Shawn Kwatra: So now we’ll address topical challenges in practice. Psoriasis is a chronic, prevalent, immune-mediated systemic disease that requires lifelong treatment.^1,2 For many patients with mild to moderate psoriasis, topicals are an appropriate first line treatment for localized skin symptoms.^3,4 So, Saakshi, before a patient ends up with a suitcase of topical treatments, it actually happens to me often. How do you assess when to break the cycle and prescribe something different?

Saakshi Khattri: Yes, as you pointed out that topicals are really they play a role in our psoriasis patients. Whether as first line, if it’s limited skin involvement or as an adjunct, if they have that plaque, which is just not going away, they’re here to stay.^1,3,4 So that’s an important thing. But then when I do have my patients in my practice that have plaque psoriasis, I always sort of plant that seed in their head that if we, let’s start you on topicals, but then if you don’t respond to it the way we want you to respond or the way you want to respond, then it’s always, it’s important to know that there are other options. And these other options can be sort of in this big umbrella of systemics. It could be oral molecules, it could be injectables.⁵ So, I kind of plant that seed. So this way the patient is aware that if we fail a topical modality, there are other options that are out there. and then I also, we have so many topicals in our arsenal, I always tell my patients that, you know what your face, if you have psoriasis on your face needs a different topical as opposed to your knees and your elbows.^4,6 And then I’m always wary whether they switch. If they end up using the one that’s for the knees and elbows on their face and vice versa.^4,6 So that’s always a consideration in my head. And often I’m sure as, as of all of you, had patients that come to you and they sort of put their arms up in the air and say that, you know what? I am not going to go home with a topical prescription. Give me something else. So, while topicals do play an important role, they’re not the end-all for our psoriasis patients.¹

Shawn Kwatra: I remember writing patient instructions and saying for the face for the genitals, for the arm, for the knee. And I remember thinking to myself, man, this is tough to follow. So Michael, how do you evaluate whether topical therapy is both effective and sustainable for your patient? Or whether it’s time to prescribe something different?

Michael Lewitt: Sure. So I assume that question stems from as monotherapy. Again, I think topicals still will have their place and do have their place in a psoriatic algorithm. But that being said, number one is a patient at treatment goal, not just with the IPC and NPF thing, but what the patient wants to be and where I want that patient to be. And also, is the patient and I frustrated with the tedious application schedule that some of the topical regimens required?

Shawn Kwatra: Absolutely, especially when you have lots of isolated areas, difficult to reach areas. I think we all probably find ourselves wondering, is this actually something that is sustainable and possible. Saakshi, what are your thoughts?

Saakshi Khattri: I mean, I totally agree with everything that’s been said so far. And also, if you sort of see that NPF said that our treat to target is reaching one percent body surface area within 3 months.⁷ So, I kind of use that as a yardstick for my patients that have plaque psoriasis that I have started on a topical just because they had limited disease. And if they don’t meet that endpoint, I do then think about systemic options on a case-by-case basis.^1,8

Shawn Kwatra: Saakshi, what are some things that, you hear patients talking about with respect to topicals?

Saakshi Khattri: I think the burden of topical use can sometimes be a lot.^9,10 I have kids. In the morning, I’m trying to get them out to school, give them breakfast, pack their bag, get to work on time. Can you imagine if I as a patient that had psoriasis had to put one topical on the scalp, another on the face, another somewhere else? I mean, that eats into the limited time that I have. So, I think those considerations should play a role in us as physicians sort of determining is this ease, is there ease of use? So, I think that is important because we can’t just—at the end of the day, it’s all about, making sure that our patients are on the same page as we are because I can prescribe my patient anything and everything, but if they feel that this is not easy to use, they will not use that. So, we need to take our patients into account. When we make decisions like those.

Shawn Kwatra: I think that shared decision making is so important. You have options, how does this fit into your life? So in a US cross-sectional survey on mild to moderate plaque psoriasis patients on topical treatment, actually around 50% of patients reported that they were not highly adherent to therapy.¹¹ So, Michael, what has your experience been regarding the application related challenges associated with topicals specifically in terms of ad adherence?

Michael Lewitt: So number one, as I, mentioned earlier, sometimes the topicals can have adverse events, including stinging and burning. We already know the disease state does. The other thing is not every topical has the same vehicle, even if they have relative differences in potency.^1,4 So when you think about a foam versus an ointment versus a cream versus a solution, different patients have different predilections for different vehicles depending on whether it’s a hair-bearing area or a scalp that is washed at different frequencies or areas again, trying to get out in the morning. If you have to put, for example, a twice-daily medication and you have to go put a suit on, like we’re all finely dressed today you know, is that going to smear? Is it going to go through the clothing? So, there are things that, you can’t hide and can’t escape. And I think we need to think about that when we’re putting together an algorithm of topicals or at least as part of the treatment process…or algorithm.

Shawn Kwatra: So, Saakshi, what are some of the benefits but also challenges that are still there in terms of topical therapy? So it could even be kind a practicality of amount of medicine that can be given, patient perspectives and thoughts.

Saakshi Khattri: Often, I get asked by patients, how much am I supposed to use? And I’ll be honest with you, I kind of don’t have a good answer for that. And most tubes are anything from 60 an average 60 grams. And you expect that they will use that for a month. And it can get challenging because the patient doesn’t know how much am I supposed to use? Will this last an entire month because the insurance is not going to cover it sooner than a month is up. So, these are sort of logistic challenges that come into play with topicals, in my opinion.

Shawn Kwatra: So, let’s take a moment to discuss how topicals, while effective for some patients, may pose additional challenges in patients with special area bulk, so difficult to reach areas.^8,11 Also skin of color patients can have unique presentations.¹² So in UPLIFT, when patients had at least one special area of involvement, 86% considered topical therapy to be moderately or very burdensome.¹³

Shawn Kwatra: So, Saakshi, in your practice what scenarios in particular with skin of color patients may make you consider going beyond topicals as well?

Saakshi Khattri: So certainly, I think scalp involvement in skin of color is a challenging area for all of us.¹² And then we kind of have limited, vehicles for scalp.¹⁴ And then our skin of color patients that have scalp involvements. Most of them, I’ve heard from them that they do not want a solution. They want like an oil that’s greasy because they tend to have frizzy hair and that oil vehicle helps with that as well.¹⁴ So we are kind of limited in what we can use in scalp involvement in our skin of color patients.¹⁴ So, I think that’s a challenging area where I do then sort of start talking about is there a systemic option that we can consider? Is that something that you’re open with? And as I mentioned, previously sort of plant that seed at that first or second visit. So that transition to something systemic is an easier, transition to make and not something that carries shock value.

Shawn Kwatra: So, Saakshi, when discussing treatment options with your patients with mild psoriasis, how do you explain that topicals may not address the underlying systemic nature of psoriasis?¹¹

Saakshi Khattri: So I think telling a patient that this is a chronic disease. And we do know that plaque psoriasis is associated with systemic inflammation.^2,15,16 Certainly the data says that if it’s a higher body surface area or higher PASI score, so they have a higher systemic inflammation, but that doesn’t discredit the fact that any psoriasis has some burden of inflammation or systemic inflammation.^1,2,16,17 So telling the patients that it’s a chronic disease, there’s some systemic inflammatory component to it,¹ and if the topicals are inadequate, as Michael said, in reaching their goals and my goals, then it’s time for a switch.

Shawn Kwatra: That’s a really important point on disease chronicity. I’ve had folks come back in and I asked them, “How are you doing?” And they said, “Well, the topical you gave me, it only works when I put it on, but then when I stop using it, it stops working.” I’m just like, well, that’s the…

Saakshi Khattri: That’s what happens.

Shawn Kwatra: That’s the disease, you can’t cure it yet.

Saakshi Khattri: So I think it’s important to tell our patients about topicals having a place in the arsenal of psoriasis treatment, but also that if they’re not reaching where they want to be, it’s time to switch.

Shawn Kwatra: So based on an international psoriasis council consensus, systemic should be considered for patients with the body surface area greater than 10% or psoriasis involving difficult to treat areas or those who have experienced failure on topical therapy.⁸ So, Michael, what are the reasons do you consider when transitioning your patients from topicals to a systemic?

Michael Lewitt: So I will be repetitive in this answer, and that the frustrated patients and the frustrated providers, not only when my suspicion is growing that there might be other psoriatic manifestations approaching or already occurring if I’m not at these goals at the IPC sets. And again, as we talked about in module one, what it means to have psoriasis for one patient might not be what it means to have psoriasis for another patient. Geographically dependent on the body, not geographically in Las Vegas versus Baltimore versus New York. But that being said, that will push me to start having that discussion with folks.

Shawn Kwatra: Absolutely. So, Saakshi, in your practice, when you encounter a patient with limited skin involvement who’s hesitant to try a systemic therapy, how do you counsel them?

Saakshi Khattri: So I don’t want to enforce my decision on them. As you mentioned, this is all about shared decision making. So if I have a patient who is a little on the fence with regards to systemic options when that transition should be made because they’re not responding to topicals, I tell them, why don’t you go home, read about the options that I’ve discussed? Why don’t you track your symptoms on a diary or a calendar to see, do you have good days, bad days? How is your disease impacting you? And then come back and see me in like 6 weeks, or 8 weeks, or three months. So when they come back and they tell me that, “You know what, you’re right, I have more bad days than good days. I’ve read about what you discussed with me, I think I’m ready to switch.” So I think a patient when they’re given time and when they feel that they have agency on their disease and agency on their treatment will be more open to listening to a physician’s suggestion.

1. Van Voorhees AS, Feldman SR, Lebwohl MG, Mandelin A, Ritchlin C. The Psoriasis and Psoriatic Arthritis Pocket Guide. psoriasis.org/ the-pocket-guide. Accessed September 29, 2023. 2. Korman NJ. Management of psoriasis as a systemic disease: what is the evidence? Br J Dermatol. 2020;182(4):840-848. 3. Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Can Fam Physician. 2017;63(4):278-285. 4. Elmets CA, Korman NJ, Prater EF, et al. Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021;84(2):432-470. 5. Menter A. Am J Manag Care. 2016;22(suppl 8):s225-s237. 6. Stein Gold L, Bagel J, Allenby K, Sidgiddi S. Betamethasone Dipropionate Spray 0.05% Alleviates Troublesome Symptoms of Plaque Psoriasis. Cutis. 105(2):97-102;E1. 7. Armstrong AW, Siegel MP, Bagel J, et al. J Am Acad Dermatol. 2017;76(2):290-298. 8. Strober B, Ryan C, van de Kerkhof P, et al. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol. 2020;82(1):117-122. 9. Feldman SR. Treatment of psoriasis in adults. uptodate.com/contents/treatment-of-psoriasis-in-adults. Accessed December 11, 2023. 10. Wozel G. Psoriasis treatment in difficult locations: scalp, nails, and intertriginous areas. Clin Dermatol. 2008;26(5):448-459. 11. Gupta S, Garbarini S, Nazareth T, Khilfeh I, Costantino H, Kaplan D. Characterizing outcomes and unmet needs among patients in the United States with mild-to-moderate plaque psoriasis using prescription topicals. Dermatol Ther (Heidelb). 2021;11(6):2057-2075. 12. Lytvyn Y, Sachdeva M, Mufti A, Yeung J. Dermatology: how to manage and recognize difference in pathophysiology and presentation in patients with skin of colour. Drugs Context. 2022;11:2021-9-3. 13. Lebwohl M, Langley RG, Paul C, et al. Dermatol Ther (Heidelb). 2022;12:61-78. 14. Kaufman BP, Alexis AF. Psoriasis in skin of color: insights into the epidemiology, clinical presentation, genetics, quality-of-life impact, and treatment of psoriasis in non-white racial/ethnic groups. Am J Clin Dermatol. 2018;19(3):405-423. 15. Kim J, Bissonnette R, Lee J, et al. The spectrum of mild to severe psoriasis vulgaris is defined by a common activation of IL-17 pathway genes, but with key differences in immune regulatory genes. J Invest Dermatol. 2016;136(11):2173-2182. 16. Woo YR, Park CJ, Kang H, Kim JE. The risk of systemic disease in those with psoriasis and psoriatic arthritis: from mechanisms to clinic. Int J Mol Sci. 2020;21(19):7041. 17. Langley RG, Ellis CN. Evaluating psoriasis with Psoriasis Area and Severity Index, Psoriasis Global Assessment, and Lattice System Physician’s Global Assessment. J Am Acad Dermatol. 2004;51(4):563-569.

Shawn Kwatra: Now we’ll talk about joint pain and early signs of psoriatic arthritis. Psoriasis primarily manifests in the skin but is a systemic disease.^1,2 People with psoriasis, regardless of severity or extent of skin involvement, are at an increased risk for developing psoriatic arthritis.³ Among patients with psoriasis, up to 40% may develop psoriatic arthritis usually within 5 to 10 years of psoriasis onset.⁴ Approximately 30% of patients with limited skin involvement may develop psoriatic arthritis, and the prevalence tends to increase with psoriasis severity.³ So we’re very lucky we have you, Saakshi, obviously a dermatologist and a rheumatologist. So what are some risk factors for your patients with psoriasis regardless of severity for developing psoriatic arthritis?

Saakshi Khattri: So I tell all my psoriasis patients, irrespective of the severity of disease that just having psoriasis is the single biggest risk factor for developing psoriatic arthritis.⁵ Most of our psoriatic arthritis patients have had plaque psoriasis before they developed psoriatic arthritis. So that’s almost like 85% patients.⁶ Not often do they have just psoriatic arthritis before plaque psoriasis, so that’s like a lesser number. So just having psoriasis or plaque psoriasis in general is like the single biggest risk factor that increases your risk of developing psoriatic arthritis. And then certainly as dermatologists, we can risk stratify that if they have scalp involvement, they have nail involvement, that places you at a higher risk.^5,7 Certainly, a higher body surface area places you at a higher risk, but that doesn’t take away the fact that even patients with low body surface area can develop psoriatic arthritis.^3,4,8 So I don’t really use that body surface area as that stratification marker in my practice. And then there are other extra articular manifestations of psoriatic arthritis: Do they have enthesitis? Have they had dactylitis or sausage digits?⁹ Because if they’ve had any of those features, and I do think strongly about psoriatic arthritis and there are also other extra articular manifestations. And then often I get asked X-rays, can we do X-rays? Will they help diagnose psoriatic arthritis? To which I say that yes, having an X-ray that shows joint space narrowing, that shows erosions does rule in psoriatic arthritis. But having a negative X-ray does not rule out, because that is thought to be based on studies out there, that it takes about 2 years from the onset of psoriatic arthritis to develop changes on your X-ray.^10,11 And I don’t want to diagnose psoriatic arthritis purely based on X-rays, I want to see if they have other risk factors. And then again in my practice, I am doing a joint exam which I don’t expect you Sean or Michael to do, or my derm colleagues to do. But I’m doing a joint exam and that helps me pick up psoriatic arthritis sooner rather than later.

Shawn Kwatra: Absolutely. So patients with involvement of certain areas, for example, scalp involvement, are approximately 4 times more likely to develop psoriatic arthritis, and patients with nail involvement are approximately 3 times more likely compared to those without these areas that are involved.⁷ So Michael, how does the risk of psoriatic arthritis factor into your treatment decisions for your patients with psoriasis?

Michael Lewitt: That’s a great question. So in regard to how the risk of psoriatic arthritis impacts my treatment decisions for patients that have psoriasis, just knowing that up to 40% of my psoriasis patients have or will develop psoriatic arthritis,⁷ plus a plethora of other things like my review of systems, areas that they may have psoriasis, like scalp and nails that have a higher propensity to develop psoriatic arthritis.⁶ For my patients that have a diagnosis of both psoriasis and psoriatic arthritis, I like to choose an agent that will cover both of those disease states.

Shawn Kwatra: Absolutely. So we know Saakshi as a rheumatologist is familiar with all sorts of scales and tools, but Michael, from your perspective as a dermatologist, are there any tools that you use to assess psoriatic arthritis in your patients with psoriasis?

Michael Lewitt: Absolutely. Again, beyond my cursory enthesitis exam, again, where I can find the Achilles, I can find the epicondyles, things like that. I’m using things that are simple and efficient in my clinic that perhaps the electronic medical record or medical assistant, but things like a validated score, like the PEST score, and then we’ll cover that in more detail what it means later.^9,12 But that’s a great, and 3 out of 5 I’m thinking about starting something that treats the joints and then also getting my pen out or my cell phone out to phone a friend in the rheumatology ward of things. And then again, review of systems are paramount asking simple questions about lower back pain that lasts for 30 minutes. And then taking a little more time with my physical exam looking at those areas you just mentioned, scalp, nails, because we know there’s a higher propensity to have or develop psoriatic arthritis.⁷

Saakshi Khattri: Michael, that morning stiffness, lower back pain thing that you said is pretty important. So psoriatic arthritis or inflammatory arthritis patients will have stiffness when they wake up first thing in the morning. And that’s the morning stiffness that we talk about. And the longer the morning stiffness, the more it points towards like an inflammatory process. But that 30-minute cutoff is what I’m asking my patients as well. Because you can have a little bit of morning stiffness just by that osteoarthritis, mechanical arthritis, but generally that’s under 30 minutes. Patients will be stiff for about 5, 10 minutes when they have osteoarthritis or mechanical arthritis. But if it’s like double digits, 30 minutes and beyond, it starts making me think of like, is there an inflammatory arthritis that’s going on? And then yes, lower back because a third of our patients that have psoriatic arthritis will have lower back or axial involvement, so asking about that lower back pain stiffness. And then in today’s world where there’s like a hybrid or a fully remote option where patients are on their chairs for like long periods of time, I even ask them, do you feel stiff off like sitting at your desk for extended periods of time? Because that also is something that’s seen in inflammatory arthritis or psoriatic arthritis.

Michael Lewitt: This is why you always remain on my speed dial.

Shawn Kwatra: Mine too. So those are all great tips at the bedside for considering psoriatic arthritis. But we know we have tremendously long wait times to get a rheumatology appointment. Oh my goodness, in my area as well. So, Michael, have you seen that? Have you seen like long wait times? And does this create a sense of urgency to identify suspected psoriatic arthritis and potentially begin treatment with an option that may be approved for both psoriasis and psoriatic arthritis within the office?

Michael Lewitt: So great question. In my geography getting into a rheumatologist can sometimes take 6 to 8 months or sometimes longer. Luckily, we have the privilege of all being on this panel together and we form relationships where sometimes for our patients, we can scoot them up a little bit but for the dermatologist in the community, that may stick to 6 to 8 months or longer. So when I have a patient that has psoriasis, and I’ve made the diagnosis of psoriasis and psoriatic arthritis, I like to treat first and ask questions later and worst comes to worse when they get to my rheumatology colleagues, if the systemic treatments need to be tweaked, added, or subtracted that’s OK.

Saakshi Khattri: Well, as a rheumatologist on the panel, I do agree with both of you.

Shawn Kwatra: Absolutely. And I actually got the exact same advice. Go ahead and start treatment, do not wait for us.

Shawn Kwatra: Absolutely. So we know that psoriatic arthritis is a heterogeneous disease that can present differently from patient to patient, most often impacting peripheral joints.^8,13 However, even when only a few joints are impacted, the burden can be substantial in the patient's life.¹⁴ So, Saakshi, in what scenarios have you observed a patient with, they even had just a few joints that were impacted by their psoriatic arthritis, but it may have had an impact on them?

Saakshi Khattri: So psoriatic arthritis is a phenotypically, pretty heterogeneous.^8,13 You can have of course psoriatic mutilans,¹⁵ which thankfully todays day and age, we don't see that often, unless of course a patient has had that previously before systemic therapies for PsA were approved. And we can have a rheumatoid-like pattern of psoriatic arthritis as well where there are small joints on the hand, the MCPs, the PIPs that can be involved.¹⁵ And the fifth phenotype is the DIP involvement.¹⁵ So because it is such a heterogeneous disease, it is such a heterogeneous phenotype, sometimes if you're not really thinking of other presentations of PsA, you can miss a patient that has PsA. So it's always good to know that it could be oligoarticular, it could be sort of rheumatoid like, and so keep an index of suspicion high when you have a patient that manifests in a way that you're probably not familiar with. And then often in my practice, I've had patients that have had psoriatic arthritis with just a handful of joints involved, like up to 5.

Shawn Kwatra: Absolutely. So we mentioned this earlier, but the psoriasis epidemiology screening tool, the PEST tool, something I use as well, I know the other panelists also do as well, is a quick way to screen for suspected psoriatic arthritis among patients with psoriasis. It compromises five key questions that assess swollen joints, history of arthritis, and presence of nail involvement, enthesitis and dactylitis.⁹ In psoriasis patients, nail disease should be considered risk factors for developing psoriatic arthritis.¹² In UPLIFT, 58% of patients with psoriasis experience joint discomfort. Of those 42% had a PEST score greater than or equal to 3, suggesting a referral to a rheumatologist.¹⁶ So, Saakshi, how do you approach asking your patients about joint pain?

Saakshi Khattri: Before I answer that question, as you were talking, it made me think. I draw the analogy to pregnancy, either you are pregnant or you're not pregnant. You can't be like partially pregnant. So either you have psoriatic arthritis or you don't. And it doesn't matter whether it's 1 joint or 5 joints. If you have inflammation in one joint and you have psoriasis, that's psoriatic arthritis. You don't have to wait for 3 or 5 or a dozen joints to make that diagnosis. I know I sidetracked. But when I have my patients in my practice, I instinctively put my rheum hat on and I'm asking them, how do you feel when you wake up in the morning? Have you noticed any joint that's swollen, that's tender? And it doesn't have to be something that's present at that instant because psoriatic arthritis sort of ebbs and flows. Patients can have good days, they can have bad days. I even go as far as asking my patients that, if I see them in the winter months, I'm like, I do feel that your arthritis is a lot more active when it's rainy outside, when it's damp when it's snowing or when it's cold, because that is something that my psoriatic arthritis patients sort of report as well. Because dactylitis, enthesitis nail, are other domains of psoriatic arthritis.¹⁷ So I do ask questions related to that.

Shawn Kwatra: Absolutely. OK, so, Michael, last question's for you. So, how do you collaborate, between the different providers, so, your dermatologist, rheumatologist, APPs, primary care providers in the holistic care of a patient with psoriasis, what's each provider's role? In your opinion, why is it timely and important to care for psoriatic arthritis in a patient with psoriasis?

Michael Lewitt: Yeah. So when I think about it, I think about first being with the patient in the room, it's an intimate setting, and they're talking, they're saying things like, Doctor, I don't want to work out because I'm embarrassed, I can't wear shorts. And then I can't lose weight because my joints hurt. And it's just the circle of life you're thinking about, they tell their primary care doctor, perhaps because they've gained weight, they've developed type 2 diabetes, and they have an endocrinologist on board. So there's a lot of different things that kind of feed each of the other manifestations or comorbidities of psoriasis. So a couple analogies I love using, for those of you that know me, I love food, and I love sports. So for food, I say it's OK if there's a couple of cooks in the kitchen, as long as we're making the same thing. So we need to collaborate and it becomes more difficult sometimes when you're not within an educational university setting where everybody's on board, same electronic medical record. So my team, we pride each other on speaking to the primary care doctors, we'll go back to sports, the primary care doctor is like the quarterback. So that being said, and then the other providers, the rheumatologist, the dermatologist, the endocrinologist, if applicable, these folks will all need to communicate together, And all those providers together, we help do that. I know that's silly of analogies, but it's how I relate to my patients and my colleagues.

Shawn Kwatra: OK, well, thanks so much everyone for their attention, and that'll conclude this session.

1. Korman NJ. Management of Psoriasis as a systemic disease: what is the evidence? Br J Dermatol. 2020;182(4):840-848. 2. Woo YR, Park CJ, Kang H, Kim JE. The risk of systemic disease in those with psoriasis and psoriatic arthritis: from mechanisms to clinic. Int J Mol Sci. 2020;21(19):7041 3. Armstrong A, 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 4.Mease PJ, Armstrong AW. Managing patients with psoriatic disease: the diagnosis and pharmacologic treatment of psoriatic arthritis in patients with psoriasis. Drugs. 2014;74(4):423-441. 5.Mayoclinic.org. Psoriatic arthritis. https://www.mayoclinic.org/diseases-conditions/psoriatic-arthritis/symptoms-causes/syc-20354076. Accessed December 11, 2023. 6. Armstrong AW, Read C. Pathophysiology, Clinical Presentation, and Treatment of Psoriasis: A review. JAMA. 2020;323(19):1945-1960. 7. Wilson FC, Icen M, Crowson CS, McEvoy MT, Gabriel SE, Kremers HM. Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum. 2009;61(2):233-239. 8. Van Voorhees AS, Feldman SR, Lebwohl MG, Mandelin A, Ritchlin C. The Psoriasis and Psoriatic Arthritis Pocket Guide. psoriasis.org/the-pocket-guide. Accessed September 29, 2023. 9. Chang J, Litvinov IV, Ly C, et al. Utilization of the Psoriasis Epidemiology Screening Tool (PEST): A Risk Stratification Strategy for Early Referral of Psoriatic Arthritis Patients to Minimize Irreversible Erosive Joint Damage. J Cutan Med Surg. 2022;26(6):600-603. 10. Ory PA, Gladman DD, Mease PJ. Psoriatic arthritis and imaging. Ann Rheum Dis. 2005;64(suppl II):ii55-ii57. 11. Busse, K, Liao W. Which psoriasis patients develop psoriatic arthritis? Psoriasis Forum. 2010;16(4): 17-25. 12. Zabotti A, De Marco G, Gossec L, et al. Ann Rheum Dis. 2023;82(9):1162-1170. 13. Gottlieb A, Korman NJ, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008;58(5):851-864. 14.Tillet W, Ogdie A, Richette P, et al. Poster presented at: EULAR 2022; June 1-4, 2022; Copenhagen, Denmark. POS1077. 15.Moll JM, Wright V. Psoriatic arthritis. Semin Arthritis Rheum. 1973;3(1):55-78 16. Lebwohl M, Langley RG, Paul C, et al. Evolution of patient perceptions of psoriatic disease: results from the Understanding Psoriatic Disease Leveraging Insights for Treatment (UPLIFT) survey. Dermatol Ther (Heidelb). 2022;12(1):61-78. 17. Coates LC, Helliwell PS. Psoriatic arthritis: state of the art review. Clin Med (Lond). 2017;17(1):65-70.

Shawn Kwatra: Now we’ll be discussing treating psoriasis beyond the skin. Plaque psoriasis is a chronic, systemic, immune mediated inflammatory disease.¹ As a result, psoriasis can manifest in multiple locations of the body in the US subgroup of the UPLIFT survey among patients with limited skin involvement.^1,2 So again, that’s a body surface area defined as 3 or less palms, 74% of patients had psoriasis and at least one special area involved.³ So the question is, how do your patients report the effect of these manifestations that they have on their lives and also their perception of disease burden? Why don’t you start Saakshi.

Saakshi Khattri: So, certainly, having patients that have a special site of involvement adds another layer of complexity to treating plaque psoriasis. I joke and say that not all plaque psoriasis or not also psoriasis is created equal. Because we know as dermatologists that even if it’s scalp, if it’s the intertriginous, or genital areas, they’re just a little harder to treat, because the available options that we have right now are sort of limited. As Michael pointed out earlier, some of them might have a little stinging or burning, and that’s just how that topical is for them in a sensitive area.^4-7 And we don’t want to create more problems than solving issues. So suddenly, if a patient does have special side involvement that sort of plays a role in my having a discussion with them, that there are treatment options which are topicals, but they could cause you a little bit of stinging, irritation.⁴ So if that happens, let me know we can think of something else. And then again, sort of beating this to a death. If they have scalp involvement, that increases the risk of psoriatic arthritis.⁸ So I also sort of plan that seed, that, you have high risk areas. While you might not have psoriatic arthritis right now, the fact that you have scalp psoriasis puts you at like a four times greater risk of having psoriatic arthritis in the future.⁸ So I cannot put all my chips on the table or cards on the table.

Shawn Kwatra: Yeah, that’s great. So Michael, what is the benefit of treating patients with multiple of these special areas with systemic?

Michael Lewitt: So, I don’t like to neglect as Saakshi was saying, the standard plaques psoriasis here is elbows and knees.⁹ It’s all important and how psoriasis bothers somebody versus another patient. But I think to myself, if I had psoriasis, I do not. What are some of the places I would absolutely not want to have it? It would be areas I couldn’t hide, areas that affected my ability to do the things I love, athletics, areas it would affect intimacy. And these are the questions that we have to ask our patients and really ask about their overall impact. And some of the topicals in the areas that we’ve discussed, like genitals, it can be a burden having to use different topicals in different areas or dealing with their own adverse events.^6,7 Also, as we mentioned, a couple modules ago, it takes the vehicular or the vehicle within which a topical is suspended, it can be a challenge for different body surface areas, different skin types, Fitzpatrick and otherwise.^10,11 And then the other thing we have to think about as providers is confusing our patients in a lot of topicals, we end up doing polypharmacy, multiple different medications that are subsequently mixed up or used inappropriately.¹²

Shawn Kwatra: Absolutely. So Saakshi, how do you approach assessing whether a topical is no longer working for your patients?

Saakshi Khattri: Well, we have sort of this yardstick or parameter that the NPF placed in front of us with regards to treat to target, the goal being 1% body surface area at the 3-month mark, whenever a new treatment, whether it’s systemic or topical is initiated.¹³ So I kind of follow that. But then again, from a patient’s perspective, I’m sure our patients want to be all clear. One percent or one handprint, patient’s handprint, is still, for some patients could be a significant disease burden. So I always take into account, what is my patient’s treatment goal? Does that align with the goal that we’ve been taught as dermatologists to go for, which is 1%.¹³ But if my patient wants it to be all clear, and what they’re on right now, that it’s a combination of topicals, if it’s not working, then I do discuss with them, what can we do to help them reach that goal that they want.

Shawn Kwatra: Absolutely. And so Saakshi, do you consider the risk of psoriatic arthritis when making treatment decisions, even in patients with mild psoriasis? So what do you look for in a treatment after topicals? And how do you approach patient preferences when you’re selecting a treatment?

Saakshi Khattri: So I will say that, when I have my psoriasis patients that have moderate to severe plaque psoriasis, I always consider one that also has an approval for psoriatic arthritis. But then that’s an easy patient to manage because they’re already at that cusp with regards to body surface area of enrollment that warrants systemic treatment. I always tell my mild psoriasis patients that they are the harder ones for me to treat, just because psoriatic arthritis diagnosis is just such a hard diagnosis to make. And again, it comes down to at that point in time when they come to see me, am I able to find a swollen joint or a tender joint? Or have they come to see me on a good day, when I find nothing on an exam? But then still, I am not at that point 100% sure whether they have or they don’t have psoriatic arthritis. So I always have this discussion where I’m like, we could start off with topicals, because you do have limited body surface area of involvement. But then, if you start feeling joint symptoms, and come back and see me sooner, because I would want to do a more formal evaluation at that point to determine whether you have psoriatic arthritis or not. And if at that follow up I’m able to determine that they have psoriatic arthritis then the transition to a systemic therapy is an easy switch to make.

Shawn Kwatra: That’s a great point. So Michael, when you see these patients, and you’re picking between therapeutics, is mentioning to the patient that this is a therapeutic that’s approved for your plaque psoriasis but it’s also approved for psoriatic arthritis, something that comes up?

Michael Lewitt: Absolutely. And I’d like to set it from the very beginning without scaring people; you don’t want to give, folks the most aggressive systemic, obviously, you see any TV commercial, and they list across all disease states that, in paradigms of medicine they list everything that could happen. But I’d like to bring it on saying, and there’s a lot of comfort and patience, knowing hey, especially someone that’s had psoriasis for a long time, they’ve comforted that topical. And then, going back, I’m going to ride the coattails of my other 2 panelists here, the NPF and IPC, they give us these treatment goals. And I like to tell a patient, I know you think you’re good, but I can do better by you. And sometimes just saying and knowing that you’re confident in doing that, that helps the discussion move along a lot more smoothly in the patient room.

Shawn Kwatra: Absolutely. So Michael, when do you consider moving from a topical to a systemic treatment? And also, what are the factors that are driving this type of a decision?

Michael Lewitt: That’s a great question. When would I consider moving from a topical to a systemic treatment? And what are some of the things that drive that choice? Well, first and foremost, topicals do work for some people and they still play a pivotal role in treating psoriasis. But some of the reasons that I might blend in or add or replace with a systemic agent would be one, a patient’s not at goal, whether that’s my goal, their goal, or the NPF’s treat to target goal. Two, if the patient’s frustrated, the topicals have become a burden to them. They’re using multiple topicals in different places while they’re trying to get ready in the morning or get ready to go to bed. That’s when I’m really starting to consider moving away from monotherapy as a topical.

Shawn Kwatra: Absolutely. So, let’s go to a different topic, so Saakshi, how often do patients get referred in particular to you? And have you noted that they are being undertreated because the patient isn’t adhering?

Saakshi Khattri: Right, so I'm in an academic institution, so I kind of get two types of referrals. The first ones are from dermatologists in the community. They have a patient that has plaque psoriasis and they might be on just a topical, or they might be on something systemic, and then they start complaining of joint pains. Michael, my wait times are not 6 months. I wish I was that popular to have a wait time of 6 months.

Shawn Kwatra: Then I'm going to start referring all my patients to you.

Saakshi Khattri: Anyway. So it's like when I have that referral come to place yes. I put my rheum sort of thinking hat on, and then it's more of like, do you have PsA at that point or not? And what can we do if I suspect that you have PsA, what can we switch you to? The other referral is within my derm department where they are again, my derm colleagues are pretty comfortable treating a patient that they suspect or has psoriatic arthritis with systemic agents. But then if, as you, Michael, pointed out a few modules ago, that I put them on a systemic for their psoriatic arthritis, if they're not responding or if they have an inadequate response, then I'll send them to a rheumatologist. So that's the other way. I get patients from my derm colleagues within my academic institution where they're on a systemic, they have a diagnosis of psoriatic arthritis, and maybe their systemic is either not working for them from get go or if they've had a secondary loss of response.

Shawn Kwatra: We talked about the long wait time to see a rheumatologist, but there are also very long wait times to see dermatologists. So Saakshi, do you have any thoughts about what a primary care provider could do? For example, they're in an area where there is especially a long wait time to see a dermatologist, which is most areas.

Saakshi Khattri: So as an internist, I will say that primary care providers are really, for the most part, the first point of contact that a patient has with the healthcare system. And then as you pointed out, if they are in an area where there is a long wait time to get to a dermatologist and if that primary care provider doesn't have a dermatologist on speed dial like we are, fortunate to have them or rheum colleagues on speed dial and or if they're in a rural setting where there isn't a dermatologist or the closest dermatologist is like a 6-hour drive, then I think if the primary care is comfortable making a diagnosis of plaque psoriasis. Is comfortable with treating plaque psoriasis, then they should be more proactive in treating our patients with the idea that eventually they can go and see a dermatologist or get plugged in to see a dermatologist. And I think as physicians, as physicians, our first goal is to help our patients. Now, whether it's a primary care provider that's helping or a dermatologist that's helping, or a rheumatologist that's helping, somebody needs to help our patients. And that's our primary goal in life as physicians.

Shawn Kwatra: Absolutely. And I think we have to give a lot of respect to primary care providers because they treat so many different conditions. So for the provider that feels comfortable I know my own father in law is a primary care provider, and he called me and he said, hey, I can't believe it. Dermatology—10-month wait for those docs who feel comfortable. I think it's entirely reasonable that they can initiate therapy.

Shawn Kwatra: Absolutely. Well, thank you so much to both of you. This is a wonderful session. And thank you to everyone for tuning in.

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