Mark Lebwohl, MD, is chairman emeritus of the Medical Board of the National Psoriasis Foundation. Additionally, he’s founding editor of Psoriasis Forum, now the Journal of Psoriasis and Psoriatic Arthritis. With this he has, also, authored or co-authored over 500 peer-reviewedarticles, and numerous textbooks, chapters, and abstracts. He joined The Dermatologist to discuss his recent study, “Impact of PASI response on work productivity and the effect of risankizumab on indirect costs using machine learning in patients with moderate-to-severe psoriasis”.
What impact can a disease like psoriasis have on a patient’s work that dermatologists may not actively consider in weighing treatment options?
First, if you treat it, it's the time taken to treat it. For example, phototherapy would be three visits a week for months, and that certainly has an impact on work.
Secondly, it's a condition which is known as presenteeism. In other words, you're at work, but the psoriasis distracts you from fulfilling your job. You're thinking about the cracks in your skin that hurt. You touch something and, instead of doing your work, since your skin cracks and bleeds you now are involved in getting the bloodstain off.
Basically, you're less productive because you have psoriasis. Imagine if you have psoriasis on your feet. Every step would hurt, so you avoid walking even though it may help at your job.
One case that comes to mind that I actually have an anecdote about is a patient of mine who was a deli worker. He would wear gloves whenever he would be preparing sandwiches. Someone saw him take off his gloves when he wasn't touching food, and they complained to the health department and to his boss. He ended up losing his job over that. Of course, this is many years ago and, today, he'd be able to appeal that.
The point is customers look at you as if you're contagious, and that interferes with your job. There are many impacts that psoriasis has on a person's ability to work, not to mention the days off they must take to care for their disease.
A recent study1 of yours compared the total work productivity impairment (TWPI) in patients with psoriasis alongside the effects of Risankizumab. What are the main highlights of the study findings?
We are now greeted with an array of treatments that are so effective, and Risankizumab is among the most effective, if not the most.
Results ranged from PASI 100, PASI 90, or PASI 75, to Physician's Global Assessment of clear or almost clear with Dermatology Life Quality Index (DLQI) patient-reported outcomes, itch, redness, scaling, thickness, and impact on the Work Productivity Index (WPAI). No matter what measure you look at, patients treated with Risankizumab do extraordinarily well, and that includes within the WPAI.
All the more reason for an employer who's thinking about the cost of these treatments to think twice. This makes his employees more productive. His employees with psoriasis can be more productive because of Risankizumab.
Alongside the results of this study, how else can advanced psoriasis therapies such as biologics or JAK inhibitors impact patient quality of life?
It's very clear that as we get to DLQIs of 0 or 1, that means that the disease is having almost no impact on the patient's life. Which should be our goal. In fact, many of the new treatments we have available now allows us to do that.
That includes all the IL-23s, of which certainly Risankizumab is a prime example and one of the most—if not the most—effective. Additionally, all the IL-17 blockers are included. These include upcoming drugs like Bimekizumab, which brings patients close to clear. When you get that close to clear, you can much more easily achieve DLQIs of 0 or 1.
Deucravacitinib is coming out and, right now, it looks like the most effective oral drug we will have, except for Cyclosporin. The difference is, while cyclosporin is not safe at all, Deucravacitinib appears to be extremely safe. Even though it is called a JAK inhibitor, it is very specific for tyrosine kinase 2. It does not appear to cross-react with the other JAK inhibitors which do have side effects of immunosuppression.
Regarding quality of life impacts, as an example, I've taken care of women with bad psoriasis who have never been fully naked in front of their husbands. They're embarrassed about what they look like. There are so many impacts that this has on your sex life, or on your personal interactions. Many of the questions that we ask don't necessarily touch on that.
Years ago, when Ixekizumab addressed a genital psoriasis indication, they asked those questions. The results were dramatic. It impacts the frequency of sex, everything about it is better when you clear psoriasis.
In a poster presented at AAD VMX based on the Corrona registry,2 it is found that patients with limited skin involvement may experience similar disease burden as those with severe psoriasis. How might this knowledge influence how we prescribe care plans?
With the Corrona Registry (noe called Corevitas), patients start on a drug, and then they can start on the registry. Some of the patients have been on other drugs that worked OK. They started out with low body surface areas, but they wanted to get even better.
This was a Guselkumab poster where we showed the baseline scores. Even in people whose starting-out body surface area was not so high, they had high enough impact on their quality of life that they wanted to go forward with a new treatment.
What it showed is you look a year later at the Guselkumab-treated patients, and their quality of life dramatically improved. What it points to is that we have some potent drugs now that give us the ability to bring most patients to close to clear and certainly to have a profound positive effect on their quality of life.
Regarding psoriasis treatment, what key takeaways do you want to share with other dermatologists?
We now have the ability to clear almost anyone to their satisfaction. If you have a patient who's not doing well enough, that they are happy with their progress in psoriasis, we have so many therapies that work well that you should give them a try.
There are many factors that go into the selection of what is the ideal therapy for a given patient. It's not just how effective they are. The difference between the most effective drugs is very small.
It's not just how safe they are, although that's always important, but most of the new IL-17, and IL-23 blockers do not have any common serious side effects. They're pretty safe and don't have any boxed warnings. There's no warning about malignancy or infection.
While we're at a good time in the treatment of psoriasis when it comes to our ability to select drugs, there are the other factors you have to look at. Does the patient have joint pain or psoriatic arthritis? Does the patient have inflammatory bowel disease? Does the patient have multiple sclerosis? Is the patient positive for hepatitis B or hepatitis C? Does the patient have a positive ANA or lupus? There's a long list of those questions. Every one of those items impacts the selection of the drug we pick, and it's important that we have access to that data.
References:
- Lebwohl M, Soliman AM, Yang H, Wang J, Freimark J, Puig L. Impact of PASI response on work productivity and the effect of risankizumab on indirect costs using machine learning in patients with moderate-to-Severe psoriasis. J Dermatolog Treat. Published online April 25, 2021. doi:10.1080/09546634.2021.1919287
- Strober B, Cronin A, Lin T, et al. Characteristics and disease burden in patients with mild to moderate vs. severe plaque psoriasis in real-world settings: results from the Corrona Psoriasis Registry. Poster presented at: AAD VMX 2021; April 23-25, 2021; virtual.
