Closing the gap between possibilities and reality in psoriasis management

Abstract

Psoriasis treatment has evolved tremendously during the last few decades. I remember, as a resident dermatologist during the mid-1990s, we treated most of our severe psoriasis patients by rotating low-to-medium efficacy therapies: topical treatments (salicylic acid, corticosteroids, dithranol) phototherapy, acitretin and less frequently cyclosporine or methotrexate. Many patients regularly spent weeks in the hospital, and treatment success was usually partial and temporary, lasting for only a few months. The introduction of first-generation biologics marked a significant shift in the management of psoriasis. Methotrexate, which was used as the comparator in clinical trials, became the standard non-biological treatment, and patients began to experience longer more complete remissions. During the last decade, several novel biologics entered the psoriasis field, which showed clear superiority over both conventional and previous-generation biologics. Some biologics have been registered even as first-line treatments, theoretically enabling the early introduction of highly effective therapy. These advancements have led to more ambitious treatment goals by both doctors and patients. Today, even a cure—that is long-term remission off-treatment—seems scientifically realistic.¹

Notwithstanding these groundbreaking achievements, dermatologists still face considerable challenges in providing optimal care for psoriasis patients. With expanding indications, exponentially growing patient populations and sky-rocketing medication prices, health funders around the world are struggling to fit therapeutic options into sustainable financing schemes.

The article by Speeckaert et al.² in this issue of the Journal attempts to elucidate whether and how the integration of novel developments in psoriasis management (such as redefined disease severity or treatment goals, newer biologics or biosimilars, personalized dosing or telemedicine) could lead to (more) sustainable psoriasis care. The authors employ a quasi-Delphi methodology and relate their research to the Belgian psoriasis management environment as an example. They conclude that several factors may contribute to better and still sustainable psoriasis management, such as the implementation of a treat-to-target approach, the use of minimal disease activity (defined as PASI90 or PGA ≤ 1; itch VAS ≤ 10 mm; absence of disturbing lesions; no moderate-to-severe adverse events; DLQI ≤ 1; full tolerability; incapacity in daily functioning VAS score ≤ 1) as optimal therapeutic objective, or the use of teleconsultations for patient follow-up.

The authors also offer a critique of the current Belgian reimbursement criteria, which mandate the utilization of three conventional antipsoriatic therapies (phototherapy, methotrexate and cyclosporine) prior to the administration of biologics. They propose that only phototherapy and one conventional therapy should be necessary before the administration of biologics. In some countries (including Hungary), access to first-line biologics is restricted to ‘older’ drugs (TNF inhibitors and ustekinumab), in addition to a requirement for prior conventional therapy. In light of recent evidence regarding the potential long-term benefits (disease modification) of early aggressive/highly effective therapy, these restrictions seem counterproductive and unnecessarily extend the patients' journey before ideal long-term treatment can be introduced.

Overall, while the article provides practical guidance and tips for balancing costs versus patient outcomes in the rapidly evolving psoriasis field, many of the authors' recommendations could not be easily extrapolated to other European countries. A significant degree of country-related heterogeneity can be observed in relation to the requirements for administering biologics including disease severity, policies concerning biosimilars, switching between biologics, or individualized dosing. The European dermatology community should make further efforts to provide a scientifically justified framework for the harmonization of treatment standards and outcomes for psoriasis in the EU. Without this, we will not be able to provide the best sustainable care for our patients, even though we now have the medicines needed to successfully treat psoriasis.

R.G. is on the advisory board or has received honoraria from AbbVie, Amgen, Beiersdorf, Bristol-Myers-Squibb, Eli-Lilly, Janssen, LEO Pharma, MSD, Novartis, Roche, Sanofi Genzyme and received travel support from AbbVie, Bristol-Myers-Squibb, Janssen, Novartis and Sanofi Genzyme.