August is psoriasis awareness month.
More than Skin Deep
“Over the last 1 or 2 years, there have been six meta-studies linking psoriasis and cardiovascular disease,” said Robert Kalb, MD, clinical professor in the department of dermatology at SUNY Buffalo School of Medicine at the American Academy of Dermatology’s annual summer meeting in Chicago. “Patients with severe psoriasis need aggressive management of cardiovascular factors. Just by having psoriasis, their risk of having a major adverse coronary event is increased by 6%,” he said. Psoriasis has also been linked to psoriatic arthritis, diabetes, depression, obesity, some cancers, and other immune-mediated diseases.
“All the drugs are controls, not cures, because the exact root cause of psoriasis, the site where the antigen stimulates the T cell, is not known,” he said. “Many patients are on an individual drug which works well, but it wears off. When they have severe psoriasis, topical therapy does not cut it: three strikes and you’re out.”
Treatments include narrow band phototherapy, a number of known conventional and biologic treatments, as well as a plethora of newly approved and experimental agents. Each has their own set of risks and benefits.
“Many patients are on an individual drug which works well, but it wears off. When they have severe psoriasis, topical therapy does not cut it: three strikes and you’re out.” —Robert Kalb, MD
For example, Cyclosporine is very good for short-term relief, “but if you switch to using it as a long-term treatment, the patient’s creatinine goes up, so you have to drop the dose,” Kalb said. Methotrexate, too, has a role to play, but doctors must check the renal function in patients before prescribing methotrexate.
Biologics may also increase risk of infection and some types of cancer. There is a two-fold increase in herpes zoster among patients on biological therapies, Kalb said.
Scientists also conducted recent trials combining the TNF blocker etanercept with methotrexate. “The drugs are combined all the time, but this was the first study in psoriasis,” said Kalb, noting that patients on the combo experienced a reduction in their Psoriasis Area and Severity Index (PASI) score by 70% at week 12, compared to 54% for those who only received monotherapy. At 24 weeks, the figures were 77% and 60%, according or Kalb’s presentation.
Side Effects/Risks Affect Adherence
“We’ve had many vehicles over the years, such as creams, gels, lotion, oil, ointment, solution, foam, and shampoo,” added Abby Van Voorhees, MD, associate professor in the department of dermatology at the University of Pennsylvania in Philadelphia, and Chairman of the Medical Board at the National Psoriasis Foundation. “But studies have found that 40% of patients note non-adherence. There are multiple causes for this: for some patients, the treatment interfered with their life, while for some patients, there are safety concerns.”
John Otrompke is a contributing writer for Plastic Surgery Practice. He is based in Chicago.