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Psoriasis Academy

Psoriasis Management

Read time: 70 mins
Last updated:30th Mar 2022

Learn more about the burden of psoriasis, and discover:

  • Common unmet needs, diagnosis, and identification of psoriasis
  • Links between cardiovascular disease (CVD) and psoriasis, with Dr Nehal Mehta
  • In podcasts and videos led by specialists, how to best manage psoriasis during COVID-19
  • Dermatologist, psychologist, and patient perspectives on wellbeing for psoriasis management

Burden of psoriasis

Psoriasis is a chronic inflammatory disease that affects approximately 2% of the population. In the majority of cases, people with psoriasis present with disfiguring, scaling, and erythematous plaques of the skin.

It is defined by the World Health Organisation as a chronic, non-communicable, painful, disfiguring, and disabling disease, for which there is no cure and with great negative impact on patients’ quality of life (QoL)1

Moderate-to-severe plaque psoriasis (with or without psoriatic arthritis) places significant social, physical and emotional burden on patients’ lives2,3. Despite treatment, many patients with psoriasis continue to experience clinical symptoms and impaired functioning4.

With the significant impact on patient’s quality of life, psoriasis impacts use of healthcare resources, associated costs, and work productivity5,6.

The visible disfiguration associated with psoriasis, particularly when on exposed areas of the body, leads to a significant psychological impact and reduction in quality of life, which can include:

  • relationship difficulties
  • employment problems
  • low self-esteem
  • avoidance of social situations and isolation7,8

Patients have reported that itching/scratching, flaking/scaling and skin pain had a significant impact on their social and emotional lives5.

Depression and anxiety in psoriasis

Psoriasis not only causes highly visible and painful physical symptoms, it is also strongly associated with psychological impairments9.

A UK primary care cohort study that assessed psychiatric morbidity and suicidal behaviour among 56,961 patients with psoriasis and 876,919 patients without psoriasis, found that patients with psoriasis had higher prevalence ratios for10

  • a history of alcohol misuse
  • bipolar disorder
  • depression
  • anxiety disorders
  • self-harm
  • psychotropic medication prescription


Impact on work productivity

The Corrona Psoriasis Registry is an independent, prospective, observational cohort launched in collaboration with the National Psoriasis Foundation. In a cross-sectional analysis of the registry, multivariable linear regression models showed that work productivity worsened with increasing disease severity3.

Compared with the mild psoriasis category, patients with moderate and severe psoriasis, as assessed by Investigator Global Assessment (IGA) scores, were significantly associated with poorer outcomes in the domains of ‘work hours missed,’ ‘impairment while working’ and ‘work hours affected’ (all p<0.05)3 as seen in Figure 1 below.

Impact on Work Productivity and Activity Impairment (WPAI) domains by IGA severity group

Figure 1. Impact on Work Productivity and Activity Impairment (WPAI) domains by IGA severity group3.

Mortality

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Unmet patient needs in psoriasis

 

Despite the availability of different treatment options for psoriasis, unmet needs may prevent patients from achieving long-term psoriasis control

Person-centered care requires that therapy is aligned with the patients’ needs/treatment goals. The German Psoriasis registry (PsoBest) has demonstrated that the majority of people with moderate-to-severe psoriasis aspire to a normal everyday life with a low treatment burden13.

Several unmet patient needs have been identified in the field of psoriasis:

Several unmet needs have been identified in the field of psoriasis

 

Psoriasis undertreatment

National surveys by the National Psoriasis Foundation have previously reported that an estimated 24%–36% of patients with moderate psoriasis and 9%–30% of people with severe psoriasis were not receiving treatment14

The Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey suggests that psoriasis is currently undertreated15. The MAPP survey showed that approximately 30% of people with moderate psoriasis, and approximately 20% of patients with severe psoriasis, were only receiving topical treatment. In addition, it was revealed that many patients are not receiving therapy that addresses the underlying inflammation and/or associated co‐morbidities (i.e., cardiovascular disease, psoriatic arthritis, metabolic syndrome)15.

Efficacy of current psoriasis therapies and long-term control

Dermatologists in the United States, Canada, France, Germany, Italy, Spain, and the United Kingdom, have previously cited concerns around the efficacy of currently available therapies as one of the key contributory factors in the unmet treatment needs that exist for patients with psoriasis15. The following treatment factors have been identified as preventing people with moderate-to-severe psoriasis from achieving long-term control17:

  • Delays in initiating systemic treatment
  • Frequent treatment discontinuation 
  • Frequent dose escalation
  • Frequent dose reduction

In addition, the efficacy from the concomitant use of ≥2 therapies with differing mechanisms of action can fail to achieve desired treatment outcomes17,18. This highlights the importance of exploring emerging monotherapies, such as IL-17A inhibitors, for achieving improved disease clearance18. Treatment goals that may be achieved through monotherapy, as highlighted by the emergence of new biologic therapies such as IL-17A inhibitors, should not be overlooked18.

Safety and tolerability of current therapies for psoriasis

Physicians in Europe and North America acknowledge that concerns around safety and tolerability of currently available therapies contribute to unmet patient needs16

Undefined treatment goals/targets in in psoriasis

The Medical Board of the National Psoriasis Foundation (NPF) has highlighted an urgent need for psoriasis treatment goals to be established and maintained in daily clinical practice; with defined treatment targets, clinicians and patients can regularly evaluate treatment responses individualised to the patient19.

The NPF observed that while most patients at 6- and 12-month visits were at the ‘acceptable’ (≤3%) body surface area (BSA) response, less than half were at the ‘target’ (≤1%) BSA response, despite systemic therapy20.

The most widely used scale for therapeutic decision making, the Psoriasis Area Severity Index (PASI), does not differentiate moderate from severe disease. A more precise classification of psoriasis disease severity could improve the risk-benefit assessment that informs therapeutic decision making.

Patient satisfaction and adherence

A systematic literature review confirms that adherence rates in psoriasis patients are suboptimal, regardless of type of treatment type or disease severity, and highlights the need to improve patient adherence and satisfaction with treatment21. In addition, more than half of US people with psoriasis surveyed between 2003 and 2011 were dissatisfied with their treatment14.

Discontinuation of traditional systemic antipsoriatic agents and interferon have been reported to occur most frequently due to adverse events22

In US clinical practice, people with moderate-to-severe psoriasis who were receiving biologic monotherapy, adalimumab in combination with methotrexate (MTX), or phototherapy, had higher overall satisfaction scores, whereas those receiving topical therapy alone had significantly lower overall satisfaction scores compared with patients receiving MTX monotherapy23

Comorbidities in patients with psoriasis

A number of conditions are associated with psoriasis, and are hypothesised to be the result of chronic inflammation associated with the skin disease24. People with severe disease are more affected by comorbid conditions than those with milder disease25,26.

It is believed that 73% of psoriasis patients have at least one comorbidity27. Such comorbidities include7:

  • metabolic syndrome (type 2 diabetes, hypertension, obesity and dyslipidaemia)
  • cardiovascular diseases
  • arthritis
  • inflammatory bowel disease
  • lymphoma
  • anxiety and depression 

Other emerging comorbidities of psoriasis include chronic obstructive pulmonary disease, peptic ulcer disease, sexual dysfunction, and obstructive sleep apnoea24

Psoriasis and cardiovascular disease

The risk of severe cardiovascular events is significantly elevated among people with psoriasis. This can be attributed to the unusually high prevalence of cardiovascular disease (CVD) risk factors observed in this group. As a result, it has been found that life expectancy for people with psoriasis is lower, and mortality rates higher than in the general population28.

Patients with psoriasis have a 5-year shorter life expectancy, than those without psoriasis most frequently due to cardiovascular disease29

Comorbidities are associated with increased mortality in people with both mild and severe psoriasis30. Although cardiovascular disease is the primary factor contributing to excess mortality, other causes of death are markedly elevated in psoriasis, including30:

  • kidney disease
  • liver disease
  • chronic lower respiratory disease
  • severe infection 
  • neurological diseases 

Elucidation of the molecular mechanisms underlying this association is still required.

However, in the video clips below, Dr Nehal Mehta, a preventive cardiologist and nuclear cardiologist at the National Heart, Blood and Lung Institute, USA, explains why synergy in the fields of dermatology and cardiology can improve psoriasis outcomes for patients using the knowledge we already have.

Association between psoriasis and increased risk of CVD

Psoriasis is not currently classified as a risk factor for cardiovascular disease, but is it time for this to change?

There is growing interest in the elevated risk of CVD observed in patients with psoriasis compared to the general population. Could an increased collaboration between specialists from the traditionally distinct fields of dermatology and cardiology be on the horizon? Find out what Dr Nehal Mehta thinks.

Mechanisms of increased CVD risk

It is well known that risk of CVD is significantly higher among psoriasis patients than in the general population, but why is this the case?

Dr Nehal Mehta explains the probable mechanisms underlying the elevated risk of cardiovascular disease among psoriasis patients.

Targeting cytokines

Dr Nehal Mehta discusses the use of cytokine inhibitors in the treatment of psoriasis, including some exciting early observational data demonstrating the possible benefits of long-term use of biologics.

 Several cytokine inhibitors are currently approved for use in the treatment of patients with psoriasis. How does the efficacy of older anti-TNF medications compare to newer interleukin (IL) inhibitors and what is the effect of long-term use of these agents on cardiovascular outcomes in psoriasis patients?

Current understanding and future application

This is a topic of multidisciplinary interest, yet there is still much to understand. What data is currently available and what does the future hold?

Dr Nehal Mehta discusses the results of two published studies demonstrating a reduction in coronary plaque associated with cytokine inhibitor use. What impact will our growing understanding of this topic have in years to come?

Advice for dermatologists

Dr Nehal Mehta shares some valuable advice on how new insights can be employed in dermatological practice.

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Psoriasis diagnosis and identification

 

The most established parameter in assessing the severity of skin symptoms in psoriasis is the Psoriasis Area and Severity Index (PASI)33-38

PASI is the first step in selecting a treatment strategy, and can provide valuable feedback in measuring long-term patient response to treatment33–38. PASI measures psoriatic disease by the severity (thickness, redness, and scaling), and the extent of the plaque coverage.

Patient response to treatment is measured as improvement in PASI score from baseline33–38.

Response to treatment is measured as improvement in PASI score from baseline

A PASI 75 response is now widely accepted as a clinically meaningful improvement33–38.

However, despite the various tools available, there is no definitively accepted definition of what encompasses mild, moderate or severe psoriasis. Moderate‐to‐severe disease is defined as a PASI >10 in the European S3‐Guidelines, and the ‘rule of tens’ (body surface area [BSA] >10%, or PASI >10, or Dermatology Life Quality Index [DLQI] >10) can be applied in the clinical setting for defining severe psoriasis37,38,40. It has been proposed that a more precise classification of psoriasis disease severity will improve the risk-benefit assessment that informs therapeutic decision making41.

The International Psoriasis Council (IPC) conducted a modified Delphi consensus process among its counsellors to categorise psoriasis severity, and to redefine access criteria to systemic therapy42.

The most preferred statement from the IPC survey ‘rejects the mild, moderate, and severe categories in favour of a dichotomous definition: people with psoriasis should be classified as either candidates for topical therapy or candidates for systemic therapy; the latter are patients who meet at least one of the following criteria: (a) BSA >10%, (b) disease involving special areas, and (c) failure of topical therapy’42. The severity definition that achieved the second highest approval rate did provide a dichotomous distinction: ‘(a) mild, or mild-to-moderate: that which can be adequately controlled with topical therapy alone; (b) moderate-to-severe or severe: that which requires phototherapy or systemic therapy (including biologics)’42.

A definition using precise numbers received only moderate support from the IPC counsellors, defining mild as BSA 0–5%, with special areas not affected, and with DLQI <5, defining moderate as BSA 5%–10% or special areas affected; or BSA 1–5% and DLQ 5–10, and defining severe as >10% BSA or special areas affected; or BSA 5–10% and DLQI >1042.

A Physician Global Assessment (PGA) score to evaluate disease severity could help clinicians rapidly evaluate psoriasis severity37.

The involvement of visible areas such as the face, scalp, hands, and nails, or the presence of severe symptoms, including itching that is not properly topically treated, may require systemic treatment43.

In clinical practice, a systemic therapy could be indicated, even if PASI or BSA is lower than 1043

Signs and symptoms of psoriasis

There are several main types of psoriasis, each presenting with different symptoms and characteristics (Figure 2). A person with psoriasis may present with more than one type, which may also change over time44.

Almirall_PA_Fig2.png

Figure 2. Types of psoriasis (Adapted7,33,44,45).

Psoriasis diagnosis and severity assessment

Diagnosis of psoriasis is primarily on clinical grounds, based on examination of plaques or skin lesions with the characteristic silvery scales.8,46,47

 

Pathology, serology, or imaging tests are usually not required for the diagnosis of psoriasis8,46,47.


Psoriasis severity depends on a number of clinical factors, and the disease is associated with a range of comorbidities and risk factors48

An assessment that accurately reflects disease severity is important, as current guidelines recommend that treatment should reflect the severity of disease rather than being initiated using a stepwise approach36-38,49.

Body surface area

The severity of psoriasis is generally determined using BSA measurements. Psoriasis is commonly classified as mild, moderate, or severe, depending on the proportion of BSA affected, as described in Table 1 below44

Table 1. Classification of disease severity by BSA affected (Adapted44). BSA, body surface area.

Classification of disease severity by BSA affected

However, if a patient’s psoriasis covers only a small area, but is very visible (for example, on the face), or debilitating (the palms of the hands and soles of the feet are affected), then the psoriasis could be disabling, and thus still be considered a severe case44. Therefore, it is important to measure the impact on the patient’s quality of life and BSA.

Impact of psoriasis on the patient’s life

Subjective measures that assess impairment in quality of life (QoL) or difficulties performing activities of daily living, including those identifying the presence of cardio-metabolic comorbidities, are important in estimating the impact psoriasis is having on the individual48.

Assessment tools in psoriasis

Several tools are available for clinicians to assess the severity of psoriasis (Table 2), and patient response to treatment.

Table 2. Tools to classify disease severity and assess treatment response (Adapted33-38,50). BSA, body surface area; PASI, Psoriasis Area and Severity Index.

Tools to classify disease severity and assess treatment response

Psoriasis Area and Severity Index 

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Patient wellbeing in psoriasis

In this three-way discussion, a dermatologist discusses patient wellbeing in psoriasis with a wellbeing expert and a person living with psoriasis. This is a dynamic and frank discussion, with each speaker offering unique experience and valuable insight on the core clinical issue of mental health and wellbeing in people with psoriasis, concluding that:

  • People with psoriasis often suffer comorbid mental health conditions
  • PASI score does not correlate with overall patient wellbeing
  • The WHO-5 questionnaire can be used to assess patient wellbeing in clinical practice
  • Patients need better mental health support

Watch the highlights and key takeaway messages from the perspectives of Professor Ulrich Mrowietz (dermatologist), Professor Jordi Quoidbach (wellbeing expert) and Jessica Towner (person living with psoriasis). You can also download our infographic on implementing wellbeing consideration into your own clinical practice.

Discussion introduction and highlights

Introduction to the discussion on wellbeing in people with psoriasis

Mental health comorbidities and their impact on people with psoriasis

Effective alternatives to medications to treat stress-induced worsening of psoriasis

Psychological approaches to supporting psoriasis patients

2

Watch the highlights and key takeaway messages from the perspectives of Professor Ulrich Mrowietz (dermatologist), Professor Jordi Quoidbach (wellbeing expert) and Jessica Towner (person living with psoriasis). You can also download our infographic on implementing wellbeing consideration into your own clinical practice.

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COVID-19

Do you know how to answer your patients’ questions about the COVID-19 pandemic? Learn how to manage your patients during the pandemic in our expert videos and podcasts.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); a virus generally cleared by the primary immune response.

However, as inflammatory lung injury and death can result from an exaggerated secondary immune response, psoriasis management with systemic and biologic immunosuppressive and immunomodulatory treatment may be impacted during the COVID-19 pandemic.

General aspects around COVID-19 and patients with psoriasis

Click here to watch videos with German subtitles

Click on the list icon in the video player (bottom, right-hand side) to directly access the answer to the below questions.

  1. Have many of your patients been in contact with you regarding COVID-19 and treatment for their psoriasis? (00:00 - 01:35)
  2. What additional steps have you taken to support your patients during the current SARS-CoV-2 pandemic? (01:35 - 02:08)
  3. Do you recommend any particular preventive measures for patients with psoriasis during the current SARS-CoV-2 pandemic? (02:08 - 02:47)
  4. What are the risk factors for a severe course of COVID-19? (02:47 - 04:06)
  5. In your opinion, should patients with psoriasis who are taking immunosuppressant drugs stop treatment to reduce their risk of severe COVID-19? (04:06 - 05:08)
  6. In your opinion, are patients with psoriasis taking immunomodulatory rather than pan-immunosuppressant systemic treatment at reduced risk of severe COVID-19? (05:08 - 06:02)
  7. Do you think that immunosuppressant treatments may be beneficial given the ‘cytokine storm’ caused by the virus in severe COVID-19? (06:02 - end).

In this part of our expert interview, we asked Professor Mrowietz some key questions around the impact of COVID-19 for patients and their treatment. These included questions about whether patients should start and continue their treatment and what to do if they are unable to attend scheduled appointments. We also asked Professor Mrowietz about the risk factors for severe COVID-19 and whether targeted psoriasis treatments could be of use in treating the ‘cytokine storm’ seen in patients with severe COVID-1964.

COVID-19 and fumaric acid ester treatment in patients with moderate-to-severe psoriasis

Click here to watch videos with German subtitles

Click on the list icon in the video player (bottom, right-hand side) to directly access the answer to the below questions.

  1. Would you recommend starting a patient on dimethyl fumarate (DMF) during the pandemic? (00:00 - 01:53)
  2. In your opinion, is there an elevated risk for infections in patients taking DMF? (01:53 - 03:02)
  3. Do you think there are any patient groups in which DMF treatment requires modification? (03:02 - 04:30)
  4. If DMF treatment has been discontinued for any reason, how should treatment be re-initiated? (04:30 - 05:45)
  5. What should dermatologists do if their patients have missed routine monitoring appointments because of the SARS-CoV-2 pandemic? (05:45 - 06:48)
  6. What would you recommend if a patient on DMF treatment develops symptoms suggestive of a viral respiratory infection, e.g., coughing, sore throat and rhinorrhoea? (06:48 - 07:39)
  7. What would you recommend if a patient on DMF treatment has symptoms of COVID-19, e.g., persistent cough, fever? (07:39 - 08:23)
  8. Are there any treatments for the symptoms of COVID-19 that would interact with DMF treatment? (08:23 - end).

The fumaric acid ester treatment dimethyl fumarate (DMF) is a systemic treatment for moderate-to-severe psoriasis which is widely used in Northern Europe, particularly in German-speaking countries and the Netherlands65.  In this part of our expert interview, we asked Professor Mrowietz some key questions around the impact of COVID-19 for patients and DMF treatment. These included questions about initiating treatment during the pandemic and how to manage the regular blood count appointments required to monitor leukocyte and lymphocyte counts66. We also asked Professor Mrowietz about the SARS-CoV-2 infection risk for patients on DMF treatment and any potential drug interactions for patients with confirmed COVID-19.

COVID-19 and biologic treatment in patients with moderate-to-severe psoriasis

Click here to watch videos with German subtitles

Click on the list icon in the video player (bottom, right-hand side) to directly access the answer to the below questions.

  1. Would you recommend starting a patient on a biologic during the SARS-CoV-2 pandemic? (00:00 - 02:05)
  2. Do you think there are any patient groups in which ongoing biologic treatment should be stopped? (02:05 - 03:04)
  3. Would you recommend any additional monitoring for patients with ongoing biologic treatment during the SARS-CoV-2 pandemic? (03:04 - 04:37)
  4. During the SARS-CoV-2 pandemic, which factors are important for dermatologists to consider when selecting a biologic for patients with psoriasis? (04:37 - 06:02)
  5. What is the role of the different biologic treatment targets with regard to the anti-viral immune response? (06:02 - 07:05)
  6. In your opinion, what insights from the safety profile of IL-23 biologics may be helpful during the current pandemic? (07:05 - 08:13)
  7. In your opinion, how does the dosing interval impact the suitability of a biologic treatment during the SARS-CoV-2 pandemic? (08:13 - 09:20)
  8. What would you recommend if a patient on an IL-23 biologic develops symptoms suggestive of a viral respiratory infection, e.g., coughing, sore throat and rhinorrhoea? (09:20 - 10:36)
  9. What would you recommend if a patient on an IL-23 biologic has symptoms of COVID-19, e.g., persistent cough, fever? (10:36 - end).


Psoriasis is a systemic inflammatory disease, discontinuation of biologic treatment could lead to a worsening of symptoms and a lower efficacy in patients after treatment interruption67. We asked Professor Mrowietz several questions on COVID-19 relevant to biologic treatment for psoriasis. These included questions about the SARS-CoV-2 infection risk for patients on biologic treatment and whether to suspend biologic treatment during active infection. Professor Mrowietz also discussed factors to consider when selecting a biologic during the current pandemic, with a longer dosing interval, such as that for IL-23 biologics, being advantageous in times of required social distancing.

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References

  1. Organization WH. Global report on psoriasis. World Health Organization. 2016.
  2. Bulat V, Šitum M, Delaš Aždaji M, Lovri I, Dediol I. Study on the Impact of Psoriasis on Quality of Life: Psychological, Social and Financial Implications. 2020.
  3. Strober B, Greenberg JD, Karki C, Mason M, Guo N, Hur P, et al. Impact of psoriasis severity on patient-reported clinical symptoms, health-related quality of life and work productivity among US patients: Real-world data from the Corrona Psoriasis Registry. BMJ Open. 2019;9(4). doi:10.1136/bmjopen-2018-027535.
  4. Schaefer CP, Cappelleri JC, Cheng R, Cole JC, Guenthner S, Fowler J, et al. Health care resource use, productivity, and costs among patients with moderate to severe plaque psoriasis in the United States. J Am Acad Dermatol. 2015;73(4):585-593.e3.
  5. Pariser D, Schenkel B, Carter C, Farahi K, Brown TM, Ellis CN. A multicenter, non-interventional study to evaluate patient-reported experiences of living with psoriasis. J Dermatolog Treat. 2016;27(1):19–26.
  6. Korman NJ, Zhao Y, Pike J, Roberts J. Relationship between psoriasis severity, clinical symptoms, quality of life and work productivity among patients in the USA. Clin Exp Dermatol. 2016;41(5):514–521.
  7. Boehncke WH, Boehncke S. More than skin-deep: The many dimensions of the psoriatic disease. Swiss Medical Weekly. 2014;144. doi:10.4414/smw.2014.13968.
  8. Cohen SN, Baron SE, Archer CB. Guidance on the diagnosis and clinical management of psoriasis. Clinical and Experimental Dermatology. 2012;37(SUPPL. 1):13–18.
  9. Dalgard FJ, Gieler U, Tomas-Aragones L, Lien L, Poot F, Jemec GBE, et al. The Psychological Burden of Skin Diseases: A Cross-Sectional Multicenter Study among Dermatological Out-Patients in 13 European Countries. J Invest Dermatol. 2015;135(4):984–991.
  10. Parisi R, Webb RT, Kleyn CE, Carr MJ, Kapur N, Griffiths CEM, et al. Psychiatric morbidity and suicidal behaviour in psoriasis: a primary care cohort study. Br J Dermatol. 2019;180(1):108–115.
  11. Ni C, Chiu MW. Psoriasis and comorbidities: Links and risks. Clin Cosmet Investig Dermatol. 2014;7:119–132.
  12. Dhana A, Yen H, Yen H, Cho E. All-cause and cause-specific mortality in psoriasis: A systematic review and meta-analysis. J Am Acad Dermatol. 2019;80(5):1332–1343.
  13. Blome C, Gosau R, Radtke MA, Reich K, Rustenbach SJ, Spehr C, et al. Patient-relevant treatment goals in psoriasis. Arch Dermatol Res. 2016;308(2):69–78.
  14. Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: Findings from the National Psoriasis Foundation Surveys, 2003-2011. JAMA Dermatology. 2013;149(10):1180–1185.
  15. Lebwohl MG, Kavanaugh A, Armstrong AW, Van Voorhees AS. US Perspectives in the Management of Psoriasis and Psoriatic Arthritis: Patient and Physician Results from the Population-Based Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) Survey. Am J Clin Dermatol. 2016;17(1):87–97.
  16. Van De Kerkhof PCM, Reich K, Kavanaugh A, Bachelez H, Barker J, Girolomoni G, et al. Physician perspectives in the management of psoriasis and psoriatic arthritis: Results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis survey. J Eur Acad Dermatology Venereol. 2015;29(10):2002–2010.
  17. Feldman SR, Goffe B, Rice G, Mitchell M, Kaur M, Robertson D, et al. The challenge of managing psoriasis: Unmet medical needs and stakeholder perspectives. Am Heal Drug Benefits. 2016;9(9):504–512.
  18. Gottlieb AB, Merola JF, Reich K, Behrens F, Nash P, Griffiths CEM, et al. Efficacy of secukinumab and adalimumab in patients with psoriatic arthritis and concomitant moderate-to-severe plaque psoriasis: results from EXCEED, a randomized, double-blind head-to-head monotherapy study. Br J Dermatol. 2021;185(6):1124–1134.
  19. Armstrong AW, Siegel MP, Bagel J, Boh EE, Buell M, Cooper KD, et al. From the Medical Board of the National Psoriasis Foundation: Treatment targets for plaque psoriasis. J Am Acad Dermatol. 2017;76(2):290–298.
  20. Merola JF, Perez Chada LM, Siegel M, Bagel J, Evans C, Lockshin B, et al. The National Psoriasis Foundation psoriasis treatment targets in real-world patients: prevalence and association with patient-reported outcomes in the Corrona Psoriasis Registry. J Eur Acad Dermatology Venereol. 2020;34(9):2051–2058.
  21. Belinchón I, Rivera R, Blanch C, Comellas M, Lizán L. Adherence, satisfaction and preferences for treatment in patients with psoriasis in the European union: A systematic review of the literature. Patient Preference and Adherence. 2016;10:2357–2367.
  22. Arnold T, Schaarschmidt ML, Herr R, Fischer JE, Goerdt S, Peitsch WK. Drug survival rates and reasons for drug discontinuation in psoriasis. J Dtsch Dermatol Ges. 2016;14(11):1089–1099.
  23. Callis Duffin K, Yeung H, Takeshita J, Krueger GG, Robertson AD, Troxel AB, et al. Patient satisfaction with treatments for moderate-to-severe plaque psoriasis in clinical practice. Br J Dermatol. 2014;170(3):672–680.
  24. Takeshita J, Grewal S, Langan SM, Mehta NN, Ogdie A, Van Voorhees AS, et al. Psoriasis and comorbid diseases: Epidemiology. J Am Acad Dermatol. 2017;76(3):377–390.
  25. Edson-Heredia E, Zhu B, Guo J, Maeda-Chubachi T, Lebwohl M. Disease burden and quality of life in psoriasis patients with and without comorbid psoriatic arthritis: Results from national psoriasis foundation panel surveys. Cutis. 2015;95(3):173–178.
  26. Edson-Heredia E, Zhu B, Lefevre C, Wang M, Barrett A, Bushe CJ, et al. Prevalence and incidence rates of cardiovascular, autoimmune, and other diseases in patients with psoriatic or psoriatic arthritis: A retrospective study using Clinical Practice Research Datalink. J Eur Acad Dermatology Venereol. 2015;29(5):955–963.
  27. Machado-Pinto J, Diniz M dos S, Bavoso NC. Psoriasis: New comorbidities. An Bras Dermatol. 2016;91(1):8–14.
  28. Hu SCS, Lan CCE. Psoriasis and cardiovascular comorbidities: Focusing on severe vascular events, cardiovascular risk factors and implications for treatment. Int J Mol Sci. 2017;18(10). doi:10.3390/ijms18102211.
  29. Siegel D, Devaraj S, Mitra A, Raychaudhuri SP, Raychaudhuri SK, Jialal I. Inflammation, atherosclerosis, and psoriasis. Clin Rev Allergy Immunol. 2013;44(2):194–204.
  30. Svedbom A, Dalén J, Mamolo C, Cappelleri JC, Mallbris L, Petersson IF, et al. Increased cause-specific mortality in patients with mild and severe psoriasis: A population-based Swedish register study. Acta Derm Venereol. 2015;95(7):809–815.
  31. Chiricozzi A, Gisondi P, Girolomoni G. The pharmacological management of patients with comorbid psoriasis and obesity. Expert Opinion on Pharmacotherapy. 2019;20(7):863–872.
  32. Elmets CA, Leonardi CL, Davis DMR, Gelfand JM, Lichten J, Mehta NN, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073–1113.
  33. Pathirana D, Ormerod AD, Saiag P, Smith C, Spuls PI, Nast A, et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatology Venereol. 2009;23(SUPPL. 2):1–70.
  34. Nast A, Boehncke WH, Mrowietz U, Ockenfels HM, Philipp S, Reich K, et al. S3 - Guidelines on the treatment of psoriasis vulgaris (English version). Update. JDDG - J Ger Soc Dermatology. 2012;10(SUPPL.2):S1-s95.
  35. Nast A, Gisondi P, Ormerod AD, Saiag P, Smith C, Spuls PI, et al. European S3-Guidelines on the systemic treatment of psoriasis vulgaris - Update 2015 - Short version - EDF in cooperation with EADV and IPC. J Eur Acad Dermatology Venereol. 2015;29(12):2277–2294.
  36. Nast A, Spuls PI, van der Kraaij G, Gisondi P, Paul C, Ormerod AD, et al. European S3-Guideline on the systemic treatment of psoriasis vulgaris – Update Apremilast and Secukinumab – EDF in cooperation with EADV and IPC. J Eur Acad Dermatology Venereol. 2017;31(12):1951–1963.
  37. Nast A, Smith C, Spuls PI, Avila Valle G, Bata-Csörgö Z, Boonen H, et al. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 1: treatment and monitoring recommendations. J Eur Acad Dermatology Venereol. 2020;34(11):2461–2498.
  38. Nast A, Smith C, Spuls PI, Avila Valle G, Bata-Csörgö Z, Boonen H, et al. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 2: specific clinical and comorbid situations. J Eur Acad Dermatology Venereol. 2021;35(2):281–317.
  39. de Carvalho AVE, Duquia RP, Horta BL, Bonamigo RR. Efficacy of Immunobiologic and Small Molecule Inhibitor Drugs for Psoriasis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Drugs in R and D. 2017;17(1):29–51.
  40. Mrowietz U, Barker J, Boehncke WH, Iversen L, Kirby B, Naldi L, et al. Clinical use of dimethyl fumarate in moderate-to-severe plaque-type psoriasis: a European expert consensus. J Eur Acad Dermatology Venereol. 2018;32:3–14.
  41. Llamas-Velasco M, de la Cueva P, Notario J, Martínez-Pilar L, Martorell A, Moreno-Ramírez D. Psoriasis moderada. Propuesta de definición. Actas Dermosifiliogr. 2017;108(10):911–917.
  42. Strober B, Ryan C, van de Kerkhof P, van der Walt J, Kimball AB, Barker J, et al. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol. 2020;82(1):117–122.
  43. Mrowietz U, Kragballe K, Reich K, Spuls P, Griffiths CEM, Nast A, et al. Definition of treatment goals for moderate to severe psoriasis: A European consensus. Arch Dermatol Res. 2011;303(1):1–10.
  44. Glasser J. About psoriasis. Bedside nurse. 1969;2(5):24–26.
  45. Twelves S, Mostafa A, Dand N, Burri E, Farkas K, Wilson R, et al. Clinical and genetic differences between pustular psoriasis subtypes. J Allergy Clin Immunol. 2019;143(3):1021–1026.
  46. Boehncke WH, Schön MP. Psoriasis. Lancet. 2015;386(9997):983–994.
  47. Diani M, Altomare G, Reali E. T cell responses in psoriasis and psoriatic arthritis. Autoimmunity Reviews. 2015;14(4):286–292.
  48. Lubrano E, Cantini F, Costanzo A, Girolomoni G, Prignano F, Olivieri I, et al. Measuring psoriatic disease in clinical practice. An expert opinion position paper. Autoimmun Rev. 2015;14(10):864–874.
  49. Feldman SR. Inflammatory diseases: Integrating biosimilars into clinical practice. Semin Arthritis Rheum. 2015;44(6):S16–S21.
  50. Langley RGB, Feldman SR, Nyirady J, Van De Kerkhof P, Papavassilis C. The 5-point Investigator’s Global Assessment (IGA) Scale: A modified tool for evaluating plaque psoriasis severity in clinical trials. J Dermatolog Treat. 2015;26(1):23–31.
  51. Bonifati C, Berardesca E. Clinical outcome measures of psoriasis. Reumatismo. 2007;59(SUPPL. 1):64–67.
  52. Palfreeman AC, McNamee KE, McCann FE. New developments in the management of psoriasis and psoriatic arthritis: A focus on apremilast. Drug Des Devel Ther. 2013;7:201–210.
  53. Torii H, Sato N, Yoshinari T, Nakagawa H. Dramatic impact of a Psoriasis Area and Severity Index 90 response on the quality of life in patients with psoriasis: An analysis of Japanese clinical trials of infliximab. J Dermatol. 2012;39(3):253–259.
  54. Gisondi P, Talamonti M, Chiricozzi A, Piaserico S, Amerio P, Balato A, et al. Treat-to-Target Approach for the Management of Patients with Moderate-to-Severe Plaque Psoriasis: Consensus Recommendations. Dermatol Ther (Heidelb). 2021;11(1):235–252.
  55. Warren RB, Hansen JB, Reich K, Paul C, Puig L. Complete clearance and psoriasis area and severity index response for brodalumab and ustekinumab in AMAGINE-2 and -3. J Eur Acad Dermatology Venereol. 2021;35(2):450–457.
  56. Strober B, Papp KA, Lebwohl M, Reich K, Paul C, Blauvelt A, et al. Clinical meaningfulness of complete skin clearance in psoriasis. J Am Acad Dermatol. 2016;75(1):77-82.e7.
  57. Amatore F, Villani AP, Tauber M, Viguier M, Guillot B. French guidelines on the use of systemic treatments for moderate-to-severe psoriasis in adults. J Eur Acad Dermatology Venereol. 2019;33(3):464–483.
  58. Robinson A, Kardos M, Kimball AB. Physician Global Assessment (PGA) and Psoriasis Area and Severity Index (PASI): Why do both? A systematic analysis of randomized controlled trials of biologic agents for moderate to severe plaque psoriasis. J Am Acad Dermatol. 2012;66(3):369–375.
  59. Feldman SR, Krueger GG. Psoriasis assessment tools in clinical trials. Ann Rheum Dis. 2005;64(SUPPL. 2):ii65.
  60. Au SC, Madani A, Alhaddad M, Alkofide M, Gottlieb AB. Comparison of the efficacy of biologics versus conventional systemic therapies in the treatment of psoriasis at a comprehensive psoriasis care center. J Drugs Dermatology. 2013;12(8):861–866.
  61. Buzney CD, Peterman C, Saraiya A, Au SC, Dumont N, Mansfield R, et al. Clearance of Psoriasis: The impact of private versus public insurance. J Drugs Dermatology. 2015;14(2):119–125.
  62. Chiesa Fuxench ZC, Callis Duffin K, Siegel M, Van Voorhees AS, Gelfand JM. Validity of the Simple-Measure for Assessing Psoriasis Activity (S-MAPA) for objectively evaluating disease severity in patients with plaque psoriasis. J Am Acad Dermatol. 2015;73(5):868–870.
  63. Sorensen EP, Fanucci KA, Saraiya A, Volf E, Au SC, Argobi Y, et al. Tumor necrosis factor inhibitor primary failure predicts decreased ustekinumab efficacy in psoriasis patients. J Drugs Dermatology. 2015;14(8):893–898.
  64. Duffin KC, Papp KA, Bagel J, PharmD EL, Chen R, Gottlieb AB. Evaluation of the physician global assessment and body surface area composite tool for assessing psoriasis response to apremilast therapy: Results from ESTEEM 1 and ESTEEM 2. J Drugs Dermatology. 2017;16(2):147–153.
  65. Walsh JA, McFadden M, Woodcock J, Clegg DO, Helliwell P, Dommasch E, et al. Product of the Physician Global Assessment and body surface area: A simple static measure of psoriasis severity in a longitudinal cohort. J Am Acad Dermatol. 2013;69(6):931–937.
  66. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020;395(10229):1033–1034.
  67. Dimethyl fumarate for psoriasis. Drug Ther Bull. 2018;55(12):141–144.
  68. Electronic Medicines Compendium. Buprenorphine. Summary of Product Characteristics. 2021. https://www.medicines.org.uk/emc/medicine/26614. Accessed 15 February 2021.
  69. Megna M, Napolitano M, Patruno C, Fabbrocini G. Biologics for psoriasis in COVID-19 era: What do we know? Dermatol Ther. 2020;33(4). doi:10.1111/dth.13467.
  70. Greis C, Meier Zürcher C, Djamei V, Moser A, Lautenschlager S, Navarini AA. Unmet digital health service needs in dermatology patients. J Dermatolog Treat. 2018;29(7):643–647.
  71. Romiti R, Amone M, Menter A, Miot HA. Prevalence of psoriasis in Brazil – a geographical survey. Int J Dermatol. 2017;56(8):e167–e168.
  72. Arnone M, Takahashi MDF, de Carvalho AVE, Bernardo WM, Bressan AL, Ramos AMC, et al. Diagnostic and therapeutic guidelines for plaque psoriasis – Brazilian society of dermatology. An Bras Dermatol. 2019;94(2):76–107.

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