Current Trends and Future Directions in Psoriatic Disease

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Dr Joseph F. Merola and Dr Colby Evans were recently honored by the National Psoriasis Foundation (NPF) for “their remarkable accomplishments"1 as physicians treating patients with psoriatic disease at its 2024 Commit to Cure Gala, which took place in Dallas, TX, on April 27, 2024. NPF President and CEO Leah M. Howard, JD, described Dr Merola and Dr Evans as "people-centric providers and fierce advocates for our community" and noted that they "exemplify the values NPF looks for in the medical professionals we collaborate with."¹

The Dermatologist sat down with Drs Merola and Evans for a lively discussion of present and upcoming advancements in psoriatic disease treatment, the importance of patient advocacy, and collaboration between dermatologists and rheumatologists.

ADVANCEMENTS IN TREATMENT

The Dermatologist: Psoriasis treatment has seen incredible progress over the last decade. What are some of the most significant advancements and how have they impacted patient care?

Dr Evans: To me, the most impactful change in my career has been the level of clearance we can hope to achieve for most patients. When I started treating psoriasis around 2001, we had the early tumor necrosis factor inhibitors like adalimumab and infliximab and they were a breakthrough compared to things we had previously, but they could not get most patients mostly clear. And then, through my career, newer mechanisms and options have come up, and more options even within the same mechanism. We are now at a place where it is very likely that many patients, especially if they have not had treatment before, can get mostly clear or entirely clear, and that really has revolutionized the patient experience.

Dr Merola: I agree and will build on that a little bit further. I remember when we had our very first biologics in psoriasis and psoriatic arthritis, and we were waiting around for a new mechanism at the time, ustekinumab, with a waitlist of patients. In many respects, it is as good a time as ever to have psoriatic disease because we do have many treatment options. I agree with my colleague that we have come a long way in the skin efficacy domain. There remains a substantial efficacy gap, however, for many patients with regard to other disease domains and comorbidities, namely, those of psoriatic arthritis. We certainly have wonderful treatments for psoriasis, but we have not hit the same ceiling of high effect for so many patients with psoriatic arthritis. This is a remaining area of unmet need and I think we are going to get more sophisticated in the future, both with some newer mechanisms, as well as some novel approaches, such as combination therapy approaches and even psoriatic arthritis prevention concepts.

Dr Evans: I agree completely. I think the progress in skin has been incredible. Now we talk about Psoriasis Area and Severity Index 90 and 100. And, although there has been tremendous progress in psoriatic arthritis, talking about 90% or 100% improvement is still elusive. I hope what you are talking about does come to fruition.

The Dermatologist: With these advancements in psoriasis treatment, what do you see as the future direction of research and clinical practice?

Dr Evans: The first thing in clinical practice is access to qualified physicians, access to the treatments themselves, and reasonable out-of-pocket costs that allow the patient to proceed with the appropriate treatment. We also must deal with complex rules from payers or from pharmacy benefit managers that do not allow an expert clinician to choose the best treatment for that individual patient. Of course, we will have new mechanisms and new drugs, and that will be important. But equally, or maybe even more, important to me is that we need to find ways for the typical patient to be able to access this panoply of options we now have. The second thing that I think is interesting is oral treatments to target biologic mechanisms. We have new oral treatments that target other mechanisms like Janus kinase inhibitors or tyrosine kinase inhibitors. But I think we may soon see oral agents that target IL-23 or IL-17, more of the pathways currently targeted by injectable biologics. And I think that could also be a big breakthrough.

Dr Merola: Completely agree. I will echo and emphasize the access piece. We can have all the drugs in the world, but if we cannot get them, it does not help anyone. I am also enthusiastic about some of the newer potential options in the pipeline, including new oral peptides offering novel opportunities for patients. Another future direction is early intervention/disease modification, as well as considerations around disease remission and the possibility of intermittent therapy in the setting of high super-response. While I am not sure we are completely there yet, we certainly are starting to see more research looking at the concepts of remission and early disease intervention, and whether there might be disease modification as such. I have personally had the pleasure of working with the NPF on their remission and cure initiative, having helped to define psoriasis remission and also working toward some definitions of psoriatic arthritis remission to help move this area of the field forward. Finally, I mentioned novel concepts such as combination therapy and prevention of psoriatic arthritis. We are starting one of the first combination trials and have been part of a novel psoriatic arthritis prevention study, both through the Psoriasis and Psoriatic Arthritis Multicenter Advancement Network (PPACMAN).

I think we have become more aware of the burden of associated comorbidities and the overall need to address these with our patients in order to truly maximize our impact. I would like to think many of us spend additional time to talk with our patients more about some of these key comorbidities, although I am not sure it is happening everywhere as much as we would like. There is a disconnect between what we know about the association of comorbidities with psoriatic disease and the treatment of these comorbidities in real-world practice. We have to continue to think critically about how we get these patients to statins, newer glucagon-like peptide-1 (GLP-1) agonists, or other cardiometabolic interventions in the context of a very busy and demanding practice that has historically been organ-targeted on skin and joints.

Dr Evans: I totally agree about the role of the dermatologist and the role of teamwork with primary care so that the dermatologist can get the ball rolling and then if it is a complex issue, the appropriate care can be found for the patient. I think for a long time we have known about comorbidities, but we are not 100% sure if treating psoriasis alone will solve all the comorbid issues. Finding out what this specific patient has and treating it or referring to someone who can treat it is incredibly important. I think we are also going to see some interweaving. We have developed this incredible tree of drugs that can treat psoriasis. But, for example, GLP-1 agonists now successfully treat obesity, and in many psoriasis trials the average patient is obese by body mass index. It may be that we begin to combine some of these agents to address broader health issues. That, of course, could be great in terms of the health of the patient, but it will be a challenge in terms of the expense and the access piece we discussed earlier.

THE IMPORTANCE OF PATIENT ADVOCACY

The Dermatologist: How have patient advocacy efforts contributed to raising awareness about psoriasis and improving access to care for patients?

Dr Evans: I think that it is incredibly important through advocacy to help the government, payers, and patients understand the full picture of what is required to treat a patient. First, they must have access to good care. Many patients are uninsured or underinsured and have high deductibles, which may make it difficult to get to a well-trained physician. They may live in a rural area that does not have a lot of access to dermatologists. Then there are the costs for medications and phototherapy copays, and these can also be barriers. Maybe the patient got prescribed the correct treatment, but now they are not accessing it because of financial or payment barriers. Working with patients to talk to payers; pharmacy benefit managers; and local, state, and federal government through larger organizations like NPF and the American Academy of Dermatology provides the ability to target each of those issues. If you only focus on one issue, such as biologic copay cost, you may help that issue but not the overall pipeline of patients.

Dr Merola: I will just add some color to that excellent comment. I think on some levels, even now, we continue to have to convince payers and others that psoriasis is not just a cosmetic disease, that this disease carries a heavy burden on patients and comes with a host of comorbidities, such as psoriatic arthritis, cardiometabolic disease, and mental health disease. We need to continue to share that dialogue with relevant stakeholders. We need to be actively advocating for legislation around step therapy, nonmedical switching, drug pricing, and access on behalf of our patients.

NPF does a beautiful job and is arguably the key patient advocacy organizations in this space. Both Colby and I work closely with the NPF, and I think we are both very proud to be part of the fundraising efforts that help to keep the NPF able to do its crucial work. NPF is a key advocate for therapeutic access, particularly for our Medicare and Medicaid patients. That is a major issue now, and it will continue to be a major issue as the population increasingly moves into the Medicare age group. We have to rely on tricks and spend tremendous effort to help these patients find their way to therapy; it remains a major gap, and one that we all must continue to address. On the physician side, we sometimes ask: Why aren't more physicians using these wonderful, targeted therapies? To be fair, we also must advocate for our colleagues and specialty as well because the payers have weaponized documentation burden and created regulatory hurdles that can be oppressive for a practice. It is hard work and a major expense for practices to get patients to these newer targeted therapies. It really takes its toll on physician wellness and contributes to burnout.

The Dermatologist: How can dermatologists engage more effectively with patient advocacy groups to ensure that patients’ voices are heard and their needs are addressed?

Dr Evans: I would say, we must work together, and we have to start small and work up. The patient and the dermatologist are both critical parts of an advocacy mission. If you are going to talk to a leader at a payer or in the government, the patient experience must be first and foremost, and the comorbidities that Joe talked about have to be presented to them, so they understand the disease because often they do not. Then they need the dermatologist’s expert knowledge about what sort of treatments we are having difficulty getting, why those difficulties exist, and how they could help the patient. For new advocates, it always helps to start small. We imagine that to advocate we need to go to Congress, and we need to talk to a Senator. And that is great when you can do it. But there are a lot of these issues happening at the local insurer level and at the state board of insurance level where it is much easier to get an audience. You can influence patient experience right there where you live. And then when you have some experience with that, it is great to partner with larger organizations like NPF, which has an advocacy day every year on Capitol Hill in Washington, DC. You can get training from experts in lobbying and go meet with federal officials. With a group of patients, a group of dermatologists, and some expert training, you can have the most impact.

Dr Merola: We can do our part by keeping the discussions about psoriatic disease active through engagement at NPF events and opportunities to continue to build psoriatic education into programming at local, regional, and national meetings, for both physicians as well as advanced practice providers. We have many opportunities to engage. As long as it is at the front of our mind, we are going to continue to have that conversation among our peers.

The Dermatologist: What role do patient support networks play in helping individuals with psoriasis cope with their condition and how can dermatologists facilitate patient involvement in these networks?

Dr Evans: Patient experiences are critical. When a new patient is diagnosed with psoriasis, one of the things that cannot be replicated is talking to other people who have the disease, who have experienced it, tried different treatments, lived with it, and faced job challenges or disability or discrimination from it. Those kinds of conversations, whether they are online or in person at meetings, are important. To me, the best way to approach that as a patient is the patient navigation center at NPF. This is a group of trained facilitators who can communicate via video chat, text, or phone to help the patient find resources, which could be a physician who is an expert in psoriasis, support groups or forms of support networks to help the patient connect with other people who are going through what they are going through, or even help with medication costs.

Dr Merola: I think the patient navigation center at NPF is a wonderful resource for patients. There are also many networks around the country and the world, such as groups like PPACMAN, the International Dermatology Outcome Measures group, and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, where patients can actively engage in research. This work is empowering to patients and ultimately is crucial to moving the field forward and doing so in a patient-centered way. Through these networks, patients and physicians can come together to ask relevant questions about the disease and think about how to improve the lives of patients through research.

DERMATOLOGY AND RHEUMATOLOGY COLLABORATION

The Dermatologist: What are the benefits of interdisciplinary collaboration when treating patients with psoriasis and psoriatic arthritis?

Dr Merola: I am passionate about this one, so I am going to jump in first. We have done some research looking at the benefits of formal and informal combined clinic models. We see that these models demonstrate more frequent and aggressive comorbidity screening activities and more timely access to appropriate systemic therapy in these settings, as well as higher patient and provider satisfaction. That said, having a formal clinic where dermatologists and rheumatologists come together is challenging. It often does not happen in the community, although there are some examples of it happening in the community. Most practically, however, these combined care arrangements demonstrate what we call facilitated communication, which is just the ability to phone a colleague or have expedited visits blocked in your schedule for patients with psoriatic disease. For example, the rheumatologist holds a few slots every week for a local dermatology partner group where particular concern about active psoriatic arthritis exists, expediting and facilitating referral opportunities. Identifying local partners who are committed to the care of psoriatic disease and reinforcing those referral patterns can help facilitate diagnosis and timely, appropriate therapy. Local combined patient care rounds dedicated to psoriatic disease is another opportunity to enhance education and patient care.

I mentioned PPACMAN earlier. This is a nonprofit we founded several years ago that focuses on combined dermatology-rheumatology clinics and facilitated interactions between dermatologists and rheumatologists, both for clinic education and research. Because of PPACMAN we have been able to develop the first psoriatic arthritis prevention interventional study and now combination therapy study. There is a lot that can happen at this interface when we get dermatologists and rheumatologists together. We also have unique training opportunities around the country at several centers where a dermatologist or rheumatologist can spend an additional year of training in a dermatology-rheumatology fellowship to cross train in these areas of need; we are starting a fellowship as such at UT Southwestern in Dallas.

I am a huge fan of how these collaborations, in the formal sense, can advance patient care and education, and, in the informal sense, can meaningfully benefit patients with these diseases.

Dr Evans: I agree, 100%. The closer we can work together, the better the outcome is going to be for the patient. A minimum standard is open communication between the dermatologist and the rheumatologist and then going further, as Joe said, having appointments reserved and being able to quickly get help from a colleague. We have seen such an explosion of knowledge in psoriasis and psoriatic arthritis, so we must work together to maximize all that we now know. I think combined clinics are a great idea. A challenge is that we need to advocate around our payment models. For example, the combined clinic where I am had to close because the patients were having 2 copays and 2 deductibles every time they came to the clinic, which was cost prohibitive for some patients. We need to work with payers and with Medicare and Medicaid to come up with ways we can advocate for patients to get that highest level of care.

The Dermatologist: What are some key challenges that dermatologists and rheumatologists face with psoriasis and psoriatic arthritis cases, and in what ways can providers work together to develop personalized treatment plans for these patients?

Dr Evans: I think access on both sides continues to be an issue. There are parts of the country where it is months to get in as a new patient to see a rheumatologist if you are not pushed to the front by your physician. There are parts of the country where there is not good access to dermatologists. There may be some technological solutions in the long term, and training dollars that may need to be reallocated so we can train more experts where they are needed. Besides access problems, there are also communication barriers. We talked about how important communication is, but I think we still suffer some of the effects of the Health Insurance Portability and Accountability Act. Obviously, we all support patient confidentiality as a critical element of the physician-patient relationship. But there are still barriers to easy communication between physicians about patient information. Many physicians, for example, still have a fax machine because it is considered by some to be a more private way of communicating information. I hope we can either develop technology or alter the regulatory environment so communication can be as facile and smooth as possible.

Dr Merola: Communication is definitely the key—simply picking up the phone or making sure that your medical record or a consultation letter includes details about not just the treatment plan but why you are choosing what you have for the patient. Another strategy is electronic health record (EHR) templates for each respective provider. These EHR templates, available for free at the PPACMAN website, remind respective providers of each other’s most current treat-to-target strategies, relevant screening elements, and other best practices. We are also actively developing best practices through the PPACMAN group for dissemination to the community.

Dr Evans: I agree that technology will hopefully be a big part of improving that communication and improving the information we collect over the long term. I think today, outside of restrictions on cost and payment, there is no reason a patient should not have individualized psoriasis treatment. We have so many options—topical, oral, biologic, and nonpharmacologic therapies—so we need to know the patient’s medical history, their comorbidities, their other medical problems that maybe are not necessarily comorbid, their social environment, their level of risk and tolerance, and what their desires for treatment are. For example, many patients would still choose phototherapy over a biologic. We need to think of it not as an algorithm that we just give this drug, then give this drug, but rather meet each patient where they are medically and personally to try to tailor their treatment. There will be some barriers to that where the payer does not want to pay for it, or it is too expensive for the patient. Obviously, we have to work within the system we have, but I would hope that we always begin from an idea of tailoring the treatment with its risks and benefits to the patient.

Reference:

The National Psoriasis Foundation announces Commit to Cure Gala honorees. National Psoriasis Foundation. February 1, 2024. Accessed April 3, 2024. https://www.psoriasis.org/npf-2024-gala-honoree-announcement