Treatment Targets in Psoriasis: Alleviating the Burden

Robert Kalb, MD, is a clinical professor in the department of dermatology at the State University of NY at the Buffalo School of Medicine and Biomedical Sciences and is a dermatologist affiliated with Buffalo Medical Group in Williamsville, NY.

Dr Kalb met with The Dermatologist to define the treatment targets for psoriasis and how often dermatologists should evaluate a patient’s progression toward a treatment target.

What are treatment targets for psoriasis?

When a patient first walks into the office with a significant burden of psoriasis, and they really haven't had effective treatment or topical therapy, I get excited to say, "We have so many options now. They're safe, they're effective. We can certainly improve your skin significantly."

I don't really tell them a specific number, but will say, “We’re looking to improve your skin and your overall quality of life significantly." So, when they come back in, we can reassess it both from a standpoint of the severity in terms of body surface area, but also how thick, scaly, and red the plaques are. Then we try to correlate that with the patient’s satisfaction.

I often have patients come back in a month just to see if they're tolerating the therapy well and seeing what's going on, but certainly at a 3-month timeframe, we like to have in the back of our mind that, ideally, we can get to 1%. If they've improved significantly, but are not quite there, you can often continue therapy. Many patients don't reach the 1% target at 3 months, but they're close or they're on their way there. And in many cases, we try to individualize the treatment for that patient. How satisfied are they with where they're at now? Do they feel that there’s been a significant improvement? However, there are some patients who don't respond to a significant degree at all at 3 months. Then we would consider switching therapies.

Now, most physicians in practice aren't doing a quality of life or DLQI [Dermatology Life Quality Index] specific measurement. So, what happens is that if you get to the 1% point, the patient’s quality of life has improved. An example that I use frequently is that most patients with psoriasis have been using topical therapy all their life and they're putting creams on every day. This is a big deal, especially when they have a large body surface area. So, when patients improve to that point of 1% or less, they comment, "Well, I don't have to use any cream anymore. I don't have to put any lotion on anymore." That specific issue, not putting cream on anymore, correlates with improvement in quality of life.

How often should dermatologists evaluate a patient’s progression toward a treatment target?

Many dermatologists use the 3-month timeframe to assess the effective of treatment. In many cases, if there’s improvement, they will continue, but you want to get to the 1% target. If the patient reaches that target at 3 months or 6 months, ideally you want to maintain the improvement. One of the issues with psoriasis is there are some treatments that work and then they kind of wear off a little bit. So, following patients every 3 to 6 months, depending on the treatment, helps you maintain that improvement.

Also, you're asking the patient, "How do you feel? Has your quality of life improved?" If they're satisfied with their treatment, in many cases we can continue even if it's 1% or 2%. Some patients have a significant portion of psoriasis remaining at 3% or 4%. However, if they're very satisfied, I don't think physicians are going to change their treatment. Although many of the current treatments work quickly, you must be a little patient. I don't want patients to be discouraged after a month because they haven't seen a huge change. I encourage them because there are so many effective treatments. If we don't get to the point where we're both satisfied, we'll have another option.

If the patient has had significant improvement but is not quite where they want to be, they may not be interested in switching treatments entirely, so we will often add some aggressive topical therapy, phototherapy, or one of the oral agents. I try to get the patient involved in decision making. We could switch their treatment or we could take a few months. We can add a therapy and we'll see where we're at. But if a patient isn’t responding, then we’ll often switch treatments.

In the initial evaluation, I try to find out how the psoriasis is affecting them on a day-to-day basis. They're not going outside with shorts on because of this. They're having trouble with their job because of the psoriasis on their hands. They're having trouble with interpersonal reactions because some of the psoriasis is visible. I try to assess that, so when patients come back, we want to get to the point where it's not affecting them to the same degree.

Often when you get to that 1% target, those things have improved significantly. I try to talk to the patient and individualize the treatment so they're satisfied. By the same token, there are some patients who have limited psoriasis remaining and it's in an area like their face or hands, and they want to improve even more. I understand that and we often switch to a drug with a different mechanism of action.

What is the patient’s role in treating to target?

The patient’s overall health, such as following a healthy, balanced diet and exercising, can aid in maintaining their improvement. Many patients have comorbidities, such as hyperlipidemia, obesity, diabetes, and hypertension. Those issues need to be addressed with the dermatologist. Often we do screening blood tests because patients may not have had these tests. If their lipids are high or if their blood glucose is high, then we often refer them to their primary care physician so these issues can be addressed. By addressing these comorbidities, we can improve the patient’s overall psoriasis situation.