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’ lives^2,3. 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 productivity^5,6.

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 isolation^7,8

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

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:

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 outcomes^17,18. 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 disease^25,26.

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?

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 treatment^33–38. 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 baseline^33–38.

A PASI 75 response is now widely accepted as a clinically meaningful improvement^33–38.

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 psoriasis^37,38,40. 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

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.

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.

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