“The question is, should we treat mild to moderate psoriasis with modern systemic therapy?, and the position that I will take is yes,” said Richard G.B. Langley, MD, at the beginning of his presentation at the American Academy of Dermatology Virtual Meeting Experience 2021. He explained the steps and reasons why dermatologists should take a similar stance with their patients with psoriasis.

The definition of mild to moderate severity of psoriasis differs among dermatologists, researchers, payers, and patients. Traditionally, the definition of mild to moderate is less than 5% body surface area (BSA) or presentation in low-impact areas; however, as dermatology moves toward a more patient-centric focus, consideration on the disease impact to patient well-being and quality of life. Mild to moderate can be considered “moderate/severe” if their disease severely impacts their life (eg, psoriasis of the hands preventing patient from working).

Dr Langley highlighted that the “mild” definition, per research from Dr Bruce Strober, underestimates disease severity in psoriasis. Mild can involve special areas (eg, scalp, genitals, palms/soles, nails, or face) but also be refractory to prior treatment with topicals. It may also be associated with psoriatic arthritis, which should be controlled appropriately.

Thus, Dr Langley explained, we need to consider what systemic therapy would mean for the patient. Dermatologists should ask what the patients treatment goals are, as well as figure out the risk-benefit ratio (The risk-benefit is excellent, hinted Dr Langley) and correspond with the payer to find out drug coverage.

What needs to happen, rather, is dermatologists consider not classifying psoriasis and mild to moderate and moderate to severe, but rather just one disease. A Delphi classification exercise found the statement with the highest score endorsed a simple, practical approach to classifying psoriasis disease severity that:

• Is based on dichotomous response to therapy (topical vs systemic);
• Considers the response to topical therapy;
• Employs a standard and simple objective criterion, such as BSA; and
• Considers anatomical location, regardless of percentage of BSA affected.

Further, Dr Langley underlined, that modern advanced therapies are both highly safe and highly effective. Dermatologists should at least consider treating patients with effective therapies, no matter what they are, and put the patient first in treatment decisions. —Lauren Mateja

Reference
Langley RGB. Treatment of “mild-moderate psoriasis” with modern systemic therapy. Presented at: American Academy of Dermatology Virtual Meeting Experience 2021; April 23-25, 2021; virtual.