Factors to Evaluate When Initiating Psoriasis Treatment

Amy McMichael, MD, and Maria Lopes, MD, MS, review factors to evaluate when starting treatment and how to educate patients on the possible adverse events from that treatment.

Ryan Haumschild, PharmD, MS, MBA: Dr McMichael, we talked about a lot of factors you utilize when you evaluate starting treatment. Could you go into a little more detail around the skin prototype, the risk of depigmentation or increased pigmentation, and some of the cultural or ethnic considerations? How do you educate patients on some of the possible adverse effects from the different treatments we’ve talked about, such as depigmentation or increased pigmentation, so they know what to expect, they’re not caught off guard, and they can still maintain that motivation to complete therapy?

Amy McMichael, MD: That’s an important problem when we use ultraviolet light to treat psoriasis. It’s an oldie but goodie, whether it’s in office or a home light. It’s been around forever, and a lot of patients can’t or aren’t able to take medications systemically because they have other underlying conditions. Biologics may have infections ongoing, so they can’t do those. Potentially, they might have liver or renal issues, so they can’t do things methotrexate. In those patients, and sometimes in kids, we’ll do ultraviolet light.

We know ultraviolet light has lots of great aspects to it. It reduces inflammation, but it also has the potential adverse effects of giving you a tan. For someone who’s already brown, they don’t necessarily want to get darker. That has to be a decision and a conversation up front to describe what might happen to the skin. You can even get burns. Even though we’re all very sensitive, some of these patients are doing this at home to minimize travel. Sometimes their light isn’t set correctly, or maybe they get a little more light than they should. They can get a burn, which can then cause hypopigmentation, hyperpigmentation, and wound care. We have to set patients up to understand that this isn’t an excuse to stop, but this is a reason to call the office and have us help them through that hard time.

Very few other drugs will give significant hyperpigmentation or hypopigmentation. The disease itself does that fine on its own. We have to explain to patients that sometimes after you get that lesion under control, you’re going to have that remaining hyperpigmentation. That way, they won’t think you’re not aware of it. If you explain it up front, then later on they’ll remember that and say, “I get that. I’m going to have to wait 6 to 9 months for clearing this.” Whether it’s hypopigmentation around the frontal hairline or hyperpigmentation on the chest, knees, or trunk—I have a great photo where you can see the very volcanic nature of the plaque of psoriasis on a patient’s back. Then it’s cleared completely, except there’s this faint, dark pigmentation in an African American woman on her back where the lesion was. It’s a nice photo matchup. She wasn’t worried, but some of our patients are. Expectation setting is truly the important thing here.

Ryan Haumschild, PharmD, MS, MBA: Having those value-added conversations with a patient up front is important because everyone has different vulnerabilities. We need to be thoughtful of that. Even the type of lifestyle someone has and how much skin they show. Some patients could have smaller portions of their body surface area affected, usually under clothes, and sometimes it could be greater.

When we think about the different locations that psoriasis can develop, Dr Lopes, how does the location of that psoriasis impact treatment selection? Ultimately, another consideration that you mentioned earlier is how that location psoriasis impacts quality of life across populations.

Maria Lopes, MD, MS: That’s a great question. Dr McMichael teed up some of these points. It’s about individualizing patient choice, setting expectations, and educating on risk benefit. Much of this depends on the location of the lesions, the visibility, the level of severity, the patient’s expectation, and whether they’re children. You may think about treatment options differently if you have an adult or a pregnant woman in terms of risk benefit and treatment options you can use. Based on the extent of their ability, they may have some limitations.

Also, it’s important to set expectations in terms of the first level of priority. As you go down the path of treatment, and as some symptoms get under control, what are the goals as you move into different stages? But go back to patient education. It’s understanding what’s important to that patient, and what symptoms linger that are important to still resolve. It’s also important to understand that you can’t cure psoriasis. Unfortunately, over time, many patients may not continue the appropriate treatments that they should be on. Then what happens with flares? But it’s about individualizing the goals in patient education and setting the right expectations.

Ryan Haumschild, PharmD, MS, MBA: Getting the patients started on the right therapy early on is so important.

Transcript edited for clarity.

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