Dr Green’s Tips: Treat to Target in Psoriasis

Lawrence Green, MD, section editor of The Dermatologist’s Psoriasis Center of Excellence and clinical professor at George Washington School of Medicine, shares his pearls on implementing the National Psoriasis Foundation’s treat-to-target approach.

Resources:

National Psoriasis Foundation website: https://www.psoriasis.org/treatment-targets
National Psoriasis Foundation Medical Board article: https://www.jaad.org/article/S0190-9622(16)30909-4/abstract

Dr Green is a clinical professor of dermatology at George Washington University School of Medicine, on the National Psoriasis Foundation’s medical board, and the section editor of The Dermatologist’s Psoriasis Center of Excellence.

Transcript

Dr Lawrence Green: Hi, everyone. This is Larry Green. I’m a clinical professor of dermatology at George Washington University School of Medicine in Washington, DC. And, thank you for listening to this podcast on psoriasis. Today, we’re gonna talk about the treat-to-target approach that the National Psoriasis Foundation has been mentioning for the past year or so and get into some details about it.

So, the approach for treat-to-target basically means that we wanna get the best outcome for our patients that have psoriasis there is. And, the National Psoriasis Foundation realizes, and I’m including myself (I’m on their medical board) we realize that the landscape for treating psoriasis has changed in the 21st century with the introduction of biologics. And, the landscape is going to continue to change in this new decade as we have newer and safer topical products as well to treat psoriasis.

So, the National Psoriasis Foundation and board-certified dermatologists, like myself, who are a part of it all around the country, want to make sure the patient understands that treatment for psoriasis has changed and there’s a much better way to treat psoriasis and we can really treat-to-target their psoriasis to be almost gone.

The goal used to be in the 20th century to make people comfortable enough with their psoriasis so the medicines don’t harm them. Somewhere find a happy zone between harming them with the medicine that could help but also had a lot of risks and side effects and down chances, chances that things could happen that we don’t want.

That’s changed in this new century. We no longer have to worry about so much downtime or potential adverse events or side effects from therapies, both topical and systemic therapies, and we can really treat-to-target the patient to try and get rid of their disease completely if possible. So, the paradigm of managing disease has really changed to eliminating or potentially eliminating the condition and controlling the condition without any adverse events.

And, that goal is being realized now and we’re getting closer and closer to it with systemic medications and, soon, in this decade, with topical medications that we see on the horizon.

The NPF medical board, a few years ago, set goal of 1% for psoriasis treatment. And, that means that someone’s psoriasis should be 99% or more gone. It’s a tough goal. To get someone to 1% or less, 20 years ago, would have been unheard of, even 10 years ago, would have been unheard of.

But the pharmaceutical industry and all the research going on in psoriasis, where actually as an aside, we’re very fortunate to be in an era where psoriasis is certainly a top-notch research condition and a lot of money and efforts are being spent in psoriasis. We’re very fortunate from those who suffer with psoriasis that this, that they live in this day and age. We don’t have to worry about 50% or 40% or 30%. We should strive for 1% or less. And, that’s what the NPF is saying.

It doesn’t mean that everyone has to achieve 1% or less. You know, you can have more on your body and still be considered a treatment success. Not talking about a lot more but that is a good, hard, realistic goal, which we couldn’t have had in the last century.

Now, we still have a ways to go. We’re not perfect. But, we want the research to continue in that respect. We want to keep the, not pressure, but keep everyone aware that that’s a goal that people with psoriasis should expect. It is a hard goal sometimes to get to, but it is a realistic goal in today’s society. And, and that’s the whole idea.

But, there are other factors besides that 1% that can be used for treatment. I mean, some people have psoriasis in difficult to treat areas like the scalp or in the groin or under the arms or on the palms and soles. And, it may affect less than 1% of the body but, potentially, be very debilitating.

In those patients, I would look for a treat-to-target approach that eliminates 90% or even 99% of what they have so that debilitating, small amount of psoriasis they have is no longer bothering them.

And then, people have limited disease itself, just mild psoriasis. If you have psoriasis on 2 or 3% of your body, say, just your elbows and knees, that still can be also debilitating even though it’s not, like I mentioned, the scalp or an intrusions area. Some of these people have very thick plaques that are difficult to treat and treat-to-target is a little different for them as well.

They should be able to have a topical medicine that should make them much more comfortable, not just manage their psoriasis, like we would have said in the 20th century, but make their psoriasis gone 90 to 99% so that they are no longer bothered by that psoriasis. And, you hope that the topical medicine doesn’t involve any adverse events or risks. And, that’s where we’re going in this second decade of the 21st century. Some are out. One is out now that I can think of and we’re doing clinical trials on products like that, so hopefully will be out in the near future for people.

So, we got the mild, the moderate, and the severe patient with psoriasis covered, uncovered, I should say, so that they no longer are covered with their psoriasis and should have less than 1% of what they had in this treat-to-target approach.

So, that’s a factor that we wanna take into consideration because we want that person to be comfortable. We want, even though they may have less than 1% body surface involved, that can still be very debilitating and painful. The goal is still, for these people, is to get them happy and get the psoriasis under control and well managed in these hard-to-treat areas.

I think recommendations for implementing it starts with talking with the patient. It starts with letting them know what the goal is. We wanna do more than manage it. We’re with you. We wanna tell you about the medicines that we have today that weren’t available 5 years ago, 10 years ago, last century. How people with psoriasis no longer need to suffer.

So, I think for us, board-certified dermatologists, it’s understanding and knowing what’s out there and all the potential medications out there, the biologics as well as orals, systemic medications, as well as new topical treatments that will be coming. Some are just starting here or are here now. All that’s available for the patient to control their psoriasis.

It’s basically patient education. I think that’s what dermatologists need to consider when using this approach and we’ve got that whole armamentarium of medications to help patients that we didn’t have earlier.

And, there’s also an emerging science about comorbidities for psoriasis, and that’s a whole other subject for another podcast. But as a teaser, I can mention that treat-to-target approach includes improving those comorbidity conditions such as high blood pressure, onset of diabetes or pre-diabetes, being overweight, heart problems, potential heart problems, all these things we’re learning the treatment may or may not but, hopefully it seems it does, improve these comorbidities.

So, that’s something important to educate patients about because I had patients all the time who fear taking a biologic. They still think biologics are dangerous and can potentially harm them, cause cancers and infections. The newer ones are very unlikely to do that, but not only that not treating someone who has severe psoriasis can potentially set their lifespan back several years.

Studies have shown that people, who have untreated psoriasis for a long period in their life, live less. They die earlier because they have all these comorbidities that occur. It’s a much bigger stress on their body to have all this inflammation going on.

And, that’s so important to tell people because they fear the treatment but what they should be fearing is the psoriasis. Untreated psoriasis has a lot of life-limiting potentials about it and I think that’s something that’s important to educate the patients about when you talk about expectations for treatment. We’re treating their skin but we’re really treating their whole body and, hopefully, adding years onto their life.

This is all about education. Educating the public, educating our patients, educating people on the Internet. There are online resources that abound these days and that can be good and bad because you can get a lot of misinformation about treating psoriasis that will not necessarily be helpful but there’s a lot of great information. And, knowing where the credible websites are, like psoriasis.org, the National Psoriasis Foundation website. That’s the most credible site there is.

The Dermatologist is a nice place for information for patients to look at. It’s for physicians but there’s good, credible information on the website as well. There is the American Academy of Dermatology website, aad.org, which has great, credible information about psoriasis and medications and how things have changed. It’s for doctors but also, for people, so the general public can look as well.

But, I would start with the National Psoriasis Foundation, because that’s not for doctors. That’s made for people who have psoriasis. And, there’s very credible information on there, including about treat-to-target strategy.

This is information we put on our own websites, that way we can talk about how we use the treat-to-target approach and can improve psoriasis much more than we could have just five years ago.

And, the next step is a cure but there’s no reason anyone should suffer from psoriasis, nor be adversely affected by the comorbidities because we can treat-to-target their psoriasis down to much more than manageable.

Thank you all for listening to this webcast on treat-to-target approach for psoriasis. I hope it fulfilled your goals and what you’re interested in. And, we encourage any feedback because we can certainly make these podcasts better. Please provide feedback at thedermatologist.com. We look forward to hearing from you. Thank you, again, for listening.