Learning From the Experts Webinar

Learn from the experts and let them learn from you through these webinars on critical topics regarding psoriatic disease.

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Learning From the Experts

Presented by
Joseph Merola, MD, MMSc
Associate Professor, Department of Dermatology,
Harvard Medical School
Vice Chair of Clinical Trials and Innovation,
Brigham and Women's Hospital

In this webinar, Dr. Joseph Merola, will present disease state education for mild to moderate psoriasis. Dr. Merola will explore key topics in patient burden and unmet need with a focus on the systemic nature of the disease, levels of severity, and the impact of special areas.

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Video Transcript

Learning From the Experts

Welcome to the first Learning From the Experts webinar! I’m Dr. Joseph Merola, an Associate Professor in the Department of Dermatology at Harvard Medical School, and Vice Chair of Clinical Trials and Innovation at Brigham and Women’s Hospital.

Today, I want to talk with you about some common misconceptions, or myths, surrounding mild to moderate psoriasis. We will go over three myths one by one, and debunk them with current evidence.

Let’s get started with myth number 1: Psoriasis is a skin-limited disease.

In actuality, we have learned that psoriasis has effects beyond the skin, so let’s take a look at the supporting evidence that debunks this common misperception.^1,2

While it is true that psoriasis often presents with well-demarcated red plaques with silvery scales on the skin, there is much more going on beneath the surface.^1-3

Psoriasis isn’t a skin-limited disease; it’s a systemic disease.1,2,4 Psoriasis is the result of a sustained, proinflammatory response that is regulated by a complex signaling pathway.^3,5,6

At the cellular level, this signaling pathway involves the dysregulation of dendritic cells, the activation of T cells, and the production of proinflammatory cytokines, which are released into the circulatory system, leading to a sustained, systemic inflammatory response.^3,5–7

Keratinocyte hyperproliferation, which presents as skin plaques, is only one result of this systemic inflammation.1,3

Patients with this systemic, inflammatory disease can present with many comorbidities, including psoriatic arthritis.2,8 In fact, psoriatic inflammation causes psoriatic arthritis in roughly 30% of people with psoriasis.² The risk of psoriatic arthritis is three times higher for patients with nail involvement, and four times higher for patients with scalp involvement.⁹

Before moving to the next myth, let’s review what we discussed in this section.

Psoriasis is indeed a systemic disease, which may have significant impacts beyond the skin. Due to the systemic mechanism of disease, which involves a complex signaling cascade, patients with psoriasis are at increased risk of developing many comorbidities, including psoriatic arthritis.^2,3,5–6,9

On to myth number 2: Body surface area, or BSA, is sufficient to understand the severity of psoriasis and the disease burden.

Consider how you determine the severity of your patients’ psoriasis in your own clinical practice.

BSA alone is not sufficient to determine psoriasis severity.10 A recent study revealed that the classification of psoriasis severity by commonly used conventional clinical measures can be incongruous with patients’ perception of their disease severity.¹¹

In the US subpopulation in the UPLIFT survey, 56.2% of patients with mild skin involvement considered their disease to be moderate or severe, and 52.2% of patients with moderate skin involvement perceived their disease to be severe.¹¹

What could be the reason for this misalignment?

This disconnect may be because of the inability of conventional clinical measures to capture certain key factors that contribute to disease severity.^1,2,12

BSA is one of the most commonly used clinical scales to evaluate whether a patient has mild or moderate psoriasis; however, it only takes the area of affected skin into consideration, and it overlooks important factors, such as severity of lesions, differential impact of special areas and symptoms such as itch, and patient perspectives.^12,13

Other commonly used clinical measures, such as the PASI, or Psoriasis Area and Severity Index, and sPGA, or static Physician’s Global Assessment of severity, do not reflect the full patient experience either.^14,15

So, what do we need to do to capture a more complete picture of disease severity? And, are factors that are not captured by conventional clinical measures important to patients?

When we look beyond BSA, we recognize that from a patient’s perspective, factors beyond skin involvement are often considered the most important factors contributing to psoriasis severity.¹⁶

For example, the 2020 UPLIFT survey revealed differences between patient and dermatologist perspectives on the burden and treatment of psoriasis. Patients ranked the type of symptoms, disease duration, and lesion location as the top three contributors to severity, whereas dermatologists ranked overall impact on patients, amount of BSA involvement, and type of symptoms as the top three contributors to disease severity.16

When taking patient perspectives of severity into account, it becomes clear that clinically evaluated measures such as BSA, PASI, or sPGA are not sufficient to determine psoriasis severity.^1,14–16

In addition to misalignment about factors contributing to disease severity, there can be misalignment between patients and providers in treatment goals.¹⁶

Patients often ranked goals other than skin clearance as important. For example, patients ranked reducing itching as their top treatment goal, followed by keeping symptoms controlled and total skin clearance.16 In contrast, dermatologists rated reducing itching seventh.17 Dermatologists ranked improving overall impact on patients as the top treatment goal, followed by near-total skin clearance and keeping symptoms controlled.¹⁶

The UPLIFT survey further highlighted the importance of patient perspective. It found that most dermatologists thought their treatment goals were aligned. But in actuality, there were some large differences.¹⁶

Let’s review what we discussed in this section. BSA alone is not sufficient to understand the severity of psoriasis and the disease burden because it only accounts for the percentage of affected skin area. In addition to BSA, it is important to consider the impact of bothersome symptoms such as itch, as well as patient perspectives on disease severity and treatment goals.^1,2,16

And the final myth we will debunk today:

Psoriasis has a minimal burden on patients who have mild to moderate skin involvement.

Consider whether your patients with mild to moderate skin involvement feel that their psoriasis is burdensome. What do you think?

Psoriasis can have a large impact on patients, even for patients with mild to moderate skin involvement.^13,16 As we mentioned earlier, there are key factors that may impact patient burden.^10,18 Let’s talk about the special areas first.

Psoriasis may feel severe when it impacts certain body regions, called special areas.^1,2,10,19 The International Psoriasis Council defines special areas as the face, palms, soles, genitals, scalp, or nails.¹⁰

These special areas may be impacted even in patients with mild or moderate skin involvement. A subanalysis of US patients in the UPLIFT survey found that among patients with BSA ≤ 3 palms, 48.3% of patients reported scalp psoriasis and 19.0% reported nail psoriasis.¹¹ Among patients with BSA of 4–10 palms, 52.6% reported scalp psoriasis and 25.5% reported nail psoriasis.¹¹

Let’s explore how special areas may impact patients’ daily lives, even for patients with mild and moderate skin involvement.1,2,10

Scalp is one of the most commonly impacted areas, and is often considered difficult to treat.^20–22 Scalp involvement may cause itching, bleeding, and flaking. Patients with scalp itch may get visible skin flakes on their clothing, which can cause them to change the color or type of clothing they wear to avoid social discomfort.^20,21

Next, let’s take a look at the challenges associated with psoriasis involvement in the nails. Symptoms that present on the nails can make it difficult for patients to complete daily tasks that require the use of their hands. These tasks may include getting dressed, tying shoelaces, or using keys.²³ Nail psoriasis is also highly visible and difficult to conceal since the hands are central to many daily activities, which places a significant burden on patients.²³

As with other special areas, the overall impact of psoriasis on patients is exacerbated by nail involvement.²³ It’s important to remember to ask your patients how special areas affect their lives in order to develop psoriasis management goals.¹

Similar to special areas, there are also symptoms, such as itch, which can have a disproportionally large impact on patients.^10,18 Psoriasis-associated itch causes patients to be more affected by their disease than those not experiencing itch.¹⁸

In the UPLIFT survey, 93% of patients with psoriasis symptoms reported experiencing itch.¹⁶

Psoriatic itch can vary between mild to severe. For example, in a United States-based study, among patients with mild psoriasis severity, 54.6% reported experiencing mild itch, and 6.4% reported experiencing moderate to severe itch. Among patients with moderate psoriasis severity, 30.0% reported mild itch and 54.6% reported experiencing moderate to severe itch.¹⁸

Let’s review what we discussed in this section. Psoriasis can have a significant impact on patients, even if they have minimal skin involvement. Involvement in special areas, such as scalp or nails, and bothersome symptoms, such as itch, can increase perceived disease severity and the burden of disease for patients with psoriasis.^10,18

Today, we debunked three myths which may lead to suboptimal management of patients with psoriasis, particularly if they have mild to moderate skin involvement. We discussed that psoriatic inflammation is more than skin deep. We also discussed how the extent of skin involvement alone may not fully reflect the burden of psoriasis, which can be substantial even in patients with mild to moderate psoriatic disease.

Therefore, when managing patients with psoriasis, we should remember to consider the systemic nature of the disease, and look beyond conventional clinical measures to ensure we are fully addressing the needs of our patients.

Thank you for tuning in and watching the first webinar in the Learning From the Experts series.

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What Topics Would You Like to Learn About in a Future
Learning From the Experts Event?