Advancing Psoriasis Patient Care

In this interview with The Dermatologist, Dr Steven Feldman discusses his session, “Better Care for Psoriasis Patients,” presented at Fall Dermatology Week 2023.

Now in its third year, Dermatology Week is a unique, multi-day event that brings together some of the leading subject matter experts from across the field of dermatology. With a focus on dermatology education over destination, Dermatology Week aims to provide practical, timely education that can immediately translate into better patient outcomes. Save the date for Spring Dermatology Week, May 8-11, or Fall Dermatology Week, November 13-16, 2024.

Steven R. Feldman, MD, PhD, is a professor of dermatology, pathology, social sciences and health policy, and molecular medicine and translational science at the Wake Forest University School of Medicine in Winston-Salem, NC.

The Dermatologist: Can you give us a preview of what will be covered during your session at Fall Dermatology Week 2023?

Dr Feldman: At Dermatology Week 2023, I have the pleasure of working with Dr Joel Gelfand. He will engage in a discussion with me about how to improve the care of patients with psoriasis. Among the key highlights will be some of his remarkable work on the epidemiology of psoriasis and its comorbidities, phototherapy, and of course my favorite topic, getting patients to take their medications better.

The Dermatologist: What research designs or methodologies are commonly used to evaluate the safety of therapeutics for psoriasis?

Dr Feldman: The safety of psoriasis treatments is studied in clinical trials, and those studies are valuable because you receive head-to-head comparison against placebos in randomized patient groups. So, you understand well what's due to the drug as compared to a placebo. Unfortunately, the placebo groups only last for 12 to maybe 16 weeks, and so you don't have the long-term placebo controls. However, at least you get a careful capture of safety event information from clinical trials in the extension phase that may last for a year, or 3 years, or sometimes even 5 years. But again, the number of patients is relatively limited, so those kinds of studies aren’t ideal for identifying rare side effects.

There are registries that may have thousands of patients, they don't have placebo groups and they're not randomized, but generally speaking, for example in the PSOLAR registry, you can get a good idea of the safety of a drug versus some of the comparators. Then finally, there's real-world evidence and spontaneous reporting. Spontaneous reporting may help identify some signals, but it's almost useless because spontaneous reports don’t show how many cases of adverse events occur and how many people were exposed. Therefore, it's difficult to get a sense of safety from those kinds of databases.

The Dermatologist: Narrowband ultraviolet B (UVB) phototherapy is an established treatment option for psoriasis. How has its role evolved in contemporary psoriasis management?

Dr Feldman: I think phototherapy may be one of the oldest psoriasis treatments we have. I think when the Bible says they sent people with leprosy out into the desert, somebody had mistranslated the word psoriasis into leprosy somewhere along the way. We've been using sunlight, broadband UVB, and now narrowband UVB. Before the biologics that we have now, phototherapy was a commonly used treatment.

But over the years, phototherapy has become less and less popular due to its inconvenience and reimbursement issues. Some patients may have to pay a copay at every visit. There are other forms of light, like going to a tanning bed or going out in the sun, and something I think is highly underutilized–home phototherapy. You can get home narrowband phototherapy, and I think that's a great option for patients. In fact, if I were running insurance companies, I'd probably require patients to try and fail home phototherapy before covering any of the expensive drugs.

The Dermatologist: Can you discuss the efficacy and safety of narrowband UVB phototherapy?

Dr Feldman: Narrowband phototherapy is a highly effective treatment. I’m uncertain whether it’s as effective as our most potent biologics, but I think it ranks quite high. So, if you have a suitable candidate who is willing to undergo treatment either at home or in the office, they can get good efficacy. The safety is terrific. While there's some risk of a sunburn and there must be some increased risk of skin cancer, that increased risk seems to be very small. Moreover, there are effects on comorbidities to consider. You might think that for individuals with cardiovascular comorbidities, a systemic treatment is preferred due to potential cardiovascular benefit. However, it’s possible, and I think it's worth listening to Dr Joel Gelfand’s insights on this, that narrowband phototherapy could also hold potential cardiovascular benefits.

The Dermatologist: What are some of the primary reasons for gaps in adherence to psoriasis treatment, and how can dermatologists effectively address and improve patient adherence to treatment?

Dr Feldman: Well, I'm biased. I believe adherence is the most significant issue in medical care, not only in dermatology, but across all fields. We possess topical therapies that are highly effective for psoriasis if patients would consistently apply them, yet they often don't. Treatment adherence is abysmal for long-term use of topicals. However, I would never blame the patients. I believe the main reason patients struggle with medication adherence is that it’s our responsibility. We failed to create the sense of accountability that's needed to get people to use medications well. I think in medicine, we sometimes do things that nobody else in any other human endeavor would do. Telling people, "Here, do this every day, I'll see you again in 2 to 3 months." Such an approach is unlikely to motivate anyone, yet it's a routine occurrence. I have a book coming out on all my tricks for getting people to use their medications, but there's a host of things you could do. I believe attending Dermatology Week to hear more about it would be a great start.

The Dermatologist: What additional tips and insights would you like to share with your colleagues regarding better care for patients with psoriasis?

Dr Feldman: When it comes to getting better care for patients with psoriasis, I think you would have a fun time attending Dermatology Week and tuning in to Dr Joel Gelfand and me. Dr Gelfand is arguably one of the leading dermatologic researchers of our generation, and he is involved in so many practical initiatives. I know I enjoy listening to him.

Reference
Feldman SR. Better care for psoriasis patients. Presented at: Dermatology Week 2023; September 20–27, 2023; Virtual.