Dermatologist Saakshi Khattri, MD: The Importance of Treating Mild Psoriasis from Within

Saakshi Khattri, MD

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Reasons to Consider Systemic Treatment for Patients With Mild Plaque Psoriasis

Psoriasis is a systemic, chronic inflammatory disease affecting more than 7.5 million people in the United States.^1,2 Plaque psoriasis is the most common form of psoriasis.³ It’s characterized by erythematous scaly plaques or patches on the skin.³ In skin of color, erythema is seen less frequently and typically appears as violaceous or hyperpigmented.^4,5 The condition is associated with a significant risk for comorbidities including psoriatic arthritis (PsA).⁵

Despite having effective treatments, psoriasis is frequently undertreated.^6,7,8 In fact, according to the Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAAP) survey results, patients received a diagnosis of psoriasis on average two years after first experiencing skin symptoms.⁷ In addition, nearly half had not seen a physician in the past year, and most patients with a BSA of ≥ 4 palm lesions were either not receiving treatment or receiving topical therapy alone.⁷

Many patients' mild psoriasis can be managed with topical treatments.⁹ However, topical therapies might be inadequate.⁹ Patients also report a higher burden of disease associated with difficult-to-treat areas and pruritus, or itching.¹⁰ These patients may need systemic treatment.

HCP Live spoke to Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist, to discuss the role of systemic therapy in plaque psoriasis and what’s important to know about timely treatment of plaque psoriasis.

HCP Live: When assessing patients with plaque psoriasis, what are your top considerations for initiating systemic therapy for patients with limited skin involvement?

Dr. Khattri: When I’m thinking about systemic therapy for a patient with mild plaque psoriasis, I consider several factors. Most importantly how affected is the patient by their disease and does the patient have symptoms in difficult-to-treat areas such as the scalp, or genital areas? I also want to know what therapies the patient has been using, what has worked and hasn’t worked, and what the patient’s goals are for treatment.

Topical treatments can improve localized symptoms, but they are unlikely to address systemic inflammation.¹¹ Topical creams and lotions can also be time-consuming or difficult to apply depending on the location of plaques.^12,13 Some topicals may stain your skin or clothing.^12,13 These limitations can affect patient adherence.^12,13 Nevertheless, topicals can be an effective treatment option.⁹ With that being said, many patients with psoriasis who use topical therapy alone report inadequate symptom improvement, which in my experience can lead to frustration.¹³

Disease severity is typically defined by the total body surface area (BSA) affected.⁹ However, in the UPLIFT survey, 58% of patients with limited BSA (BSA ≤ 3 palms) rated their current symptoms as moderate or severe.¹⁰ Three out of five patients in the study with BSA ≤ 3 palms and disease in at least one special area rated their psoriasis as moderate or severe.¹⁰ These are the types of patients that may benefit from a systemic treatment.

Limited BSA with manifestations in difficult-to-treat areas can have a substantial disease burden.¹⁰ This indicates a systemic treatment may be warranted.

I also recommend systemic treatment for appropriate patients with concurrent PsA and evidence of joint damage such as swelling, stiffness, pain, or tender joints.

It’s important to discuss treatment goals with every patient. Treatment should be individualized based on patient needs and preferences. Plaque psoriasis impacts each patient differently, and a treatment strategy needs to be realistic. If a patient isn’t consistently adhering to topical treatment or seeing improvement, it may be time to consider another option. Thankfully there are a wide range of therapies available today to offer patients.

HCP Live: There are a growing number of systemic options in plaque psoriasis. What factors should clinicians consider when choosing a systemic therapy for their patients?

Dr. Khattri: It is great to see treatment options expand for patients with plaque psoriasis. There are several factors to consider when choosing a systemic therapy for a patient, including route of administration, laboratory testing and dosing frequency.

In addition, as previously mentioned, some patients may find it challenging to apply topical therapies to special areas such as the scalp or intertriginous sites such as the genital area, and a systemic therapy can be helpful in these instances. ^{2,10, 12} As with any other chronic lifelong disease, it’s also important to establish short- and long-term treatment goals with each patient. ²

In terms of administration, some patients may prefer a medication with an oral route of administration versus an injectable, or they may have a fear of injections.

HCP Live: Can you highlight some recent findings from studies on ongoing unmet needs of patients with plaque psoriasis?

Dr. Khattri: Real-world outcomes data can highlight the burden of plaque psoriasis for patients and help clinicians better understand unmet needs of patients.

For example, real-world outcomes data on 304 systemic-naïve patients with mild to moderate plaque psoriasis defined as ≤10% BSA found that a substantial percentage of patients showed none to or minimal improvement in overall skin clearance, including in special areas, and symptom resolution despite treatment with topical therapy.¹⁴ Following a mean duration of 6.9months on their current topical treatment, approximately half of patients' BSA remained the same (48.2%) or worsened (2.0%).¹⁴.14 Moreover, many patients (71%) had residual plaque psoriasis in special areas including the nails (92%), scalp (76%), genitals (68%), and face (66%).¹⁴This 2022 study was published in Journal of Dermatological Treatment.

Outcomes data published in Dermatologic Therapy in 2021 found that mild to moderate plaque psoriasis patients with BSA ≤10% also highlighted unmet needs of systemic-naïve patients, including treatment adherence.¹³ The findings were based on a survey of 175 patients and showed that roughly half (49.7%) of patients reported they were not highly adherent to their topical treatment.¹³ Reasons for nonadherence included forgetfulness (23%), frequency of application (17%), consistency of the treatment (13%), and difficulty in applying the treatment (11%).¹³ These are important considerations for some patients who may not be achieving desired results.

In the study, patients reported using a median of three topical treatments since being diagnosed and that they ]had been using their current topical medication for a median five years.¹³ Out of the 96% of patients who reported itchiness, soreness, pain, or stinging in their skin prior to starting their current topical treatment, 87% reported having these symptoms persist despite their current therapy, and more than a quarter of patients reported their therapy did not result in improvement in their itch and pain.¹³ In addition, 93% of patients reported persistent plaque psoriasis in one or more special body areas.¹³

Studies such as these underline the impact of plaque psoriasis on patients and need for strategies to improve its management.

HCP Live: Why is it important to treat plaque psoriasis in a timely manner?

Dr. Khattri: There is still a lingering perception that plaque psoriasis is just a skin disease, which is not true.¹³ Greater understanding of the pathogenesis and systemic inflammatory nature of psoriasis has advanced the development of therapies that can address the underlying inflammation. Thanks to these developments we have even more effective treatments to improve outcomes for patients. Yet more education is needed around the system-wide burden of plaque psoriasis and how systemic therapy can help, so that more patients can take advantage of therapies that treat the disease from within, at the cellular level.

To learn more about about a systemic treatment option visit BeyondTopicals.com.

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References

1. Armstrong AW, Mehta MD, Schupp CW, Gondo GC, Bell SJ, Griffiths CEM. Psoriasis Prevalence in Adults in the United States. JAMA Dermatol. 2021 Aug 1;157(8):940-946.
2. Van Voorhees AS, Feldman SR, Lebwohl MG, Mandelin A, Ritchlin C. The Psoriasis and Psoriatic Arthritis Pocket Guide: Treatment Algorithms and Management Options. 6th ed. The National Psoriasis Foundation.
3. Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005;64 Suppl 2(Suppl II):ii18- ii23.
4. Kaufman, BP, Alexis, AF. Psoriasis in Skin of Color: Insights into the Epidemiology, Clinical Presentation, Genetics, Quality-of-Life Impact, and Treatment of Psoriasis in Non-White Racial/Ethnic Groups. Am J Clin Dermatol 19, 405–423 (2018).
5. Menter MA, Armstrong AW, Gordon KB, Wu JJ. Common and Not-So-Common Comorbidities of Psoriasis. Semin Cutan Med Surg. 2018;37(2S):S48-S51.
6. Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003-2011. JAMA Dermatol. 2013 Oct;149(10):1180-5.
7. Lebwohl MG, Bachelez H, Barker J, Girolomoni G, Kavanaugh A, Langley RG, et al. Patient perspectives in the management of psoriasis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis Survey. J Am Acad Dermatol. 2014;70(5):871–881.e871–830.
8. Strober BE, van der Walt JM, Armstrong AW, Bourcier M, Carvalho AVE, Chouela E, et al. Clinical Goals and Barriers to Effective Psoriasis Care. Dermatol Ther (Heidelb). 2019 Mar;9(1):5-18. doi: 10.1007/s13555-018-0279-5. Epub 2018 Dec 21.
9. Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol. 2020 Jun;82(6):1445-1486.
10. Lebwohl M, Langley RG, Paul C, Puíg L, Reich K, van de Kerkhof P, et al. Evolution of Patient Perceptions of Psoriatic Disease: Results from the Understanding Psoriatic Disease Leveraging Insights for Treatment (UPLIFT) Survey. Dermatol Ther (Heidelb). 2022 Jan;12(1):61-78. Epub 2021 Oct 25.
11. Korman NJ. Management of psoriasis as a systemic disease: what is the evidence? Br J Dermatol. 2020 Apr;182(4):840-848. doi: 10.1111/bjd.18245. Epub 2019 Oct 15.
12. Elmets CA, Korman NJ, Prater EF, Wong EB, Rupani RN, Kivelevitch D, et al. Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021 Feb;84(2):432-470.
13. Gupta S, Garbarini S, Nazareth T, Khilfeh I, Costantino H, Kaplan D. Characterizing Outcomes and Unmet Needs Among Patients in the United States with Mild-to-Moderate Plaque Psoriasis Using Prescription Topicals. Dermatol Ther (Heidelb). 2021 Dec;11(6):2057-2075. Epub 2021 Oct 14.
14. Kaplan D, Hetherington J, Lucas J, Khilfeh I, Nazareth T. Real-world health outcomes in US adult patients with mild to moderate plaque psoriasis taking topical therapy. J Dermatolog Treat. 2022 Sep;33(6):2844-2852. Epub 2022 Aug 3.