Considering Plaque Psoriasis Comorbidities in Treatment Plans

“If you look around the country, more and more dermatology PAs and nurse practitioners are taking a primary role in the treatment of patients, specifically with biologics,” said Lauren Miller, MPAS, PA-C, a board-certified dermatology physician assistant at Southern Skies Dermatology & Surgery in Alabama, during the Dermatology Times DermView custom video series, “Perspectives in the Management of Plaque Psoriasis.” She was joined by T.J. Chao, MPAS, PA-C, a board-certified dermatology physician assistant at Atlanta North Dermatology and Skin Care in Woodstock, Georgia. The duo discussed comorbidities and new treatment options in plaque psoriasis.

Lauren Miller, MPAS, and T.J. Chao, MPAS, discussed the importance of talking with patients about what they define as a successful treatment.

“In regard to the skin portion of the disease itself, I don’t think it’s progressive,” Chao explained. “Now, when you’re talking about psoriatic arthritis, that’s a different animal. We definitely know that’s progressive. We know that even in a small amount of time, if we don’t treat our patients with a proper therapy, we could have joint deformity and joint destruction occurring. In regard to other disease states, we know there’s a strong interplay with comorbidities, with things like metabolic syndrome, as well as obesity, depression, and inflammatory bowel disease. There is a lot going on with these patients. It’s more than just the skin.”

Getting the Conversation Started

Chao and Miller emphasized the importance of having a conversation with a patient to try to gain an understanding of what the patient defines as a successful treatment, whether it’s a body surface area of 0, Investigator’s Global Assessment score (IGA) of 0, or the ability to get through their day-to-day routines, hobbies, and work.

“I think sometimes as providers we have to think beyond what we see on the skin. We also know obviously that there are some symptoms that maybe we can’t visualize. We can’t visualize the itch, we can’t visualize how that affects the patient [mentally]. And so, one of my favorite questions I like to ask my patients is, “How does your disease affect your life? What does it prevent you from doing?” I ask that to every patient, and I ask it at every visit,” Miller shared.

More Than Skin Deep

Newer therapeutic options and mechanisms of action are now available, including FDA-approved tapinarof (Vtama)—the first-in-class aryl hydrocarbon receptor agonist. Tapinarof can be utilized in all severity types for patients with plaque psoriasis.

“Speaking specifically about tapinarof, I’ve had over 100 patients whom I’ve prescribed that product to,” Chao said. “I’ve seen it help drive improvements in the disease. If you look at the mechanism of action of tapinarof, essentially it binds to the aryl hydrocarbon receptor and drives through gene transcription normalcy of the cell. You’re trying to get it to homeostasis and not allow those pathogenic cytokines to occur, like T helper 17 releasing pathogenic interleukin-17 (IL-17) cytokines…it’s an agonist that drives normalcy of cells essentially. You see a change in the psoriasis that’s a little different from what you might have seen in the past with topical steroids.”

Miller noted that aryl hydrocarbon receptors can affect patients more than skin deep.

“One of the interesting things about aryl hydrocarbon receptors is that they’re found throughout the body in different areas, not just the skin,” Miller shared. “It’s very ligand specific. Depending on what it binds to and where it is in the body are going to determine what the effect is.”

Miller also mentioned how it is often more beneficial for the patient to not have to try more than 1 product from a co-pay standpoint, and tapinarof could serve as a catch-all option.

Tapinarof Safety Data

There are no head-to-head trials with tapinarof and roflumilast. Tapinarof has 52 weeks of long-term safety data, and efficacy is maintained throughout.

“What’s different are some of the data that you have with tapinarof that show a remittive effect,” Chao explained. “Patients in the long-term extension PSOARING 3 trial were able to stop therapy eventually and go a long time, in some cases 4 months, without any return of disease. That’s landmark, and it’s completely different from what we’ve seen before. We’ve never had data to show that until now.”

Presence of Comorbidities

Miller and Chao agreed that the most significant comorbidity clinicians should keep an eye out for is psoriatic arthritis.

“If they have psoriatic arthritis, it’s going to have the biggest impact on decision-making,” said Chao. “In those patients, I may lean more toward anti-tumor necrosis factor inhibitors or IL-17 inhibitors in the treatment of their disease to get better control over their joints and skin. Now, if you have patients who have inflammatory bowel disease, you may want to stay away from IL-17s. That’s something that could potentially have an impact on the patient. Also, I would say if they have a lot of inflammatory conditions, heart disease—you may want to consider being potentially more aggressive with systemic agents.”

Miller likes to look at it as one big puzzle with multiple pieces coming together. “I think we all have our own algorithm, but every patient is so different that there isn’t a one-size-fits-all [answer] when it comes to trying to choose a therapeutic...But I agree with you 100%, you have to take into account comorbidities because we’re thinking about safety,” she expressed.

Treatment Considerations

The most important thing—Chao and Miller have learned this from treating patients with the newer products over the past year or so—is that clinicians need to advocate for patients and take that extra step to educate. If they are used to using steroids and then they use tapinarof, they may think it’s not working because it is not totally clear in 2 days. The drug’s remittive effect will allow them to stop using the product over time.