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

Findings from a network meta-analysis published in JAMA Dermatology by Armstrong et al. in February 2020 had similar findings, with anti-IL-17 and anti-IL-23 therapies clearing skin most effectively and PASI 90 rates around 70%.⁷ The PASI 90 rate for TNF inhibitors and anti-IL-12/23 (ustekinumab) ranged from 17.9 to 43.9%.

Dr. Evans acknowledges the limitations of data like these, noting that “head-to-head blinded trials remain our best tool for understanding relative efficacy in psoriasis, but these are unfortunately expensive and difficult.” However, he does agree that “database analyses can certainly be useful tools, and these seem to confirm the common belief among dermatologists that IL-17 and IL-23 agents are the most broadly effective for the skin.”

He continues to stress that, “this being said, the treatment of psoriasis is highly individualized based on patient factors, including common comorbidities like PsA, inflammatory bowel disease and coronary artery disease.”

As for TNF inhibitors, Dr. Evans does think there is a continued role for them in the treatment of psoriasis, saying, “They remain good choices in patients with substantial PsA and are often required by payers as part of a step therapy scheme. They also continue to be used for other indications; for example, adalimumab for hidradenitis suppurativa, or off-label for cutaneous sarcoid and granuloma annulare.”

The Dermatologist’s Ideal Rheumatologist

What does Dr. Evans hope for in a co-managing rheumatologist? “Good communication is key when collaborating in the care of a psoriasis patient,” he says. “I generally prefer for one physician to be the ‘quarterback,’ usually based on whether the skin or the joints are the more pressing issue for that specific patient. If the joints are more severe, I generally prefer the rheumatologist manage the biologics and orals, while I can add topical or ultraviolet therapies as adjuncts.”

A Paradox of Choice?

In 2021, multiple guidelines, multiple drugs and multiple specialists may indeed create a paradox of choice; however, the many choices we now have for the treatment of psoriasis and PsA allow for a bespoke style of care, tailored to the individual patient. The armamentarium of bDMARDs in psoriasis and PsA exemplifies when more is more.

So call the co-managing dermatologist, embrace the guideline gray area, and personalize drug selection to the patient sitting in front of you. Their skin and joints

will thank you.

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Samantha C. Shapiro, MD, is an academic rheumatologist and an affiliate faculty member of the Dell Medical School at the University of Texas at Austin. She received her training in internal medicine and rheumatology at Johns Hopkins University, Baltimore. She is also a member of the ACR Insurance Subcommittee.