Controlling psoriasis symptoms eludes these patients

Optimal management of psoriasis symptoms falls short for about three in 10 patients with moderate plaque psoriasis and one in five with severe psoriasis.

Solutions to close those gaps include better drug selection. But a big part has to do with addressing patient adherence issues, which can be accomplished when dermatologists develop strong therapeutic alliances with patients, according to an article in the March supplement of Seminars in Cutaneous Medicine and Surgery.

Practical strategies can help dermatologists and other providers develop the alliances, optimizing psoriasis management, they write.

Study author April W. Armstrong, M.D., M.P.H., tells Dermatology Times that one of the primary reasons patients don’t achieve optimal management of their psoriasis is that they may not be aware of available, highly efficacious treatment options.

In other cases, patients are concerned about the adverse effects from some medications because they lack complete information about the risks versus benefits of today’s treatments.

“Therefore, it is important that clinicians and patients strive to obtain accurate and complete information regarding [risks and benefits] for any medication in order to make an informed decision regarding therapies,” says Dr. Armstrong, who is associate dean for clinical research at Keck School of Medicine, University of South California, Los Angeles.

Still another common reason patients do not adhere to treatments is thinking they can stop or change treatment because their psoriasis improves. The problem is many current medications require long-term treatment, she says.

One remedy:  A strong therapeutic alliance

Patient adherence to psoriasis treatment is especially challenging with topical medications. One study of 1,200 psoriasis patients found nearly three quarters did not use the topical therapy the way it was intended.

“Owing to their fast-acting efficacy and less-frequent administration, biologics do not have the same adherence issues that other psoriasis therapies have,” the authors write.

In fact, one study found nearly 100 percent adherence to biologics versus 93 percent for phototherapy and 75 percent for topical psoriasis treatment.

The dermatologist’s role in a strong therapeutic alliance is understanding a patient’s expectations from treatment and treatment preferences; then, designing treatment based on those.

There is no one-size fits all approach when it comes to psoriasis treatment, the authors write. And dermatologists need to ask patients what about treatment is most important to them, including ranking options, such as rapid results, convenience, risk and adverse effects or treatment at home versus the clinic.

Communicating to build the alliance takes time and follow-up. In a survey of 26 dermatologists and 50 patients, researchers found most dermatologists spent five to 10 minutes on the first psoriasis treatment consultation. Patients surveyed indicated dermatologists need to spend more time explaining treatment.

Careful follow-up, or close monitoring, can significantly reduce nonadherence, researchers have found.

“For patients with mild-to-moderate psoriasis who are prescribed topical therapy, a follow-up visit at one month is prudent,” the authors write.

But for patients starting on a systemic medication, it is important to follow-up immediately, to ensure those patients have no additional questions regarding injections, risks and benefits, Dr. Armstrong says.

“The providers can consider lengthening the visit intervals after the patient feels comfortable taking the medication and the psoriasis has improved substantially,” she says.

The authors suggest that once psoriasis patients and dermatologists have established a preferred treatment plan, dermatologists should provide patients with written instruction and clearly set expectations from treatment, including timelines for improvement, potential side effects and when to let dermatologists know about potential side effects. If dermatologists use off-label dosing, they need to address that with patients, too, in order to avoid confusion with product labeling.

Dr. Armstrong says that she has found patience is a valuable asset when customizing psoriasis treatment to meet the patient’s needs.

“If the patient is resistant to trying a therapy recommended by you, the provider, don't try to push it onto the patient during the initial visit. This is because more work needs to be done with regard to patient education, eliciting patient concerns and addressing those concerns, before the patient will willingly take the medication,” she says. “Think of the therapeutic journey as a long road [on which] the two of you have embarked, and the initial visit with the provider may not be a home run. It is important to bring the patient back frequently to provide relevant educational materials and address their concerns head on.”

DISCLOSURES

This paper is part of a continuing medical education supplement that is supported by an educational grant by Ortho Dermatologics. The authors of this study have industry ties, including the one interviewed for this story. Dr. Armstrong has served as investigator, advisor and/or consultant to AbbVie, Janssen, Novartis, Lilly, Regeneron, Sanofi, Leo, Science 37, Modernizing Medicine and Ortho Dermatologics.

REFERENCES

Wu JJ, Armstrong AW, Gordon KB, Menter MA."Practical Strategies for Optimizing Management of Psoriasis," Semin Cutaneous Med Surgery. 2018 Feb;37(2S):S52-S55. doi: 10.12788/j.sder.2018.012.