Biologics can provide clear – or almost clear skin – with few side effects in more than half of those who take them, according to experts and data from numerous studies. But too many patients with moderate to severe psoriasis are receiving only topical therapy or no treatment at all.
Cost and issues with insurance coverage remain barriers to appropriate treatment (though many drug companies offer patient assistance programs that partially or completely cover medication costs for those patients with commercial insurance). And some dermatologists are reluctant to prescribe systemic medications, says Alice Gottlieb, M.D., Ph.D., professor of dermatology at New York Medical College at Metropolitan Hospital in New York City and member of NPF’s medical board.
The reasons, she says, include unfamiliarity with systemic therapies, which include biologics, concerns about side effects, and an incomplete understanding of the effects of psoriasis and psoriatic arthritis (PsA) on overall health and quality of life.
Under-treatment is overwhelming
In the U.S., just 20 percent of dermatologists prescribe 80 percent of the biologics for psoriasis, notes George Martin, M.D., who is in private practice at Dr. George Martin Dermatology Associates in Kihei, Hawaii, and sits on NPF’s medical board.
“Another issue is that up to 40 percent of people with psoriatic arthritis are undiagnosed by dermatology practices. Many clinicians in dermatology are failing to ask critical questions about its symptoms, including joint pain, unexplained swelling of the fingers or toes, decreased range of motion, chronic low back pain or unexplained fatigue,” he says. “This means these patients aren’t being referred to rheumatologists, though we know that early and appropriate treatment is needed to prevent irreversible joint destruction.”
Gottlieb, who is triple-boarded in dermatology, rheumatology and internal medicine, says patients are often misinformed about both the risks and benefits of systemic therapies.
“Many patients who come to me with moderate to severe psoriasis have been told something like, ‘You don’t want these dangerous biologics because psoriasis won’t kill you.’ Both parts of that statement are false,” she says. “Biologics are remarkably safe – their benefit-to-risk ratio is the best of any of our therapies for psoriasis – and the data show having that moderate to severe psoriasis or psoriatic arthritis are independent risk factors for cardiovascular disease and a host of other conditions.”
Tips for talking to your doctor
If you’re treating your psoriasis or PsA, but don’t like how you look or feel, you may need more aggressive therapy, say Gottlieb and Martin. Their advice starts with having an honest, productive conversation with your physician.
Learn everything you can about the significant, potentially life-threatening health issues linked to psoriasis and PsA, as well the benefits of systemic therapies. Treating PsA early and appropriately can prevent permanent joint damage. Though more research is needed for definitive answers, studies suggest that biologics can lower risks for the cardiac events, like heart attacks, to which people with psoriatic disease are vulnerable.
Raise your expectations.
With a growing list of highly effective systemic medications, Gottlieb says you should expect that, with adequate, appropriate treatment, your psoriasis and PsA will have minimal to no impact on your quality of life.
“The goals of the NPF medical board’s Treat to Target strategy are to achieve an affected body surface area of less than 1 percent within three months of starting treatment,” Martin says. “If you’re not there, and you clinician isn’t open to changing treatment, it’s time to seek another opinion.”
Explain why you’re unhappy with your current treatment.
Martin suggests beginning with a statement like, “I’m not happy with how well my treatment is working,” and then offering specific examples of why you’re unsatisfied. For instance, explain that psoriasis gets in the way of your intimate relationships or that PsA is keeping you from playing your favorite sport.
“Sometimes dermatologists see the skin but don’t think beyond it to other quality-of-life-affecting symptoms,” he adds.
Seek that second opinion.
As noted, not all dermatologists are equally comfortable prescribing systemic drugs or providing the complex care people with psoriatic disease often need. Finding the right physician means doing research and asking the right questions.
Gottlieb suggests researching potential dermatologists online to understand their experience treating psoriatic disease as well as the range of therapies they offer. “Review their websites to learn what conditions they treat and how,” she says. “Look up their names on PubMed to see if they’ve published any scholarly papers in the field. Call their office and say something like, ‘I understand there are highly effective systemic therapies for psoriasis. Which ones do you offer?’ ”
Academic medical centers typically have faculty who specialize in psoriatic disease and these experts can provide an informed second opinion, adds Martin.
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