Speakers at AMCP 2023 reviewed the treatment paradigm for plaque psoriasis, highlighting recently approved drugs and patient preferences for treatment.

Plaque psoriasis is a chronic, immune-mediated disease that causes systemic inflammation. More than 3% of US adults have psoriasis, and plaque psoriasis comprises a majority (80%) of cases.

Effective treatments are available, but there is no cure for psoriasis, said Lynsey Smith, PharmD, BCACP, clinical pharmacy specialist in drug use management–dermatology, gastroenterology, rheumatology, Kaiser Foundation Health Plan of Colorado.

Plaques may appear anywhere on the body but most commonly form on the scalp, trunk, gluteal fold, and elbows and knees. Patients may experience disproportionate reductions in quality of life if plaques form on the face, palms, soles, genitals, or intertriginous areas, Dr Smith said.

Nearly half (46%) of patients with psoriasis experience moderate to severe reductions in quality of life, said Leah M Howard, JD, president and chief executive officer, National Psoriasis Foundation.

Research shows 28% of people with psoriasis also have depression. Some 9.7% experience suicidal ideation or self-harm, which is more than double the rate of the general population, Ms Howard noted.

“The impact on quality of life is huge,” Ms Howard said. 

Additionally, psoriasis is associated with a range of comorbid conditions. These include psoriatic arthritis, cardiovascular diseases, metabolic syndrome, mental health conditions, inflammatory bowel disease (IBD), cancer, renal disease, sleep apnea, chronic obstructive pulmonary disease, uveitis, and hepatic disease. 

“The good news…is that, unlike other chronic diseases, there are lots of treatment options. There are treatment options at all levels of disease severity and all [ages],” Ms Howard said.

Therapeutic Options for Plaque Psoriasis

The American Academy of Dermatology and National Psoriasis Foundation Joint Psoriasis Guidelines recommend topicals, phototherapy, systemic non-biologics, and biologics for this patient population.

Dr Smith reviewed the pros and cons of each type of therapy.

Topical Therapies

Topical therapies are intended for patients with mild-to-moderate or localized psoriasis, Dr Smith said. This class of agents includes corticosteroids, vitamin D analogues, retinoids, calcineurin inhibitors, coal tar, roflumilast, or tapinarol. 

Topicals are beneficial insofar as they allow for a range of potency, dosage forms, and vehicles, and patients and prescribers have several treatment options depending on application area. Topicals can be combined with other topical agents, and generics are available to minimize costs.

However, topicals are not an ideal option for treating large surface areas, and topical steroids should only be used for 2 to 4 weeks in order to minimize adverse effects, Dr Smith said.

Phototherapy

Narrowband ultraviolet B light therapy can be used to treat patients with mild, moderate, or severe disease.

Overall, phototherapy is safe, well tolerated, and convenient due to patients’ ability to administer the treatment at home after a one-time cost. Phototherapy is administered twice or three times per week and can be used alongside other therapies.

“[Phototherapy] is also a good option if patients want to avoid systemic therapy,” Dr Smith said.

This treatment option is associated with longer times to skin clearance, however. Patients may not have the space to accommodate home units, and in-office treatments can be cumbersome, Dr Smith said. Additionally, insurance coverage for home units varies.

Dr Smith also advised caution when considering phototherapy in patients with a history of melanoma or multiple nonmelanoma skin cancer.

Systemic Non-Biologics

Non-biologic systemic therapies such as methotrexate, acitretin, cyclosporine, apremilast, or deucravacitinib can be considered in patients with moderate to severe psoriasis.

Most of these agents are available in oral formulations and as generics, and they are associated with less immune suppression than biologics, Dr Smith said. Additionally, medications such as methotrexate and apremilast can treat multiple immune conditions at once which may be useful for patients with comorbidities.

However, non-biologics are less effective than biologics and are associated with side effects. 

“Several of these medications require lab monitoring for safety purposes,” Dr Smith said.

Biologics

TNF-α inhibitors, IL-12/IL-23 inhibitors, IL-17 inhibitors, and IL-23 inhibitors are biologic agents used to treat patients with moderate to severe psoriasis. Biologics are more efficacious than topicals or phototherapy and can treat multiple immune conditions. 

“If a patient has psoriasis and IBD, you may be able to have one medication that does treat both conditions,” Dr Smith said.

But biologics can be expensive, and “some of them range around $80,000 per patient per year,” Dr Smith said.

Biologics must be administered intravenously or subcutaneously, and biologics are also associated with more contraindications, warnings, severe infection risk, and immunosuppression than other therapies.

Recently Approved Therapies

The US Food and Drug Administration has recently approved 4 drugs for psoriasis, said Kayla Braestrup, PharmD, BCACP, clinical pharmacy specialist–dermatology and gastroenterology, Kaiser Foundation Health Plan of the Northwest. 

These include apremilast’s expanded indication approved in December 2021; tapinarof 1% cream approved in May 2022; roflumilast 0.3% cream approved in July 2022; and deucravacitinib 6-mg tablets approved in September 2022.

Apremilast is a systemic non-biologic treatment available in tablets for oral administration. Dr Braestrup recommended providers ensure patients use the titration pack to mitigate nausea. Apremilast may cause or worsen depression and is not recommended for use with strong CYP3A4 inducers, she added.

Tapinarof is a topical therapy with no drug-drug interactions, contraindications, or restrictions related to where it can be used on the body. However, studies suggest tapinarof is associated with high rates of folliculitis compared to placebo.

Tapinarof is “likely not going to be used as a first-line topical agent at this time, due to the availability of generics and our other mechanisms; however, this does provide an additional option to our patients who are candidates for topicals who either do not respond to our traditional therapies or had adverse events,” Dr Braestrup said.

Roflumilast is another topical with no restrictions on where it can be applied. Dr Braestrup advised roflumilast has drug-drug interactions with systemic CYP3A4 inhibitors; CYP3A4 and CYP1A2 dual inhibitors; and oral contraceptives containing gestodene and ethinyl estradiol. Roflumilast is also contraindicated for patients with moderate to severe liver impairment, Dr Braestrup said.

Deucravacitinib is a systemic non-biologic treatment administered orally. Long-term safety data on deucravacitinib is still pending, but in the meantime, providers should monitor patients periodically for triglyceride and liver enzyme elevations as well as adverse effects typically seen with JAK inhibitors, Dr Braestrup said.

“Deucravacitinib is a TYK 2 inhibitor, which is a member of the JAK family. Because of this, deucravacitinib has the potential to have similar risks of the JAK inhibitors that are currently on the market,” such as mortality, major adverse cardiovascular events, and thrombosis, Dr Braestrup said. 

Combining Therapies

In addition to reviewing the treatment landscape, presenters offered considerations for using combination therapy in patients with plaque psoriasis. 

“In thinking if a patient is appropriate for combination therapy, you would want to think about their disease severity. What is the patient’s goal for control of their disease? What combination of therapy would be appropriate?” Dr Braestrup said.

Beyond accounting for patient preferences, comorbidities, and treatment history, minimizing health care costs and disrupting adherence are also important considerations, Dr Braestrup said. Additionally, tapinarof and roflumilast have not been tested in combination with other therapies yet, but they are not expected to raise new safety concerns, Dr Braestrup said.

Presenters recommended a step-wise approach to prescribing therapies for patients with psoriasis.

“Patients overwhelmingly want clear skin, but they also want to take control over their disease—control that many are lacking today, given that about half of our community is either not treating their disease at all or undertreating it,” Ms Howard said. “Ultimately, they want the ability to enjoy a normal life. Many of today’s treatments can get our patient community there.”