Regardless of specialty, health care providers often lament the lack of therapeutic adherence by patients. A shared decision-making (SDM) model may help dermatologists improve this and other aspects of care through careful conversations and considerations to the patient’s preferences and lifestyle.
Jason E. Hawkes, MD, MS, is associate professor of dermatology at the University of California, Davis, and a member of the National Psoriasis Foundation (NPF) Medical Board. In an interview with The Dermatologist, he reviewed how he empowers patients with psoriasis through communication and involvement in creating their care plan.
How do you explain the need for a long-term management approach to patients with psoriasis?
Most patients who come into the clinic understand that their psoriasis may be a long-term or chronic condition, because they have another family member or a close contact who also has the disease. However, there are still a large subset of patients who do not understand psoriasis is a chronic disease. I like to start the discussion there, because they oftentimes have only thought about their disease as being “skin only.”
A patient’s willingness to pursue particular treatments that might seem invasive, such as a pill or injection, is largely dictated by how bothered they are by their skin disease. I try to balance this by explaining that untreated, more widespread psoriasis has implications that extend far beyond the skin. We know that a number of comorbidities are associated with psoriasis, such as cardiovascular disease, hypertension, stroke, psychological conditions like depression, diabetes, and obesity. The potential impact of these comorbidities now need to be weighed in their decision as to how they prefer to treat their disease. It really serves as a warning to these patients that they need to think of their chronic psoriasis as more than a skin-limited condition. It makes the discussion more meaningful to the patient, because they understand that not treating their disease is a decision with potentially negative implications.
What about the stubborn patient with psoriasis?
Younger patients, who have not had the disease for many years, will occasionally say my health has been fine; I don’t have any heart disease, I’ve never had a stroke or a heart attack. Of course we express that we are grateful for that, but we should let the patient know that while they have not had any of these psoriasis-associated comorbidities, they are at a higher risk of these conditions down the road.
We have to explain to the patient that what they do now—exercise, eating well, avoiding smoking, and so on—are going to impact their long-term health. An easy example of this is photoprotection. The effects of the sun do not appear immediately, but we know many years later, we see skin cancers and other sun-related damage to the skin. In a similar way, we explain to patients that the goal of aggressive, targeted therapy for psoriasis is to also keep them healthy long-term and that we are trying to limit the underlying chronic skin disease’s impact on other internal organs. That approach typically changes the conversation and opens the patient up to considering more effective treatments of their disease as a potential prevention to these known comorbidities.
What resources are helpful for patients newly diagnosed for psoriasis?
I try to start patients out with a basic handout on psoriasis and psoriatic arthritis as well as some simple information on the psoriasis-associated comorbidities. This step is primarily due to the fact that there is a lot of inaccurate or incomplete information out there, so I want to make sure that they are getting something in front of them that is scientifically and medically accurate. Reviewing those handouts becomes their “homework” after meeting with me in the office for the first time.
I also tend to refer patients to the National Psoriasis Foundation (NPF) website and provide them with a list of some of the commonly used therapies that we may consider for their skin disease. Through the NPF’s forums or conversations with a known contact who has psoriasis, patients may also begin to think about other aspects of the disease that they would not have thought about on their own. This gives them additional information to read about and digest at their own pace.
This “homework” also allows them to start to think ahead to that next conversation we will have about their long-term disease management, and I feel this creates a stronger personal investment into their care. Patients are empowered with that information, and we can incorporate what they have learned and their preferences into the overall strategy for how they want to manage their disease.
How do you approach SDM in the psoriasis care plan?
I try to incorporate patients into a SDM process as often and as early as possible. You can offer patients the most effective biologic therapy, but without their buy-in and participation in the development of their treatment plan, its unlikely to have its maximal impact on their skin and/or joint disease.
We know that there is something satisfying and empowering about driving your own health and your own treatments. I find that I can tell patients to do certain things to treat their psoriasis, but if they have objections or reservations, then patients just are not going to do it. Suddenly, treatment compliance becomes a big factor. But if a patient comes to the clinic armed with their own research and treatment preferences, then we know we have options that can be pursued with the patient’s support. This has a tremendous impact.
Dermatologists also really need to have a clear understanding of what is most important to the patient regarding their psoriasis, such as a particularly bothersome body part affected by their disease or their preference for oral vs injectable vs topical therapies. When we have a clear understanding of what is important to the patient, then we have to step back a little bit and ask what are the aspects of their disease that might lead me toward or away from a particular treatment class or agent?
One of the big dividers in managing patients with psoriasis is whether they have skin disease only, joint disease only, or skin and joint disease. We know that therapies are not equally effective in all of these different scenarios. There are some medications that are highly effective for the skin disease that do not work very well in the joints. There are others that are clearly effective in the joints but have a much lower efficacy in the skin. Importantly, we have therapies, such as some of the newer targeted biologics, that are highly effective in the skin and joints compared with some of the first-generation biologic agents. We should incorporate the goals of therapy from the patient’s perspective and marry them with these specific clinical aspects of their disease to talk through potential therapies.
Another factor that often drives the decision-making process, unfortunately, is the patient’s insurance coverage and benefits. We see this happen a lot; we identify a particular medication or several agents that are likely to be highly effective in a specific patient, but we just cannot get them covered under their insurance plan. There are limitations, particularly in those patients with Medicare, Medicaid, and even some state insurance plans that just do not have broad, evidence-based coverage for biologic therapy. The insurance industry also routinely operates under a double standard by denying coverage for a requested medication that is known to be effective for psoriasis or atopic dermatitis but is not approved for these specific indications (ie, off-label use), yet in other circumstances they turn around and require a documented failure of these same high-risk, off-label medications such as methotrexate or cyclosporine before they will approve a safer, more expensive biologic with FDA-approval for these inflammatory skin conditions. In addition, the NPF continues to advocate for patients on state and national levels for access to more comprehensive health coverage, including working towards legislative action against these harmful step therapy policies.
Dermatologists should also work with industry and pharmaceutical partners who have very generous programs that can help provide medication coverage and/or bridge benefits when insurance does not cover a particular therapy that would be ideal for our patients.
Bonus question: What else should dermatologists remember when it comes to psoriasis?
Approximately 85% of our patients have classic plaque psoriasis, the type seen in textbooks or lectures. The failure to recognize or consider the less common variants of psoriasis (inverse, guttate, scalp, palmoplantar, pustular, and erythrodermic subtypes) leads to frequent misdiagnoses. Their nonplaque psoriasis goes unrecognized for a longer period. For example, inverse psoriasis is often confused with intertrigo or tinea cruris, so when these patients end up in my clinic, they figure they have had a chronic fungal infection of the groin the whole time and are not prepared for a discussion about psoriasis and its various treatments.
Dermatologists, and really all health care practitioners, should educate themselves and be able to recognize some of the other variants of psoriasis. We do a disservice to patients affected by these other variants when we put so much emphasis on plaque psoriasis. This is also important for our industry and pharmaceutical partners who exclude these patients from ongoing clinical trials, which leads to FDA drug approval labels that are restricted to plaque psoriasis only. This makes it even harder for patients with these less common clinical subtypes to get psoriasis-approved medications. I think it would be a huge advance in our field to incorporate the psoriasis clinical subtypes into our ongoing trials that are testing highly effective, safe, and targeted therapies.
Note: Providers are encouraged to visit the NPF for resources for professional members at www.psoriasis.org/medical-professional-membership/.
References
1. Elmets CA, Leonardi CL, Davis DMR, 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. doi:10.1016/j.jaad.2018.11.058
2. Umar N, Schaarschmidt M, Schmieder A, Peitsch WK, Schôllgen I, Terris DD.
Matching physicians' treatment recommendations to patients' treatment preferences is associated with improvement in treatment satisfaction. J Eur Acad Dermatol Venereol. 2013;27(6):763-770. doi:10.1111/j.1468-3083.2012.04569.x.
3. Nair PA, Badri T. Psoriasis. In: StatPearls. Treasure Island; 2020. Accessed January 21, 2020. https://www.ncbi.nlm.nih.gov/books/NBK448194/
