An expert's perspective on treatment failure
A conversation with Jeffrey J. Crowley, M.D.
From November/December 2007 Psoriasis Advance
Jeffrey Crowley, M.D. |
People with psoriasis know the heady feelings of happiness when their skin clears up following a successful treatment—but they also know heartbreaking disappointment when their treatment fails and psoriasis returns. Coping with these emotional extremes can be a bumpy ride.
Jeffrey Crowley, M.D., a board-certified dermatologist in Bakersfield, Calif., discusses treatment failure and how patients can best cope when their treatment loses effectiveness.
How common is it for patients with moderate to severe psoriasis to experience treatment failure and flare following a period of successful treatment?
Many treatments will improve and even clear psoriasis for months and sometimes years. Unfortunately, some patients will have their psoriasis return or flare. Some return of psoriasis, while frustrating, is very common, and often topical medications can bring improvement. A
flare of psoriasis while on a previously successful treatment is less common and certainly can be devastating.
Psoriasis flares while on treatment may be due to
a number of reasons including infections, other
illnesses and emotional stress. Additionally, in
some patients, the psoriasis may have found a
way to "bypass" the current treatment that was
previously so successful. We do not know why this
happens, but it is part of the complex nature of
psoriasis and the body's immune system. Do not
despair if your psoriasis flares on one treatment, as
it will likely respond to another type of treatment.
Do certain classes of drugs or treatments tend
to stop working over time, or do all treatments
eventually become less effective?
A return of psoriasis, after a period of control, can happen with all treatments. Methotrexate and cyclosporine-A can both lose effectiveness
over time. In my experience, the anti-TNF drugs
can have some loss of effect over time. I have
seen this happen in patients within a few months
on Remicade (infliximab), six to 12 months
with Humira (adalimumab), and with Enbrel
(etanercept) it may be seen after one or two
years. The T-cell drugs may also lose effect over
time. I have seen Raptiva (efalizumab) patients
occasionally suffer a flare of psoriasis while on
therapy, which may require treatment with
another medication and/or discontinuation of
the drug. Amevive (alefacept) is also susceptible
to loss of efficacy. Some of my patients who have
done well with one 12-week course of Amevive
have not responded as well to a later course. Even
phototherapy may lose effect. The bottom line
is, all therapies, no matter how successful at first,
sometimes stop working.
What factors can cause a treatment to stop
working?
By far the most common reason I see is that the
patient misses doses or stops treatment altogether.
However, even the most dedicated patient
may find that a treatment loses effectiveness.
Scientifically, we do not know exactly why this
happens. With the biologics, this may involve the
body making "antibodies" to the medication, or
the body "chewing up" the medication shortly
after it is given. With the complexity of the
immune system, the inflammatory cells involved
in psoriasis may simply find another way to cause
psoriasis.
What steps should patients take if their treatment
fails? At what point should they see a doctor about
it?
I consider treatment failure to be the point where
the patient is no longer satisfied with the current
treatment. If you are not happy with how your
psoriasis is doing while on a given treatment, you
should see your doctor and discuss other options.
Some of my patients become frustrated and even
angry when a treatment fails. Sometimes they
will stop treatment altogether. Unfortunately, this
often makes the psoriasis worse and that usually
just makes them feel depressed. Psoriasis patients
have more treatment options today than ever
before and will have even better and safer treatments
within the next couple of years.
Is it realistic for psoriasis patients to expect total
clearance of their psoriasis?
Given some of the newer treatments, some
patients will experience complete clearance of
their psoriasis, but most will not. Even when
psoriasis symptoms clear, the disease is still in
the body. For most, the psoriasis will return to
some extent even after a period of clearance. I
tell patients that they will most likely experience
a significant improvement—less scaling, fewer
plaques, less itch and less joint pain in cases
of psoriatic arthritis. I do not tell my patients
that they are likely to be completely clear. I also
remind them that, to date, we have no cure for
psoriasis and that we are in this for the long run.
Patients say it can be emotionally devastating to
have a treatment work and then suddenly stop,
leaving them in a rebound. What advice can you
give them to cope with going from one extreme to
another?
Even with recent breakthroughs in psoriasis
treatment, the disease can continue to frustrate.
Some patients do not respond as well to treatment
as others. There is always a small possibility of
a flare on treatment. More common though,
is a treatment that slowly stops working.
Communicate your concerns with your doctor.
Make sure your doctor knows what treatment
results you want to achieve. Your psoriasis
treatment team includes your family, friends,
doctors, nurses, the National Psoriasis Foundation
and, of course, you. You need to have your team
on your side when dealing with the flares and
breakthroughs that you may experience with
psoriasis.
To connect with others who may be experiencing ups
and downs in their psoriasis treatment, go to
www.psoriasis.org/forum.
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