Addressing Unmet Needs in Psoriasis Treatment

Five leading nurse practitioners and physician assistants from across the country shared pearls taken from experiences in patient cases during a recent Dermatology Times Around the Practice custom video series titled “Advanced Practice Provider Perspectives on Advances in the Management of Plaque Psoriasis.”

“Psoriasis has been around for so long. We started getting treatment options in the 1920s and thought it was just a topical condition,” said Alexa Hetzel, MS, PA-C, discussion moderator. “Now we really understand that it’s more of a systemic autoimmune condition and have expanded treatment options.”

Efficacy of Deucravacitinib in Plaque Psoriasis

Deucravacitinib has a distinctive selectivity and the novel mechanisim of action differs from Janus Kinase (JAK) inhibitors. The panel discussed deucravacitinib’s distinct features that make it a strong tool in their armamentariums.

“It’s a TYK2 selected inhibitor that specifically targets. It is an oral agent once daily that it targets IL-12 and 23, same mechanism of action, and focused target of action that we see with the biologic agents that we’re getting with this oral agent,” Lakshi Aldredge, MSN, ANP-BC, explained. “One of the differences between biologics and the pills as we know, is that we’re used to thinking of biologics being highly targeted, very safe. Whereas the traditional pills that we’re used to, such as apremilast, methotrexate, cyclosporine, we think about them having a wide effect within the immune system and perhaps may not be as safe, and perhaps contributing to end-organ damage. With deucravacitinib, this is not the case. We see in an oral agent highly specific action focusing on TYK2 inhibition, which we know seems to play an active part in controlling IL-12 and IL-23, both of which have been identified as key cytokine players in the pathogenesis of psoriasis.”

Patient Case Presentations

The panel reviewed 3 different cases and gave insights to how they would approach each patient and treatment plan.

Case 1 

A 50-year-old woman has been diagnosed with plaque psoriasis for 5 years. She has no joint involvement but it is covering 18% body surface area with numerous plaques especially located on her hands. She has tried multiple different topical therapies that she really does not like because they feel greasy, especially on her hands.

Laura Bush, DMSc, PA-C, DFAAPA, said, “I would say 18% would be way too much psoriasis for me. I would sit down with her and explain that this is a whole body disease, that it’s an inflammatory cascade in her immune system and that treating her systemically will help all her areas in her body and not just putting something on the skin. I can also correlate with her on the fact that I would not have time to put creams on 18% of my body. She has already said she’s non-compliant because she doesn’t like it so it’s really important to get her to have the buy-in.”

In Aldredge’s experience, insurance companies often require her to try step therapy to get some of the more effective biologic and oral therapies. “I think it’s really important for this woman that we understand what her hesitancy is with some medications so that we can clarify misconceptions,” she said. The panel also expressed the importance of asking about feasibility, practicality, and work and housing situations to better evaluate the best treatment options.

Case 2 

A 23-year-old woman with plaque psoriasis presents with several thick, scaly, well-defined erythematous plaques that are silver in color. Very textbook for us to nail this diagnosis. It’s very prominent, especially on her elbows and thighs as well as her scalp, and it’s covering 15% of her body surface area. She mentions having rashes in the past, but nothing really severe. She was initially started on Apremilast, but complained of nausea and diarrhea.

The panel agreed deucravacitinib would be this patient’s next best option. Terry Faleye, MPAS, PA-C said, “An oral agent would be awesome for her, but if she wants an out-of-sight, out-of-mind treatment, she may be perfect for an injectable once every 3 months.”

Case 3 

A 40-year-old woman with a 10-year history of plaque psoriasis has been treated previously with various topical treatments and phototherapy with very limited benefit to her. She continues to experience persistent plaques on her scalp, elbows, and knees. This is affecting her quality of life because she feels embarrassed, and now it is starting to affect her clothing choice. She is shying away from social situations, which is hard to see. Especially when you are having that conversation, they will not look you in the eye. You know she is having a hard time when they won’t look you in the eye.

Empathy and validation are key in cases when the patient feels defeated. “Not only can we help her with her skin, but also having a discussion with her just about the psychosocial aspects of this,” explained Jennifer Connor, MPAS, PC-C. “Clearly she’s got some depression, which we know goes hand-in-hand with psoriasis and helping to point her in the right direction and understanding that this is part of this disease process [is important].”

Addressing Unmet Needs

Even with the rapid expansion of the treatment spectrum over the past decade, there are still unmet needs that patients have. The panel agreed that investigative treatments will help address unmet needs, such as a clear understanding of which biologic will work for a particular patient depending on clinical history and comorbidities.

“I’m also really excited that companies are looking at and getting extrapolating data specifically for psoriasis in specific body regions, hard to treat areas, males, scalp, genitals, palmar pustular. We have an agent for the first time focusing on generalized pustular psoriasis. Again, very small number of patients, but incredibly debilitating. So I think it’s really exciting that, even [with] some of the existing drugs, getting further information about how they can be utilized more effectively,” Aldredge concluded.