Diagnosis and treatment of psoriasis are suboptimal, despite a substantial body of research into the condition and an increasing number of effective and safe systemic therapies.1 The toll taken by undertreatment is serious and must be addressed, according to a recent article by Gottleib et al that analyzes practice gaps in psoriasis management1. The authors emphasize the importance of designing an individualized treatment regimen, based on disease severity, impact on QOL, and previous responses or contraindications to psoriatic therapies.
Treatment guidelines emphasize that topical monotherapy should be used only in the setting of localized disease.2,3 Widespread cutaneous lesions, severe involvement of the palmoplantar surfaces, genitalia, scalp or nails, and psoriatic arthritis require systemic therapies. Biologic agents are the “gold standard for systemic treatment of psoriasis and psoriatic arthritis” because they provide “more rapid and complete control of disease signs and symptoms and a more favorable side effect profile” than do earlier agents, such as methotrexate.1
Gaps and Barriers
A significant number of practitioners rely on stand-alone topical therapy, thereby depriving patients of the cardioprotective effects of currently available systemic therapies. Barriers to appropriate prescription of systemic therapies include lack of confidence in prescribing them, the cumbersome process of obtaining preauthorization from insurance companies and pharmacies, economic disincentives, cost, and tiering.
Recommendations for Improvement
- Physicians should receive additional training in the selection of psoriasis treatments
- Disincentives designed to deter prescription of systemic therapies should be limited.
- Medical practice models should integrate dermatologists, primary care physicians, physician assistants and nurse practitioners into psoriasis management.
- Clinically practical, patient-centered treatment outcome measures to assess psoriasis clearance and comorbidities should be developed.
Cardiovascular Risk Factor Screening
Patients with psoriasis, especially those with severe disease or psoriatic arthritis, have a higher prevalence of CV risk factors, including hypertension, diabetes, obesity, dyslipidemia, and insulin resistance.1 These increase the risk for coronary artery disease, myocardial infarction, stroke, and cardiovascular (CV)-related death. The proinflammatory cascade responsible for psoriasis may have a systemic effect leading to increased risk of cardiovascular disease (CVD). Treatment with anti-TNF agents and other systemic therapies reduce the inflammatory burden as well as the risk of CVD.1 The National Psoriasis Foundation recommends screening psoriatic patients for CV risk factors beginning at 20 years old.4