Disease Burden and Progression of Plaque Psoriasis

Mark Lebwohl, MD: Hello and thank you for joining this HCPLive® Peer Exchange titled, “Advances in the Management of Plaque Psoriasis.” Psoriasis is a chronic inflammatory immune-mediated disease that is characterized by a complex pathophysiology. Recent advances in the understanding of psoriasis pathogenesis have clarified the pivotal role of interleukin-23 [IL-23]. This cytokine has become the therapeutic target of a new category of biologic drugs for psoriasis. In this HCPLive® Peer Exchange discussion, I am joined by a panel of my colleagues, all experts in the field of dermatology. Together, we are going to discuss the advances in diagnosis and review the current and novel treatment strategies for psoriasis, including IL-23 inhibitors.

I’m Dr Mark Lebwohl, Waldman professor and chair of dermatology at the Icahn School of Medicine at Mount Sinai in New York. Participating today on our distinguished panel are Dr George Han, assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai in New York; Dr Brad Glick, dermatologist and principal investigator at GSI Clinical Research in Margate, Florida; and Dr Scott Gottlieb, chief of dermatology at the Brandywine Hospital and associate professor of dermatology at the University of Pennsylvania, Philadelphia, Pennsylvania. Thank you so much for joining us, let’s begin.

Let’s first discuss the impact of psoriasis on our patients’ lives. Scott, you see plenty of patients with psoriasis. How does it impact their quality of life, what they do day to day?

Scott Gottlieb, MD: I think it impacts their quality of life in every single way. One of the biggest ways that I got to learn about this is I saw the results of a study in which patients with a number of different chronic diseases were asked how they were doing from a psychosocial standpoint. And it turns out that they asked patients who had things like cardiac disease, congestive heart failure, diabetes, some had strokes, depression, any cancer. And they asked all these patients, including patients with psoriasis, how they were doing from a psychosocial standpoint. And it was only patients who had depression who felt that they were doing worse than our patients with psoriasis from a psychosocial standpoint. So that meant that people with cancer and really life-threatening conditions imminently felt that they were doing better from a psychosocial standpoint.

On a more personal level, I’ve certainly had a number of patients who have been ostracized by the community, who have been put into a position in which they were unable to live their lives fully, whether it be exercising, going to the beach, or even going to school. So I think it really impacts quality of life in almost every single way, and I think we as a country understand that and value that, and we’ve taken it upon ourselves as a country to make sure that these people are well taken care of.

Mark Lebwohl, MD: Brad?

Brad Glick, DO, MPH: I think that occupationally it’s really important, too. We have to think that people have to work, and with impairment of this significant inflammatory burden that these patients have on their skin, not to mention that they’re at risk for getting psoriatic arthritis, it really impacts their ability to work on a day-to-day basis. So occupational impact, as well, I think is huge.

Scott Gottlieb, MD: I totally agree. That and our country’s health craze. Most people with psoriasis on the hands and the feet can’t really participate in a lot of those fundamentally important activities of life.

Mark Lebwohl, MD: Apart from the direct psychological impact that psoriasis has, there are a lot of comorbidities associated with psoriasis, and that certainly impacts our patients as well. George, you want to tell us about those?

George Han, MD, PhD: Certainly, we touched on some of the psychosocial aspects of psoriasis, but also we have to remember that a lot of psoriasis patients are inflicted with other medical diseases: metabolic disease, cardiovascular diseases. These are things that we really have to keep in mind. We have data now showing that severe psoriasis is strongly linked to mortality from cardiovascular disease, and the burden on our patients is great. I think we really have to consider diabetes, cardiovascular disease, and all those things in our approach to the overall treatment of our patient and approach them more holistically.

Scott Gottlieb, MD: Even as recently as maybe 5 or 10 years ago, I used to think of psoriasis as just this ugly skin disease that affected quality of life, that sometimes affected the joints. And now I really think about it as a systemic inflammatory disease, most obvious on the skin and sometimes the joints, but as you said, it really affects almost all the organs in our body. I think the challenge is going to be if treating psoriasis aggressively and lowering systemic inflammation is going to lead to improvement and better control of, or even prevention of, some of those comorbidities.

Brad Glick, DO, MPH: I think inflammatory bowel disease [IBD] is important to mention, too, with a significant number of patients having a risk of inflammatory disease, Crohn disease, and ulcerative colitis, particularly Crohn disease. It’s important in our conversation with our patients because it impacts our decision-making tree for selecting our therapies. For instance, inflammatory bowel disease and the use of certain interleukin inhibitors like interleukin-17. And we have to have these important discussions with our patients.

I think IBD is a very important component of this, particularly since we talk about joints and psoriatic arthritis, that 30% of patients with psoriatic skin disease may end up developing psoriatic arthritis. And we think that we’re in the trenches and we see the skin disease ahead of time. Those patients may not develop psoriatic joint disease until 10, 12, or even 15 years later. And it’s very much the same for inflammatory bowel disease, in that the skin may predate that inflammatory bowel disease. So these questions regarding comorbidities are very important with our patients. I think it also is representative of our interactions with our colleagues these days, too, our GI [gastrointestinal] colleagues and our partners in rheumatology as well.

Scott Gottlieb, MD: When I interact with the patient, I get a lot of pushback sometimes about starting a systemic medicine or biologic medicine. And I say to my patients now that not starting a biologic may ultimately be an important medical decision, as important as starting one, potentially if we do get data showing that some of these biologics can either prevent or better control the comorbidities.

Transcript edited for clarity.