A Dematologist’s Perspective on Choosing an Anti-Psoriatic Drug

We are fortunate to have clinical practice guidelines for the management of psoriasis and psoriatic arthritis (PsA) from multiple organizations to help navigate today’s rapidly evolving therapeutic landscape. We are further fortunate to have multiple specialists to manage these conditions: rheumatologists and dermatologists. However, multiple guidelines, multiple drugs and multiple specialists can create a paradox of choice, with an abundance of options creating anxiety in the chooser.¹ (For an overview of all the options available to treat psoriatic arthritis, see “Psoriatic Arthritis Treatment Update.”)

The goal of treatment in psoriasis is simple: clear skin. In psoriatic arthritis, the goal is no more complicated: clear skin, happy joints. But with so many ways to meet the same goals, where should we start? In this article, we explore how the dermatologist selects a therapy, and how the rheumatologist and dermatologist might best collaborate to achieve the same end.

Clinical Practice Guidelines

In 2018, the American Academy of Dermatology and National Psoriasis Foundation released joint guidelines for the management and treatment of psoriasis with biologic therapies. These guidelines notably did not identify a preferred drug class as firstline therapy.²

The same year, the ACR and the National Psoriasis Foundation released a joint guideline for the treatment of PsA. Tumor necrosis factor (TNF) inhibitors were conditionally recommended as first-line biologic agents for PsA.³

In 2019, EULAR updated its guidelines for the pharmacologic management of PsA. Notably, the initial biologic disease-modifying anti-rheumatic drug (bDMARD) selection recommendation was expanded to include TNF inhibitors and anti-interleukin (IL) 17 or anti-IL-12/23 medications, as opposed to the 2015 guidelines, which endorsed TNF inhibitors for the firstline treatment of PsA.⁴

Guidelines from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in 2015 supported the use of TNF inhibitors, anti-IL-17 or

anti-IL-23 drugs as first-line treatments, depending on the clinical scenario. Updated GRAPPA guidelines are in progress, with anticipated publication in 2021.⁵

Dermatologist Perspective

Although well intentioned, this alphabet soup of guidelines can be overwhelming, as can the laundry list of available therapeutics (see Figure 1). Colby C. Evans, MD, a dermatologist in Austin, Texas, and a board member and former chair of the National Psoriasis Foundation, helps us understand drug selection from the dermatologist’s perspective. He comments on the role of methotrexate, when he adds a biologic, how he selects a biologic and what he is looking for in a co-managing rheumatologist.