Psoriasis and Psoriatic Arthritis

Abstract

Psoriasis is a dynamic systemic disease that can have a profound affect on a patient’s self-esteem. Fortunately, numerous therapeutic advances have been made over the last 10 years. In order to help patients manage their disease, healthcare providers should be aware of the modifiable risk factors that may exacerbate psoriasis. Additionally, exploring the impact the disease has on a patient and how it may change over their lifespan will help ensure appropriate therapies are used. Patients are unique so one medication will not fit all of our patients’ needs. In this paper, the authors look at available treatment options for psoriasis and psoriatic arthritis. Educating psoriasis patients, in addition to collaborating with patients and other healthcare providers, may help initiate therapies that will result in patients living their lives to the fullest.

PSORIASIS IS A PREVALENT disorder estimated to affect about two percent of the general population of Europe and North America and more than a quarter of these cases (27%) will present as psoriasis in children under the age of 16 years.1

Although much remains to be discovered, the pathophysiology of psoriasis has been increasingly elucidated in recent years. Activated immune cells elaborate pro-inflammatory cytokines (such as TNF-alpha, interferon-γ, interleukin 17 [IL-17], IL-22, IL-23, IL-12, and IL-1β), which promote keratocyte hyperproliferation, angiogenesis, and inflammation in the skin. These pro-inflammatory cytokines have emerged as promising pharmaceutical targets for psoriasis and psoriatic arthritis.2

Children, adolescents, young adults, pregnant women, seniors, men, women, and those suffering from diabetes, heart disease, cancer, and other conditions may have different treatment objectives and distinct needs in psoriasis care. For example, geriatric patients with psoriasis require special considerations in that these patients may suffer from comorbidities and the risks of polypharmacy with medications that could potentially interact with psoriasis drugs. Additionally, seniors have slower drug metabolism than younger patients, diminished renal and bone marrow function, and may experience drug-induced or drug-exacerbated forms of psoriasis. Finally, they are also more likely to have difficulty in self-administering medications or presenting for clinic-based therapies.3 In summary, psoriasis patients need individualized care throughout their lifespan.

THE CLINICAL CONTINUUM OF PSORIASIS

The clinical presentation of psoriasis may vary across the lifespan of the patient with differences noted between adult, adolescent, and childhood variants. While children may have plaque psoriasis like adults, pediatric lesions tend to be smaller, thinner, and less scaly, especially in new-onset disease.4–6 Pustular or erythrodermic psoriasis is more typically observed in pediatric than adult patients.4 Infants and children under the age of two years may present with psoriatic diaper rash,5,6 a clearly demarcated rash in the diaper area followed by more widespread dissemination of psoriasis-type lesions. Although early onset childhood psoriasis is rare, it can be a difficult diagnosis. Conventional treatments for diaper dermatitis are not effective in treating psoriatic diaper rash and its refractory nature may help elucidate the diagnosis, thereby avoiding unnecessary biopsies.4

A great challenge in managing patients with psoriasis is educating them, and their families, to the fact that psoriasis is likely going to be a lifelong condition that—at best—can be controlled, but not cured. The goals must be to find ways to maximize clearance of the disease, monitor for comorbidities, and minimize flares. We have found that a therapeutic alliance between the patient and provider is a necessary foundation for therapy success. It is believed that the better patients and family members understand psoriasis, the better their degree of treatment adherence.4,8 Additionally, we have found that given the chronic nature of this dynamic disease, better outcomes have been obtained working collaboratively with patients.

Patients with psoriasis often experience comorbidities, some of which may be advanced or have potentially severe consequences, such as obesity, diabetes, cardiovascular disease, and depression.9–11 These comorbidities should always be considered, especially if signs or symptoms present at an earlier age than expected. For example, a middle-aged adult might be expected to occasionally have a painful joint, but this would require additional assessment should it present in the first few decades of life. Psoriasis patients may not be seeing or may not even have a primary care provider, making the dermatology visit even more valuable to the patient’s overall health, regardless of the type and severity of disease.12

While it may be tempting for patients with mild-to-moderate psoriasis to think of it as “just a skin disease” or to trivialize its effect on their lives, these patients also have an increased inflammatory burden and are at elevated risk for psoriasis-associated comorbid conditions.13,14 Furthermore, any uncontrolled psoriasis can worsen and may adversely affect function, physical appearance, self-esteem, quality of life, and other psychological factors.

Different life stages and psoriasis treatment considerations appear in Table 1.

TABLE 1.

Managing psoriasis across the patient lifespan. Note that for all groups, the types of psoriasis include psoriatic plaques (mild to moderate-severe), guttate psoriasis, and psoriatic arthralgia and treatment options for all groups include phototherapy, topicals, systemics, and biologics. All patient groups are vulnerable to psychosocial issues and comorbid conditions.

POPULATION	PHOTOTHERAPY	TOPICALS	SYSTEMICS	BIOLOGICS	COMMENTS
Children <12 years old	Yes	Yes	Toxicity	Possible	“Messiness” may limit some treatments
Teens 12–17 years old	Yes	Yes	Yes	Possible	Particularly prone to psychosocial distress
Young adults	Yes	Yes	Yes	Yes	Insurance coverage may be an issue; patients susceptible to depression, obesity, and substance abuse; patients may be concerned about their reproduction
Pregnant patients	Yes	Yes	Possible	If biologic therapy has already started before pregnancy, it is not clear if it should be discontinued	Psychosocial issues; reproductive concerns
Women	Yes	Yes	Yes	Yes	Women are more vulnerable to psychological distress over psoriasis than men; women may be more interested than men in natural treatments and lifestyle modifications
Adults	Pros and cons	Yes	Yes	Yes	Comorbidities in this population include depression, obesity, metabolic syndrome, sexual dysfunction, arthralgia, cancer, infections, tobacco or alcohol abuse
Adults with cancer	May be contra-indicated in some	Yes	Pros and cons	Pros and cons	Potential drug-drug interactions must be considered
Geriatric patients	Steadiness can be an issue with UVB	Thinning skin may limit their use	Possible	Access issues	Potential drug-drug interactions must be considered in light of high rates of polypharmacy in this population; treatments may be cost prohibitive; unclear how to manage psoriasis as patient nears end of life

TREATMENT OPTIONS FOR PSORIASIS

Psoriasis treatments include phototherapy, topical preparations, systemic agents, biologics, and psychosocial interventions. The three main phases of psoriasis treatment may be described as rescue, transition, and maintenance. The goal is always to clear or minimize disease and comorbidities as early as possible. Different therapies (and goals) may be appropriate for each stage. Combination therapy (using more than one treatment modality) may also be be necessary to obtained appropriate disease control. Within these categories, numerous treatment options exist for psoriasis, and the clinician must consider the patient’s age, personal preferences, quality of life, Psoriasis Area and Severity Index (PASI), and other relevant factors (such as insurance coverage, patient’s age, other drugs the patient may take, comorbid conditions, costs, the “hassle factor” of various treatments, and so on) when making prescribing decisions.5,15 In the case of a mild or “limited” (such as few plaques on elbows or knees) psoriasis, topical agents may be appropriate. Systemic drugs are introduced for refractory limited disease in high-impact areas, more “widespread” or extensive disease, or when lesser treatments have failed.5 In addition to formulating treatment strategies, clinicians should help the patient develop lifestyle changes. Preventing psoriasis includes managing those known factors that can trigger or exacerbate the disease. These may be endogenous (e.g., skin trauma, upper respiratory tract infections), exogenous (e.g., certain drugs), or psychological (e.g., stress, anxiety), smoking, and obesity.16

Although many patients seeking treatment for psoriasis are children, there are limited data available from randomized controlled trials (RCTs) for psoriasis treatments in children and no treatment guidelines for pediatric psoriasis patients. Psoriasis specialists have been using systemic medications including conventional and biologics to treat pediatric psoriasis patients for years. Finally, in November 2016, etanercept was approved for pediatric use.

Systemic drugs and biologics are important therapies in the armamentarium against psoriasis, because psoriasis often involves significant body surface area and often affects high-impact areas (e.g., face, genitals, hands, feet) that may not be possible to treat effectively with topical products or phototherapy (Table 2).

TABLE 2.

Some prominent drugs used to treat psoriasis and/or psoriatic arthritis.

TREATMENT	DRUG TARGET	PSORIASIS APPROVAL IN U.S.A.	PSORIATIC ARTHRITIS APPROVAL IN U.S.A.	BIOSIMILAR?
Adalimumab	TNF-α	2008	2005	Biosimilar is approved (adalimumab-atto)
Apremilast	PDEF4	2014	2014	n/a
Certolizumab Pegol	TNF-α	NA	2013
Etanercept	TNF-α	2004	2002	Biosimilar is approved (etanercept-szzs)
Golimumab	TNF-α	NA	2009	n/a
Infliximab	TNF-α	2006	2005	Biosimilar is approved (infliximab-dyyb)
Ixekizumab	IL-17A	2016	NA	n/a
Secukinumab	IL-17A	2015	2016	n/a
Ustekinumab	IL-12/23 p40	2009	2013	n/a

IL=interleukin; n/a=not applicable; TNF=tumor necrosis factor

Biologics have increasing appeal to patients because of direct-to-consumer (DTC) advertising efforts in the United States, word-of-mouth discussions among family members and friends who achieved good results with biologics, and the fact that many psoriasis patients are young individuals with a modern lifestyle and no interest in the limitations of older systemics. Biologics have been shown to offer exceptional efficacy compared to traditional systemics, such as methotrexate, acitretin, and cyclosporine. Additionally, biologics may have protective capabilities for some common comorbidities. They may be safer in patients who drink alcohol or in patients who may become pregnant. Furthermore, biologics can be prescribed with fewer lab tests, no liver biopsy, and no hypertension issues—all matters that can become burdensome with other drugs for psoriasis. The role of biologics in the pediatric psoriasis population remains uncharted. While the widespread prescribing of biologics to pediatric patients with psoriasis is just beginning in the United States, for years etanercept, adalimumab, and infliximab have been approved for pediatric use for juvenile idiopathic arthritis (etanercept and adalimumab)17,18 and Crohn’s disease (infliximab).19 Despite the limited evidence in the literature about the use of biologics in pediatric patients with psoriasis, their role is of increasing interest to clinicians due to superior efficacy, more convenient dosing regimens compared to traditional agents, fewer necessary laboratory tests, and their theoretical lack of end-organ toxicity.20

In considering biologic therapy for the older pediatric patient, it must be taken under consideration that many adolescents may be sexually active but not forthcoming about their sexual activity. Pregnancy in this population cannot be ruled out. Moreover, teenagers and younger adults often consume alcohol but, again, may not admit it to their parents or physician. For these reasons, methotrexate may be contraindicated. Acitretin should rarely, if ever, be considered in male teens and never in females.

In evaluating biologics, an important metric can be the Number Needed to Treat (NNT). The NNT may be defined as the number of patients who must be treated in order to achieve one good outcome; thus, the lower the NNT, the more likely a treatment will achieve the specified outcome in an individual patient (Table 3).

TABLE 3.

Number Needed to Treat to achieve a PASI score of 75 or 90 using various treatment options for psoriasis.21

DRUG	NNT TO ACHIEVE PASI 75	WEEKS TO ENDPOINT	NNT TO ACHIEVE PASI 90	WEEKS TO ENDPOINT	DOSE/DETAIL
Methotrexate	6.0	12	43.5	12	CHAMPION
Apremilast	3.6	16	--	--	ESTEEM 1
Etanercept	2.2	12	4.8	12	50mg biw
Adalimumab	1.6	16	2.3	16	40mg EOW
Ustekinumab	1.6	12	2.9	12	90mg
infliximab	1.4	10	2.2	10	5mg/kg IV
Secukinumab	1.3	12	1.7	12	300mg
Ixekizumab	1.2	12	1.4	12	80mg

biw=biweekly; EOW=every other week; IM=intramuscular; IV=intravenous; kg=kilogram; mg=milligram; NNT=number needed to treat; PASI=Psoriasis Area Severity Index; wk=week

OTHER PRESCRIBING CONSIDERATIONS FOR PSORIASIS

Psoriasis treatments include topical, systemic, and biologic agents, all of which have the potential to cause pharmacokinetic drug-drug interactions for patients at any age. In a study of 150 patients with psoriasis with at least two or more prescriptions, 92 percent had a total of 612 drug-drug interactions (4.49 drug-drug interactions per patient) with higher rates in patients between the ages of 45 and 60 years (n=311, 50.8%).22 The mean number of drug-drug interactions per patients increased in those who took more drugs and was highest (9.67 interactions per patient) in those taking over 10 drugs.22

When prescribing tumor-necrosis-factor-alpha (TNF-α) inhibitors, the clinician must evaluate the candidate and weigh their potential risks. For example, etanercept may be a good choice for women who may become pregnant or those with hepatitis C, while patients with comorbid Crohn’s disease or concomitant hidradenitis may obtain benefit from adalimumab or infliximab. Ustekinumab may be preferential for those patients with coexisting inflammatory bowel disease, demyelinating disease, or those who dislike self-injections

Patients with psoriasis treated with secukinumab saw better results than older biologics, but may develop mild-to-moderate candidiasis (4.7% at 300mg) and/or exacerbation of Crohn’s disease.23,24 Ixekizumab, approved in 2016, is the newest biologic to be approved for the treatment of psoriasis.26

Apremilast is a small molecule targeting PDE-4 that is prescribed twice daily as an oral pill, except in cases of renal insufficiency. While its effectiveness in psoriasis is modest, apremilast requires little or no laboratory monitoring and may appeal to biologic weary patients.27,28 Side effects associated with apremilast include weight loss, nausea, and diarrhea; suicidal thoughts and depression have been reported, but are much more rare adverse events.

PSORIATIC ARTHRITIS: DIAGNOSIS

The Classification Criteria for Psoriatic Arthritis (CASPAR) was recently revised based on prospective data collected from 588 patients with 536 controls who had rheumatoid arthritis (RA), ankylosing spondylitis, undifferentiated arthritis, connective tissue disorders, or other similar conditions. The CASPAR criteria consisted of established inflammatory articular disease with at least three points from the following: current psoriasis, history of psoriasis, family history of psoriasis, dactylitis, juxta-articular new bone formation, rheumatoid factor negativity, and nail dystrophy. All characteristics scored one point each except for current psoriasis, which scored two points. A score of 3 or more indicated psoriatic arthritis (PsA). This new CASPAR scale has high specificity (98.7%) and sensitivity (91.4%).29 In a study of 949 consecutive patients with plaque psoriasis as diagnosed by a dermatologist, 30 percent (n=285) were diagnosed with PsA by a rheumatologist and 40 percent of those diagnosed with PsA had no previous diagnosis of PsA. This supports the notion that PsA is prevalent in psoriasis patients but often goes undiagnosed (Table 4).30

TABLE 4.

Diagnosing psoriatic arthritis may be accomplished with some basic screening questions and a nail examination. In a study (n=524), a negative response to all four questions correctly ruled out the diagnosis of psoriatic arthritis in 95.3% of patients. On the other hand, positive responses to all four questions plus observed changes in the nails led to the correct diagnosis of psoriatic arthritis in 89% of patients.31

QUESTIONS/ASSESSMENT
Do you have joint pain or swelling?
Do you have morning stiffness?
Do you have psoriatic arthritis?
Have you ever had X-rays taken of your joints?
Nail assessment

PSORIATIC ARTHRITIS: TREATMENT

The more established treatments for PsA include nonsteroidal anti-inflammatory drugs (NSAIDs), methotrexate, sulfasalazine, leflunomide, PGE4-inhibitors, and anti-TNF-α agents. Drugs that target specific interleukins (anti-IL-12/23 drugs, anti-IL-17A drugs, anti-IL-17A/F drugs, anti-IL-23 drugs) and the newer drugs that target the pathways of the Janus-kinase/signal transducers and activators of transcription (JAK-STAT) have either been developed or are being investigated for use in this condition, although some of these, including some IL-17A and IL-17A/F inhibitors and anti-IL-23 inhibitors are not commercially available while others, such as the JAK-STAT inhibitors, along with methotrexate and leflunomide are not FDA approved for use in PsA. Each of these drugs presents its own profile of risks and benefits that must be carefully evaluated on a patient-by-patient basis. An overview of drugs, their advantages, and potential limitations appears in Table 5.

TABLE 5.

Short summation of drugs available to treat psoriatic arthritis

DRUG	ADVANTAGES	DISADVANTAGES	TOXICITIES	LIMITATIONS	COMMENTS
Methotrexate	Experience with drug, cost, formulary, simplicity of administration	Efficacy limited	Liver, bone marrow, pulmonary	Contraindicated for patients who consume alcohol	Should not be used in obese or diabetic patients, has a relationship to metabolic syndrome
Apremilast (PDE4 inhibitor)	Ease of administration (oral agent), no lab testing needed	Cost, formulary, efficacy limited	Early side effects include headache, diarrhea, and nausea	Depression	May cause weight loss
TNF-α Inhibitors	Effective across multiple disease domains, experience with drug, formulary	Cost, safety	Opportunistic infections, reactivation of tuberculosis infection, tumors, rare events		n/a
IL 12/23 Inhibitors	Less frequent dosing required, efficacy	Cost, formulary, efficacy issues with those who did not respond to TNF-α inhibitors	Infections		n/a
IL-17A Inhibitors	Effective, flexible dosing	Cost, formulary, “new” (not a lot of clinical experience)	Infections, candida(?), inflammatory bowel disease		May be associated with depression

n/a=not applicable

Biologic therapy holds promise for psoriasis in that it is associated with increasing numbers of PASI-90 and PASI-100 scores for patients. For example, in controlled trials, PASI-100 was obtained by seven percent of methotrexate patients (16 weeks),32 20 percent of adalimumab patients (16 weeks),33 and 39 percent of ixekizumab patients (12 weeks).34 A large subset of psoriasis patients taking etanercept monotherapy were able to achieve PASI scores of 90 or higher at 12 weeks: 40.9 percent (low dose) to 52.6 percent (medium dose) and 64.2 percent (high dose). At 24 weeks, 50.3 percent, 62.1 percent, and 71.1 percent for low, medium, and high doses, respectively, achieved PASI scores of 90 or higher.35 A short description of selected recent studies evaluating drugs for treating psoriatic arthritis appears below.

Methotrexate. In a subanalysis of the TICOPA treat-to-target study in early, drug-naïve psoriatic arthritis patients (N=206), the standard-care arm of the study was treated at the physician’s discretion but often received methotrexate; the control arm had methotrexate monotherapy for 12 weeks. At 12 weeks, 22.4 percent had minimal disease activity (MDA) and methotrexate patients had less dactylitis and enthesitis (63% and 26% decrease, respectively) from baseline.36

Apremilast. The PALACE studies evaluated the safety (PALACE 1-3) and effectiveness (PALACE 4) of aprimelast as first systemic treatment option in psoriatic arthritis patients who were naïve with respect to drug-modifying AR drugs (DMARDs).37 From the study PALACE-4, 527 patients were randomized to placebo, apremilast 30mg twice a day, or apremilast 20mg twice a day. At 16 weeks, a 20-percent improvement on the American College of Rheumatology response (ACR20) was 29 percent (apremilast 20mg) and 32 percent (apremilast 30mg). The most commonly reported adverse events were were nausea (8.9%), diarrhea (7.7%), and headache (5.9%). The most common infections were nasopharyngitis (4%) and upper respiratory tract infection (3%). The study concluded that APR monotherapy resulted in sustained improvements in the symptoms of psoriatic response and was generally well tolerated over 156 weeks of therapy.37

Adalimumab. Adalimumab is a fully human, anti-TNF-α monoclonal antibody evaluated in a placebo-controlled study in 313 patients with moderate to severely active psoriatic arthritis who did not respond well to NSAID therapy.38 Patients were randomized to be subcutaneously administered either 40mg adalimumab or placebo every other week for 24 weeks; patients were evaluated at baseline, Weeks 2 and 4, and then every four weeks. At 12 weeks, significantly more adalimumab patients had achieved (American College of Rheumatology) ACR20 than placebo patients (58% vs. 14%, respectively, p<0.001). A subset of the adalimumab patients (n=69) were evaluated with the PASI system and more than half (59%) achieved PASI-75 at 24 weeks compared to one percent of the placebo patients (n=69, p<0.001). Functional and quality of life improvements were also observed with adalimumab over placebo.38 Similar results have been seen with the other anti-TNF blocking agents, such as etanercept, infliximab, and golimumab

Ustekinumab. The PSUMMIT1 and PSUMMIT2 studies evaluated patients with active psoriatic arthritis and who were either metrotrexate naïve, methotrexate experienced, or experienced on anti-TNF-α drugs.39 Patients were randomized to receive subcutaneous ustekinumab 45mg or 90mg or placebo at Weeks 0, 4, 16, 28, 40, and 52. Patients were then asked for patient-reported outcomes (POROs) on the Health Assessment Questionnaire Disability Index (HAQ-DI), Dermatology Quality of Life Index (DLQI), and 36-item Short Form health survey physical and mental components (SF-36 PCS)s as well as being assessed for pain, disease activity, and the impact of the psoriatic arthritis on the patient’s productivity at Weeks 0, 24, and 52. At Week 24, both ustekinumab groups showed significant improvements over baseline in the HAQDI, DLQI, and SF-36 PCS assessments compared to placebo patients. Clinically meaningful improvements in HAQDI, DLQI, and SF-36 PCS occurred significantly more often at Week 24 in ustekinumab groups than placebo. Improvements also occurred for ustekinumab patients in terms of pain, disease activity, and impact of psoriatic arthritis on productivity and these benefits were durable to 52 weeks.39

Secukinumab. The IL-17 pathways play a crucial role in the pathology of psoriatic arthritis and secukinumab (like ixekizumab) inhibits the inflammatory cytokine IL-17. To evaluate the effectiveness of secukinumab in psoriatic arthritis, the FUTURE1 and FUTURE2 trials enrolled over a thousand patients into a randomized, placebo-controlled study.40 To be included in the studies, patients had to have psoriatic arthritis that did not respond adequately to TNF-α inhibitors or who had not ever previously received TNF-α inhibitors (TNF-α-inhibitor-naïve patients). The studies concluded that secukinumab is an effective agent in treating psoriatic arthritis. See Table 6 for description of results from these two studies.

TABLE 6.

Study descriptions and results for the FUTURE1 and FUTURE2 study evaluating the use of secukinumab in patients with active psoriatic arthritis.40 Both studies were randomized, placebo-controlled studies and FUTURE1 had three study arms, while FUTURE2 had four study arms.

STUDY	ARM 1	ARM 2	ARM 3	ARM 4	RESULTS
FUTURE1	IV Secukinumab 10mg/kg at Weeks 0, 2, 4, followed by subcutaneous secukinumab 150mg every 4 weeks thereafter	IV Secukinumab 10mg/kg at Weeks 0, 2, 4, followed by subcutaneous secukinumab 75mg every 4 weeks thereafter	Placebo; patients were switched to subcutaneous secukinumab 76mg at Weeks 16 or 24, depending on response	n/a	At Week 24, ACR20 response rates were 50%, 50%, and 17.3% for secukinumab 160mg, secukinumab 76mg, and placebo, respectively (p<0.001 for both active arms vs. placebo)
FUTURE2	Subcutaneous secukinumab 300mg every week from baseline to Week 4 and then every four weeks thereafter	Subcutaneous secukinumab 150mg every week from baseline to Week 4 and then every four weeks thereafter	Subcutaneous secukinumab 75mg every week from baseline to Week 4 and then every four weeks thereafter	Placebo; patients were switched to subcutaneous secukinumab 76mg at Weeks 16 or 24, depending on response	At Week 24, ACR20 response rates were 54% for secukinumab 300mg (p<0.0001), 51% for secukinumab 150mg (p<0.0001), and 29.3% for secukinumab 300mg (p=0.0399) vs. 15.3% for placebo

ACR=American College of Rheumatology; IV=intravenous; Kg=kilogram; Mg=milligram; n/a=not applicable

Ixekizumab. In the SPIRIT-P1 study, ixekizumab was evaluated in biologic-naïve patients with active psoriatic arthritis (n=417) who were randomized into three study groups for subcutaneous drug administration: ixekizumab 80mg once every two weeks, ixekizumab 80mg once every four weeks, adalimumab 40mg every two weeks, or placebo.41 Both ixekizumab groups (every 2 and 4 weeks) were initiated with a starting dose of 160mg. Significantly more ixekizumab patients achieved an ACR20 response; results were 62.1 percent, 57.9 percent, 30.2 percent, for ixekizumab every two weeks, every four weeks, and placebo, respectively, p≤0.001. There was significant improvement in functional ability and decreased disease activity in both ixekizumab groups versus placebo at Weeks 12 and 24. Plaque psoriasis cleared significantly more with ixekizumab than placebo (p≤0.001). Treatment-emergent adverse events occurred significantly more often with ixekizumab (65.7% to 66.4% vs. 47.2% with placebo, p<0.05). The rate of treatment-emergent adverse events with adalimumab 40mg every two weeks was 64.4 percent.41 As noted previously, although ixekizumab is FDA approved for the treatment of psoriasis, it has not been approved for PsA.

PATIENT-CENTRIC CARE FOR PSORIASIS AND PSORIATIC ARTHRITIS

As healthcare moves more and more toward patient-centric models of care, so-called “patient-reported outcomes” (PRO) have been the focus of increased interest. In a study of cancer survivors, it was found that PROs may more accurately reflect the patient’s symptoms than the physician’s assessment.42 In dermatology, it has been found that PROs likewise do not entirely align with provider’s assessments.21 Improvement may not be enough, especially if complete clearance is possible and sustainable.21 For example, with psoriasis, higher PASI responses are associated with greater improvements in the patient’s quality of life.43 Thus, more focus on PROs can help dermatologists better meet their patients’ needs and expectations.

CONCLUSION

For the modern dermatologist, the wealth of available treatment options for psoriasis and psoriatic arthritis (including the old standards and new cutting-edge pharmacological products) holds great promise and new products in the pipeline may confer greater benefits to even more patients. Treatments for psoriasis and/or psoriatic arthritis must be individualized and the breadth of the psoriasis armamentarium allows us this clinical versatility.

Clinicians must be aware of all of the prescribing choices in order to help patients access the best therapies for psoriasis and psoriatic arthritis. Similar patients may respond quite differently to the same agent. Clinicians need to be prepared to offer a multitiude of options for each patient. A simple discussion of the patient’s treatment goals and concerns can help guide treatment at present and throughout the patient’s lifespan.