James Q. Del Rosso, DO: Dr Glick, you might be looking at patients with psoriasis who have different presentations of disease or severity of disease. Give us an overview of how you look at treatment selection in terms of what’s available. Let’s start with topical therapies you have to choose from.

Brad Glick, DO, FAOCD: It depends on the presentation of the patients. We still have topical corticosteroids that are highly affected. In mild disease with no comorbidities, with a lot of background medications but not a lot of background baggage, topical steroids are great. We still have topical vitamin D and topical calcineurin inhibitors. But we’re in such a new generation. As Ben said, with targeted therapies, we tend to think of the biologics, but we have topicals that are targeted now because they’re targeted to those same cytokines that we’ve learned about in the last 25 to 30 years. It’s all very new.

When I approach the patient, it’s very different from even a year ago, when we got some of these new therapies. We still use a lot of topical corticosteroids and vitamin D analogs and some of the fixed-combination therapies, which we’re still using. There are some unique ones that have some unique vehicles. But just in this past year, we’ve had these unique nonsteroidal anti-inflammatory therapies that are not broad. They’re very selective. They work inside the cell. Peripherally speaking, they’re downregulating these cytokines that Ben was just talking about very much like the biologic therapies that we have in our toolbox.

Largely, for my selection of patients, it’s going to depend on the amount of psoriasis they have and the degree of comorbidities in their background. I’ll look at their PGA [Physician Global Assessment] to some degree. My electronic health records have allowed me to do that as well. Depending on the BSA [body surface area]—3%, 10%, 15%, 20%—I’ll decide where I go with those topicals. If someone isn’t responding well, if they don’t have a lot of background comorbidities, or if they do and the disease progresses, that’s my opportunity to enter with systemic therapies.

James Q. Del Rosso, DO: PGA, that’s the Physician Global Assessment?

Brad Glick, DO, FAOCD: Yes. In the past, I never would have considered utilizing that, but it sits in my electronic health records. It’s important not so much in how I assess my patients—because by and large, we’re looking at percentage of body surface area. We’re using our palms as 1% for consideration of how much disease someone has. But it’s there in mild, moderate, and severe disease. It’s also pretty important for us to document it when we’re trying to get a therapy approved, when we get into that access piece of our discussions about how to get therapies for our patients.

James Q. Del Rosso, DO: This therapy is approved only for moderate to severe disease, and you’re going back and forth on those issues.

Transcript edited for clarity