Dr. Merola spoke next to the importance of a thorough skin examination by the rheumatologist. “We often say that about 80% of patients with PsA present with skin before joint disease, and about 10 to 15% present with joints first before the onset of cutaneous psoriasis. I think that’s probably an overestimate.
“If we had the patient undressed and really went looking, we might find psoriasis in other locations, especially intertriginous/body fold areas.” ‘Inverse’ or intertriginous psoriasis may be found in the axilla, inframammary region, inguinal folds, intergluteal cleft, abdominal folds; it is also important to examine the nails.
“Inverse psoriasis is not uncommon. Up to 23% in our published series of almost 4,000 patients had inverse disease. And inverse psoriasis is one of the phenotypic subsets that increases the risk of developing PsA,” he continued.2,3
Divergent Skin & Joint Disease
“Remember, we can really only optimize a patient’s quality of life by optimizing both their skin and joint disease,” Dr. Merola said. If the joints are responding well to treatment but residual skin disease remains, depending on the severity, options include adding topicals, adding apremilast or switching biologic therapy to another that better targets skin lesions.
Adding topicals is a good choice for many with mild or moderate residual disease when the joint disease is otherwise well controlled, but glucocorticoid topicals have downsides. All come with the risk of skin atrophy, and different prescriptions for different areas of the body confuse patients and prescribers alike.
But Dr. Merola had some great news to share: “We now have two recently FDA-approved non-steroid topicals that don’t cause skin atrophy and can be used on skin anywhere, just once a day. Roflumilast cream is a once-daily topical phosphodiesterase-4 inhibitor (PDE4i) that also works particularly well in the intertriginous areas from recent data. Tapinarof cream is a once-daily aryl hydrocarbon receptor agonist that has also shown promising results.”4,5
Dr. Merola reminded us to familiarize ourselves with the primary data in psoriasis studies where robust head-to-head data are available; not just those from PsA trials. He elaborated, “A well-done, recent network meta-analysis showed that interleukin-23 inhibitors (IL-23i) and IL-17i worked best in terms Psoriasis Area Severity Index-75 (PASI-75) and even PASI-100 (100% clear skin); these are some of our highest efficacy agents.”6
He drew attention to a new TYK-2 inhibitor, deucravacitinib, as an oral option. It has demonstrated superior efficacy and tolerability to apremilast in clinical trials for psoriasis.
