, please."

So you checked her out. You said, "Hey, by the way, when you wake up in the morning, do you have any issues getting moving? Do you have stiffness in your hands, your feet? Do you suffer from plantar fasciitis? Have you ever had a hot, swollen joint for no good reason on one of your fingers and your toes?" You're screening for psoriatic arthritis. This patient says, "Yeah, actually, that's weird. It does take me like 15 or 20 minutes to really loosen my hands up every morning when I get out of bed." And I have had this nagging plantar fasciitis for years with no resolution with physical therapy and oral over-the-counter anti-inflammatories.

Otherwise, patient is in excellent health. A laboratory screening is done, 100% normal, everything's screened, and she has no history of solid tumor or blood cancer. She has no history of inflammatory bowel disease. So you do your physical exam. Patient has 21% body surface area, whether you calculate it by the palm of the hand or by the rule of nines, she comes out at 21. She has severe four out of four grades psoriasis based on the investigator global assessment. And then you ask about itch over the past 24 hours. Where's the worst itch imaginable? And she tells you seven out of 10. This is a patient that is literally reaching across the table, begging you for help with her disease. Kara, are you representing your team?

Kara Gooding:

So we know yes, obviously this is a great candidate for a biologic and she's a young female. She is going to want to be better really fast, right? She's on social media. She's going to take pictures of her skin every day after we give her that injection in the office, and she's going to be posting those pictures. And we all decided we want rapid onset of efficacy and we want a good review. So we need this patient to be better as fast as possible. So that IL-17 is going to deliver in that rapid onset of action. And we also know that we're going to cover for her probable psoriatic arthritis. So she's complaining of that stiffness in her joints in the morning, the plantar fasciitis, some signs that we see of psoriatic arthritis. So we know we're going to cover for that. And if I was a rheumatologist and the patient came in and they only had psoriatic arthritis, we know that they're going to put that patient on an IL-17 first before they would put them on a 23.

So we know we have one particular drug that we could put her on that we all collectively said, "Yes, we've seen patients come into our office and they're telling us that a week to 10 days after we started their injection, their skin was already clear." And again, she wants to be better very, very fast.

Joe Gorelick:

Any additional points that you would like to put home for this case?

Kara Gooding:

Yes. She does not have any history of inflammatory bowel disease, so she's a great candidate for this IL-17 class. She brushes her teeth multiple times a day. She's very concerned about her oral hygiene. So she has toothbrushes at work. She has those little wisps in her car, so we're not really worried about that with her. And she has no history of depression, but she feels like she's on the onset of having depression if we do not get her skin clear very, very quickly.

Joe Gorelick:

Okay. Well, you make an excellent case for IL-17 inhibition, yet I think there can be a case to be made for IL-23 inhibition. Professor Nguyen?

Andrea Nguyen:

We saw the same 36-year-old woman, and we have a little bit of a slightly different take from our encounter with her, right? So this 36 year old female, she's jet-setting a lot. She doesn't have time for the fridge, the refrigeration. She has to travel for work. She's on social media taking pictures in whatever exotic place she is traveling. Dosing less often is much easier for this patient so she can travel, take her flights, go wherever she's going and living her best life, right? She's going to YOLO now that she's going to get really clear skin.

All right. She's got 21% body surface area, a lot of facial involvement. We're concerned about psoriatic arthritis. IL-23, we have good skin coverage. We have good joint data. This patient, while she does not have a history of IBD, she's very concerned about side effects, right? She's really concerned here about side effects. So she's like, "I don't have any IBD, but I don't want anything that has any risk to give me IBD. I also am not currently depressed, but you never know. You never know." While she doesn't have any history of oral candidiasis, she has had yeast infections before. She's not really excited to throw that into the mix of her dating profile adventures and encounters. So no risk there.

Joe Gorelick:

So what about her joints? You feel like you've got robust enough data? I mean, is it radiographic in position data with 23s?

Andrea Nguyen:

Yes, we do. So we have with the APEX trial, we have a radiographic inhibition of progression that we saw with our fully human IL-23 inhibitor with guselkumab. It's because the study design was not structured really to enrich the patient population, specifically looking for those types of patients. So they did it again. J&J said, "I'm going to invest a large percentage of our funds looking at this because we're confident potentially we can hit this." So radiographic progression, they saw it play in films afterwards that they have inhibition looking at the modified van der Heijde score.

Joe Gorelick:

Well, I would suggest that maybe there's a place for both, but you make excellent case on this side and on that side. And how lucky are we to have multiple agents that we could choose? And there could be access or formulary restrictions, and as strongly do feel this way, you may be forced to be in another one to have to choose a different class. But nonetheless, we have great options. It's important to see the risks and the benefits of both of these particular classes and understand them really well so that you can present them to your patients in clinics.

Host:

We've got another case coming up, but first, here's this episode's Dermalorian Derm Decoder. PRP, or platelet-rich plasma, continues to generate buzz. Dermatologic surgeon, Dr. Gilly Munavalli, helps make sense of its benefits and proper use.

Gilly Munavalli:

Platelet-rich plasma is still very popular around the world. It's inexpensive. I mean, it's your own products from your own body, so nobody has an issue with that typically. You just have to do the blood draw. We use it in our office quite a bit, actually. We use it for hair for patients with endogenetic alopecia, male, and female. There is very good data that shows that you can impact the quality of the hair, the size, a little bit of the growth, the thickness by using it periodically. So we do use it for that. I love it for, as you said, for device and laser post-treatment regimens. It does contain a lot of growth factors that are in these platelets that help seem to speed up wound regeneration, collagen formation. So I either, and it can be put on topically or injected intradermally, which is allowed. So we do use that quite a bit, especially after bigger procedures like laser resurfacing where patients every day of less downtime counts.

Host:

Let's get back to a case discussion. As Joe Gorelick discusses unique considerations in pediatric psoriasis, the patient he presents had previously been seen by numerous dermatology providers.

Joe Gorelick:

This child, when I saw him first as a nine-year-old, he was nine, and he had skin disease for the past three years, and he was on topicals only. He was on prescription topical corticosteroids, one of which was clobetasol, and the mom had some concerns about that. And he had therapeutic trials with some of the non-steroidals as well. It was hard for them to keep up with the topical regimens. And even when they did them religiously, the kid wasn't clear enough. And so they presented probably a year or two ago to me to talk about systemic therapeutic options for him. So at that time, we had several agents approved, but now we have more. So this patient was graded as an investigator global assessment of moderate disease. It affected his quality of life severely. He had psoriasis on parts of his body that he could not cover. Even with the baseball hat, the plaque on the frontalis and up into his scalp showed. He had a significant amount of itching, which wasn't graded. His body surface area was 8%.

So think about this. Would you consider a systemic agent for a nine-year-old that had failed all these things? Would you give this patient apremilast, which is now approved down to six years of age? That's an oral. Would you give the patient etanercept, right? Old school TNF-alpha inhibitor. Guselkumab now is approved down to age of six and ustekinumab is approved for pediatrics and ixekizumab also approved for pediatrics. I think that this decision is based on efficacy as well as safety. I think apremilast is a great option because it's an oral, but that oral agent can be tough with gastrointestinal side effects and it's twice a day. Compliance could be a potential issue. Enbrel, the TNF alpha inhibitors, you would have to inject that or pull it out of a syringe and calculate the dose. That would be a little tricky. And maybe years ago, that was your only option, but you probably have better options.

So guselkumab was not available on the market when this patient presented. Ustekinumab was Stelara, which would be another good option. And ixekizumab was also approved when this patient presented. So what this patient was actually started on was ixekizumab, which is Taltz. I saw him first in October and then in November, after just 28 days on the medication, you can see ixekizumab IL-17A inhibitor patient was almost clear. You can see the post-inflammatory or the ghosty sort of remnants of psoriasis on the posterior aspect of his upper arm, but his body surface area is decreasing down less than 1%. So he responded really well. This patient is a unique nine-year-old that he was totally cool to get a shot or have his mom give him a shot.

If you're treating your patients and you're seeing them back in a month, two months or three months, and you're not getting them to almost clear, clear, you got to say, "Hmm, am I treating this patient with the right medication for this patient?" And I would challenge all of us to be as ambitious as we can and choose the best therapeutics possible for these patients to give them a chance to having as close to normal skin as possible. So don't go three years, four years, five years passing out creams and lotions and potions with impractical regimens to apply them when we have systemic options that are rooted in data that shows safety, but also efficacy for these patients.

Host:

April is Rosacea Awareness Month. For the DEF NPPA In the Know social media series, nurse practitioner Wendy Cantrell shared some thoughts on educating patients with rosacea about proper skincare.

Wendy Cantrell:

This is what every single one of your rosacea patients needs to know. I'm a nurse practitioner in dermatology for about 25 years. Every single patient that sees you for rosacea needs to have a baseline gentle skincare regimen. They need to have a very gentle cleanser. They need to have a great oil-free moisturizer because the barrier of rosacea skin can be compromised. And then you also need to have an excellent sunscreen. And it really is worth the time explaining the difference between a mineral sunscreen and a chemical sunscreen because mineral sunscreens reflect the sun surface, whereas a chemical sunscreen, the sun's radiation is absorbed into your skin, and that can be a rosacea trigger for some patients.

And the other thing is your patients need to pay attention to what causes them to be red and have flares. It could be foods, it could be stress, it could be temperature, it could be weather changes. Every rosacea patient might be different. I recommend them opening a little notes app on their phone and kind of trying to keep up with what might be their triggers. Not that they can avoid all of their triggers all the time, but it is something good for them to know. This is DEF In the Know.

Host:

That's it for this episode of the Dermalorian Podcast. You can find previous episodes anywhere you stream pods. The Dermalorian podcast is produced for the DEF by Physician Resources. Thanks for listening.