Triggering Factors and Assessing Severity of Plaque Psoriasis
OCTOBER 23, 2019
Mark Lebwohl, MD: One of the other things that we certainly see is an impact not only of the disease itself on the patient but on the patient developing other bad habits. For example, if you look at the frequency of smokers in the psoriasis population versus non-psoriasis patients, it’s dramatically higher. Drinkers of alcohol, binge drinking, is much more common among psoriasis patients than among non-psoriasis patients. Even things like exercise have been shown to be less frequent in psoriasis patients, more frequent in non-psoriasis patients. And of course, we see that our patients on average are obese. The average psoriasis patient is obese. In clinical trials, the average weight is usually around 90 kg, that’s almost 200 pounds.
Brad Glick, DO, MPH: Now, with few exceptions, that weight does impact their responses to therapy as well, for many of the drugs.
Mark Lebwohl, MD: That’s correct, yes.
George Han, MD, PhD: It does seem to go both ways, and a lot of patients get into this catch-22: psoriasis worsening, the obesity, they don’t want to go work out, the smoking habits, it all builds together. And I think it’s important that we have a way to cut that cycle and really impact the change on the patients, which I think will impact a lot of other aspects of their life as well.
Mark Lebwohl, MD: While we’re talking about making them better so that we impact their quality of life, how do we assess the severity of disease of psoriasis patients? What do they do in clinical trials and what do we do in our office, George?
George Han, MD, PhD: A lot of times you look at the clinical trials and you’re looking at PASI data, Psoriasis Area and Severity Index. You’re looking at IGA, Investigator’s Global Assessment. But in practice, we go to our patients and say, “How are you doing? How’s the psoriasis? How’s your life? How’s your quality of life doing?” I think those are most important for us. Certainly, I think if we go by a metric, maybe body surface area might be something more approachable for most patients. If you look at the official guidelines when we define mild, moderate, or severe, we have those cutoffs based on body surface area, 3% to 10% being moderate, above 10% being severe.
But I think it’s important to note that it’s not a linear process because with that 1 spot of psoriasis that lingers on a patient on their lower back, for 1 patient, they may be very happy with the improvement they’ve gotten so far based on the treatments we’ve given them. And for another patient, that might be that 1 thing that just sticks in their mind that they can’t stand, and they just can’t move on with other aspects of their life. That can be very burdensome from a psychosocial aspect. I think we have to be really cognizant and aware that our patients might approach similar respective objective numbers differently than we might.
Scott Gottlieb, MD: I totally agree with that, each patient will look at their disease a little bit differently. Having said that, there’s any number of studies to show a nice correlation between PASI scores and improvement of the Dermatology Life Quality Index. And those have really impacted me in my prescribing habits. The more clear skin that a patient has, of course, the better that they feel they’re doing in terms of quality of life, such that patients with PASI 75, they’re very happy; patients with PASI 90, they’re thrilled; and patients with PASI 100, virtually all of them say it has no impact in their quality of life. If we’re treating a lot of our patients and we as a country have invested in these people to improve their quality of life, it makes every sense in the world to me to clear their skin as much as possible, thereby improving the quality of life as much as possible. And so I really try to use medicines that aim as high as possible in terms of clearance.
George Han, MD, PhD: I think you bring up an interesting point because when we’re thinking about the relative levels of clearance, most of the medications that we have, at least from a systemic biologic point of view, work very well for psoriasis. What we don’t want to get caught in is a patient who’s doing better, but they don’t know how good they could get with something else. And we don’t want to become complacent together, you could say. I have a lot of patients for whom that’s happened where they’re very happy and then we somehow decide we want to switch, and then they get clear and they say, “I didn’t even know I could be this clear,” and of course they’re happier, but they were already happy before. It’s interesting to be in that landscape.
Scott Gottlieb, MD: I’ve actually asked that question among my peers, and virtually all of them say, “patient happy, physician happy.” But we all know that if a patient is happy, I know I can make them happier if there’s still room to go. But it’s hard to get our peers to look at it that way and to suggest to the patient that perhaps even a higher level of clearance will make them happier. I think it’s a huge investment that we’re making as a country in these drugs, and I think that we owe it to our patients to improve the quality of life as much as possible.
Brad Glick, DO, MPH: I think now in the third decade of biologic therapies, in general, not only in our space of dermatology but in other immune-mediated diseases, our patients are beginning to become extra savvy, too. I think we said previously, and there have been studies that indicated this, that maybe 100% clearance perhaps wasn’t so important. But I think our patients are knowledgeable now. They understand that they have that possibility, and I think we need to educate them that they can get that 100% clearance, that we have agents that can really advance the improvement of their disease.
Scott Gottlieb, MD: The other thing to think about is that I was speaking with one of our colleagues who’s a psychiatrist and a dermatologist, and he was saying that the worst thing you could do is get a patient clear and then they lose efficacy, that’s really one of the worst things you could do from a psychosocial standpoint for a patient. So I also look at long-term efficacy and try to make sure I’m using drugs that will maintain the benefit over a long period.
Brad Glick, DO, MPH: Well, this puts the burden on us also to explain that certainly none of the therapies that we have at this point are cures for psoriasis, but our ability to control their disease and manage it not just with a singular therapy, but with other adjunctive therapies and involvement of our colleagues and psychosocial intervention I think is crucial in their overall care and meeting their burden of disease.
Transcript edited for clarity.