Reexamining Remission in Psoriasis

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More than 7.5 million adults in the United States live with psoriasis every day. An estimated additional 600,000 adults in the United States live with undiagnosed psoriasis. This chronic inflammatory condition is associated with significant burden of disease, including increased rates of mortality and decreased quality of life.¹

BSA Targets and Remission

In 2016, the National Psoriasis Foundation (NPF) established the first psoriasis treatment targets in the United States.² These recommendations, designed through consensus-building processes among the NPF medical board, expert dermatologists, and psoriasis patient representatives, stipulate that the treatment goal is to reduce a patient’s psoriasis down to 1% body surface area (BSA) less than 3 months after starting a new treatment. If the patient does not meet the target after 3 months of treatment, an acceptable 3-month treatment response is a BSA improvement of 75% from the patient’s baseline level or a BSA of 3% or less.

Despite advances in research and an increase in available treatment options, data have shown that nearly 50% of patients living with psoriasis who achieve a BSA of 3% or less do not feel their disease is in remission. Studies have shown that patients with inadequately treated psoriasis experience a significant impact on their physical and emotional well-being, as well as on work productivity and employment status.^3-5

Patient Perceptions of Psoriasis Remission

A recent study, utilizing data from the NPF annual survey, examined perceptions of remission in psoriasis patients in accordance with the established guidelines.6 Specifically, this study explored patient perspectives of not being in remission despite achieving BSA targets. The results suggest that even 1% to 2% BSA is an unacceptable treatment state for patients, with the majority mentioning disease activity involving high-impact areas such as the scalp, ears, face, palms, soles of feet, or genitals.

Analysis of respondents’ comments revealed the following themes:

• Continued presence of psoriasis

• Active signs of psoriasis on their body

• Continued presence of psoriasis symptoms

• The chronic nature of psoriasis

• Disease activity on high-impact locations

• Experiencing a disease flare and/or itch

Although only a small number of individuals with 0% BSA indicated lack of remission, nearly 40% reported that they felt this way due to treatment reliance for continued skin clearance. “Understanding why patients do not feel that their disease is in remission represents an important step in defining remission for psoriasis. Improvement in skin involvement is often used as an endpoint in clinical trials,” says George Gondo, director of patient-centered research for NPF. “While achieving 75% to 90% improvement in disease severity is tremendous from the standpoint of a therapeutic candidate, that measure does not necessarily translate to the patient feeling like their disease has gone away.”

Conclusion

While disease targets are important in establishing baseline efficacy of treatment, the finding that marked improvement in disease severity is not viewed as disease remission by patients underscores the importance of shared decision-making in clinical care and the role of providers in taking patient perspective into account when discussing treatment course.

Jess Smith is the senior manager of analytics and outcomes at NPF.

References

1. Gondo G, Eakin G, Van Voorhees A, et al. Psoriasis health indicator report. National Psoriasis Foundation. January 2024. Accessed August 23, 2024. https:// www.psoriasis.org/health-indicator-report

2. Treat to target. National Psoriasis Foundation. November 2016. Accessed August 23, 2024. https://www.psoriasis.org/treat-to-target

3. Armstrong AW, Robertson AD, Wu J, Schupp C, Lebwohl MG. Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States: findings from the National Psoriasis Foundation surveys, 2003–2011. JAMA Dermatol. 2013; 149(10):1180-1185. doi:10.1001/jamadermatol.2013.5264

4. Blauvelt A, Gondo GC, Bell S, et al. Psoriasis involving special areas is associated with worse quality of life, depression, and limitations in the ability to participate in social roles and activities. J Psoriasis Psoriatic Arthritis. 2023;8(3):100-106 doi:10.1177/24755303231160683

5. Strober B, Duffin KC, Lebwohl M, et al. Impact of psoriasis disease sever- ity and special area involvement on patient-reported outcomes in the real world: an analysis from the CorEvitas psoriasis registry. J Dermatolog Treat. 2024;35(1):2287401. doi:10.1080/09546634.2023.2287401

6. Gondo G, Smith J, Liao W. Perceptions of psoriasis patients with BSA ≤3% not being in remission: insights from the National Psoriasis Foundation annual survey. J Invest Dermatol. 2024;144(8 Suppl):S57. doi:10.1016/j.jid.2024.6.346