'Team-based' derm-rheum approach yields optimal outcomes in psoriatic disease
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Joint care by a dermatologist, rheumatologist and other specialists can mitigate the “accelerated trajectory of comorbidities” that can often happen in patients with psoriatic disease, according to a presenter at ACR 2020.
“Having a team-based approach can hopefully optimize outcomes,” Joel Gelfand, MD, MS, vice chair of clinical research, medical director of the dermatology clinical studies unit and director of the psoriasis and phototherapy treatment center at the University of Pennsylvania Perelman School of Medicine, told attendees.
“Comorbidities are well established with psoriasis now, emphasizing the point for multidisciplinary care,” Gelfand said. Cardiovascular disease is prevalent, along with metabolic and mood disorders, Crohn’s disease and even T-cell lymphoma of the skin, in rare cases. “These issues are evolving and need to be explored in our patients.”
While tackling all of these issues can seem overwhelming, Gelfand offered a starting point: the amount of body surface area of skin affected by psoriasis can indicate the likelihood of comorbid conditions. “BSA has important prognostic implications,” particularly for mortality, he said.
After BSA has been established, Gelfand performs a detailed physical examination and medical history of the patient that includes documentation of symptoms, prior therapies used and response to those therapies, natural history of the disease, cancer incidence, smoking status and presence or absence of IBD or other inflammatory events. “I try to encourage patients to be up to date on vaccinations, and, of course, quit smoking,” he said.
An exhaustive cutaneous examination should include particular focus on the scalp and a search for “subtle” disease in the genitals and the pits of the nails, where psoriasis can hide, according to Gelfand. These are areas that “do not respond well to topicals,” he said. “We must consider treating these patients with systemic agents. That is what we in dermatology are here for, to establish a clinical diagnosis.”
Once a diagnosis has been made, clinicians have a cross-section of oral medications and four classes of biologic therapies from which to choose in order to help patients meet their goals.
“What I want to make sure you understand is how we in dermatology think about outcomes,” Gelfand said. “PASI90 is considered to be the gold standard. Skin clearance matters. We are trying to get their skin to be as close to clear as possible.”
Gelfand stressed that the choice of therapy is critical to achieving skin clearance, noting that interleukin-17 and IL-23 inhibitors are preferable to TNF inhibitors. “Guselkumab (Tremfya, Abbvie) and risankizumab (Skyrizi, Abbvie) are more effective,” he said.
In addition, bimekizumab (UCB) has demonstrated a “pretty remarkable level of efficacy,” often reaching PASI90 scores of 85%.
“Generally, IL-17 inhibitors have the fastest onset,” Gelfand said. “IL-23 inhibitors have the best persistence.”
Turning to the co-management aspect of patient care, Gelfand said patients “really enjoy” the use of derm-rheum clinics, but he underscored the difficulties of making this a reality. “It takes a fair amount of administrative work behind the scenes to make this happen,” he said.
Flexibility is critical to making joint patient care work, according to Gelfand. “Combined clinics occur in many different ways,” he said, noting that it can be done virtually, in person, or via other forms of communication.
While it is critical to determine which clinician should run point for care of any given patient, Gelfand suggested that this decision is often fairly straightforward. “Whatever the dominant system is involved, that is who is going to be in charge,” he said.
“If a patient has both bad skin disease and joint damage, we work it out on a case-by-case basis,” he said. “Communication is key, but this is how we get valuable outcomes for our patients.”
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Gelfand JM. Dermatologists and Rheumatologists Co-Managing Psoriatic Arthritis. Presented at: ACR Convergence 2020; November 5-9, 2020 (virtual meeting).
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