Activity Transcript

Philip Helliwell, MD: Hello, I'm Dr Philip Helliwell. I'm a professor of clinical rheumatology at the University of Leeds in the United Kingdom. And I'd like to welcome you to this program entitled, “The Psoriasis to Psoriatic Arthritis Continuum: A Case-Based Discussion.” This is being presented by Medscape in collaboration with GRAPPA, The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.

With me today is Dr Joseph Merola, a dermatologist and rheumatologist in Boston at the Brigham and Women's Hospital, and an associate professor at Harvard Medical School. Also we have Dr Alexis Ogdie, associate professor of medicine and epidemiology at Penn State University. And Wendy Olsder, who is a GRAPPA patient research partner, but more importantly, a doctoral candidate at the Department of Industrial Engineering and Innovation Sciences at Eindhoven University of Technology in the Netherlands. Welcome.

Psoriasis and psoriatic arthritis are systemic inflammatory disorders that can significantly impact a patient's way of life. And they are common, with psoriasis affecting 3% of the population. The impact is not only physical but also emotional and social. And it's important to consider the comorbidities that we see with these conditions. Essentially, psoriasis is not just the skin; it's a systemic inflammatory disease with significant comorbidities. And the other important aspect here is that the treatment landscape has changed dramatically over the last 20 odd years. And it's fast moving, and it's difficult to keep up to date with the changes that have been made. And we are now moving towards a much more personalized medicine approach. Today we're going to discuss some of the common elements of managing and treating patients with psoriasis and psoriatic arthritis, and we'll use 2 cases to illustrate this.

Our first case is a 24-year-old Black male patient, who was recently diagnosed with moderate to severe psoriasis. He's had psoriasis for a long time, but it recently became worse, as we've just heard. He's had previous medications with topicals and intermittent phototherapy, no systemic treatment. When examining this patient, he's overweight with a body mass index (BMI) of 31 kg/m2. He's got typical psoriasis, with psoriatic plaques over his chest, his back and his extremities, particularly elbows and knees, and in his scalp. He's a graduate student, and there's no known family history of psoriasis. He smokes and drinks alcohol socially, not excessively.

If I now turn to our dermatologist on the panel, Dr Merola, how would you assess this patient from a dermatological point of view when he comes to see you?

Joseph F. Merola, MD, MMSc: It's a great question, Philip. I might start with the traditional comment, and then I'll bring us a bit up to date. I think a little more historically we would've gone by, for example, a body surface area (BSA) measurement to make the assessment of severity. Is this more mild, moderate, or severe disease, with traditional cutoffs being less than 3% being mild, 3% to 10% or so being moderate, above 10% being severe -- where a patient's hand print is about 1% or so of their BSA. But I think the discussion has really shifted of recent, and our ideas about disease severity have really moved to include much more nuance about impact on quality of life, about areas of what we call areas of special interest, in terms of also impact. Is this a small BSA, but it's involving his face, or his palms and soles, or genital skin, or somewhere that really would be potentially more impactful on the patient.

I think at this point it would be a conversation very much about how much this psoriasis is bothering him. And then, of course -- we can unpack this later -- but it sounds like he's used topicals, he's used light therapy. While effective, I will also say often for our patients, they become a bit frustrated that they've had to use topicals for so long. They may find them messy, greasy. They may find them a little bit inconvenient given the frequency with which they have to use said topicals, for example. I think we'll hear a little bit more, but it certainly sounds like this patient is, indeed, in the moderate to severe category by what we've heard so far.

Dr Helliwell: Just out of interest, do you use a formal assessment tool, such as the Psoriasis Area and Severity Index (PASI), or the Physician's Global Assessment (PGA), or some other tool?

Dr Merola: Yeah, it's also a great question. The honest answer, at least I think for most of the US, and I know in some other areas, globally, folks may be asked to use the PASI. I wouldn't say we routinely use the PASI in clinic. I like to document, for sure, a BSA. I think that's easy enough. And I think it's easy enough to also document what I call a "gestalt PGA." Is the patient mild, moderate, severe? I think it's great to have that in the note to be able to see change over time, document change over time. It also does allow for other nuance, such as the PGA x BSA metric, where you can almost recapitulate a PASI in practice. But I think it's helpful if we document at least a BSA and/or PGA in our clinical notes to have some assessment of how severe the skin disease is. And you can include any area, genitals, scalp, etc.

Dr Helliwell: Very important to document. And I'm interested, Dr Ogdie, what assessments you use of this skin as a rheumatologist? I presume you do assess the skin when you're looking at your patients.

Alexis R. Ogdie, MD, MSCE: I do. And I actually also use a BSA and PGA. I find that really easy to document. And not every visit do we have to get the patient fully undressed, but the patients can also accurately quantify their BSA overall by the number of palms of psoriasis on their body. I sometimes use their help in quantifying their current BSA.

Dr Helliwell: Yes, indeed. And we've developed a self-assessment tool where patients do that and send that information in, along with their joint assessments. I'm getting the impression that nobody seems to do the PASI routinely in clinical practice. Is there any particular reason apart from its complexity? And the points you've made about sites and the impact, it's always reported in clinical trials, but it's not a practical clinical tool, is what you're saying.

Dr Merola: It's interesting, Phil. I'll jump in just to say, I think it is a little bit cumbersome. It is a little bit burdensome. One can become fairly facile in taking them down. Again, some of our colleagues internationally use them because of payer requirements or otherwise. But I think increasingly, especially with some of our newer therapies, we've gotten patients often to really much better control. And also the PASI doesn't really translate well at very low BSA and at more mild disease, so I'm not sure it's of relevance either when we get down near the really low range of activity. And so for many reasons, I've transitioned over to using BSA and PGA clinically -- although certainly PASI has its role in clinical research, and again, in certain settings.

Dr Helliwell: Yes, I work in a multidisciplinary clinic with a dermatologist. We do get the patients undressed, but she will do a gestalt PASI. Because we do have payer requirements, PASI of 10 or more, if you're giving biologics, and she'll just look at the patient and say that's a PASI of 15 or whatever. That's one way around it. There is an alternative way.

I guess there are ways of easing your PASI, if you like. It may be appropriate to mention the GRAPPA app at this point. This is a freely available app you can download onto your smartphone, and it's got a number of functions in it. And one of them is a PASI calculator, which eases the assessment. You don't have to do any calculations, for instance. It's also got screening questionnaires and the Dermatology Life Quality Index (DLQI), but we'll come onto that perhaps as we go through this case.

Let's go back to our patient now. You've done your assessments, Dr Merola. His BSA is 8%. His PGA is 3 out of 5, and the PASI is 12. This represents moderate to severe psoriasis. Part of the assessment, then, is to start to understand what else is going on with this patient, because psoriasis is not only a skin disease. I've said it's systemic inflammation and there are important comorbidities, such as metabolic syndrome, cardiovascular disease, depression, and so on, and of course, psoriatic arthritis. I think it's always important to try and assess the patient and the impact of the disease on the patient. So maybe, Dr Ogdie, you could tell us a little bit more about the comorbidities and extra dermatological manifestations of this condition.

Dr Ogdie: Yes, so there are multiple different conditions that are associated with psoriasis and psoriatic arthritis. I'll focus first on psoriasis. Among patients with psoriasis, metabolic comorbidities are very common. They have elevated prevalence of hyperlipidemia, obesity, hypertension, diabetes, and elevated incidence for many of these as well. These are important things to keep in mind as you're talking to the patient about history elements. But also when you're reviewing their labs and you see that elevated glucose, sometimes we're the first one to pick up their diabetes because we're the one checking labs. So all things to think about. Additionally, because of these metabolic comorbidities, many of these patients also have fatty liver disease. Beyond the metabolic comorbidities, there's also a strong association with depression and anxiety. The prevalence of depression and anxiety in the psoriasis population is significantly elevated from the general population, so also things to keep in mind. These really have a major impact on our patients' quality of life, and sometimes treating the skin can actually improve the depression, because the depression is often tied to embarrassment or other symptoms related to the psoriasis itself.

Dr Helliwell: Do you ever use the DLQI to get a handle on the psychosocial impact in these patients? I should say DLQI stands for Dermatology Life Quality Index, also on the GRAPPA app incidentally. Do you ever use this in your clinics, either of you?

Dr Merola: A number of our clinics do give out the DLQI in advance of a patient visit. I think it can be helpful in some respects. I'll be honest, I think a lot of clinics do not use a formal assessment in this context. We can certainly come back to this, but I think if we're not going to use a formal assessment like a DLQI or PROMIS measure or something else that might be relevant. I do think then we have to ask the patient about the impact of psoriasis on their quality of life. I think we can have it both ways and so, then at that point again, we can chat about this later, but I make sure that I'm asking about from a skin standpoint how the skin is impacting the patient with regard to itch, making sure I'm asking about sensitive area involvement, because they may not feel comfortable sharing that, including genital psoriasis and such. I ask about impact on sleep, on work, family life, and even things like clothing choice -- can all be impacted. I do think if we don't use a validated quality of life measure, then we have to at least own some of those questions in the visit so, at least, one or the other.

Dr Ogdie: In rheumatology, we don't use the DLQI. But in our clinic, for example, we use the RAPID-3, which has 3 questions about depression, anxiety, and sleep. So you're going to get a sense of those qualities, as well.

Dr Helliwell: It's clear that psoriasis affects the patient in a lot more ways than just their skin, and it's getting to the bottom of that that is part of the consultation and management of these patients. And perhaps we should turn to Wendy now. As a patient or someone who has psoriasis, what's your perspective on its impact on your quality of life?

Wendy Olsder, MSc: I totally agree. I think psoriasis can have a big impact on patient's quality of life, and it definitely also has on mine. And for me, it really is the location of the psoriasis, as Dr Merola was saying, as to whether it impacts my life. For instance, if the plaques are on my elbows, then I can cover them up and it's okay. But if it's on my scalp, then it has more impact on my quality of life. I think it also depends on the person. I'm young, so for me it's really a burden and you get problems with your body image, but there may also be people who don’t care as much, so assessing this quality of life is really important.

Dr Helliwell: Yes, my patients often, particularly if it affects their hands, the palms and the nails, feel very concerned about body image and the impact. You can't go around wearing gloves all the time, particularly during the summer. I agree. That's important.

Let's go back to our case now. We've asked the right questions and find that he's depressed, and he self-treats by smoking marijuana. He's got difficulty with intimacy. He's single and he wants to go out with somebody, date, as you say in America. He's uncomfortable working out in a public gym. And he did have his DLQI score done, which was 15, which is on the moderate to severe range. The score is from 0 to 30 of the DLQI. In addition, he's had trouble getting the right diagnosis, referral, and treatment. I must wonder whether that is because of his skin color. I just wonder what perspectives you've got on that, Dr Merola.

Dr Merola: Again, I think this is a rich case, and I'll start with the skin of color, and I may come back to some of those other points. I think it sounds like he has fairly classic disease from the description, so I'm not sure whether or not this particular case would be a diagnostic challenge the way it's described with extensor extremity plaques and scalp disease and such, although it could be. I would say that one of the biggest challenges in patients with skin of color is the residual dyspigmentation. Even though we may get the inflammatory component under control, there is either hyperpigmentation that lasts for much, much longer than the treated inflammation, or because of our topical treatments -- topical steroids and such -- hypopigmentation or such. So I think there is that excess burden in patients with skin of color. In some cases I think some of the subsets of disease may lead to challenges in diagnosis, including inverse disease, other areas where it may morphologically look a little bit different. So I think that there certainly is that element.

I also want to highlight it mentions having difficulty with intimacy. And, by the way, I'm not sure what you call it apart from dating in the UK. You'll have to enlighten me.

Dr Helliwell: It's probably an age thing.

Dr Merola: But I will say that we know that there are some data suggesting that upwards of 60% of patients report having ever had genital involvement of their psoriasis. That's not minor. It's a majority of patients. And so it's something we often, even as dermatologists, don't bring up or don't look at. And I'm certainly sure my rheumatology colleagues are much less likely to be doing genital skin exams. I do think that it's something that we have to, at least keep in mind and make our patients comfortable with asking about, and making sure that we're addressing it as such. Because it certainly would be of issue for a young gentleman here.

Dr Helliwell: Yes, and I think in the UK, we're very much focused on other cultures and ethnicities now. People are showing delayed diagnoses and different responses to treatment, which may be cultural or it may be genetic. We don't know quite yet, but we must be seeing these patients in a different light, I think, which is perhaps the important point to make. Coming back to his comorbidities and associated diseases, Dr Ogdie, what sort of tests should we be doing on him on a regular basis to monitor for these?

Dr Ogdie: Well, I think at least once we want to screen this patient for cardiovascular disease, so ask him about family history of cardiovascular disease, ask about other risk factors, like smoking, for example. Discuss with him his weight, and that obesity not only has an impact on his psoriasis severity but also on potential cardiovascular risk. Check his lipids; check either fasting glucose or HbA1c so that it has been done at least once according to guidelines. That's USPSTF guidelines in the United States, at least. These are all things that you can do. It doesn't have to be done in 1 visit, but over the continuum of care.

Dr Helliwell: And would you look for malignancies, other immune disorders, such as inflammatory bowel disease (IBD)? That is certainly something that we think about from time to time, but how assiduously would you go after these other comorbidities?

Dr Ogdie: I think most of those are things that we're going to ask about in the review of systems. We'll ask about diarrhea and/or constipation, blood in the stool. And then for malignancy, the one we're most concerned about for young patients who have psoriasis, is non melanoma skin cancers. Those are the ones that are most increased by our therapies. A typical skin check once a year might be helpful for those types of patients, and this patient has had light therapy before, which might make him more at risk for that. Most of our therapies have an associated risk with non-melanoma skin cancer, so it's just something I counsel about wearing sunscreen, for example, especially when they're on these therapies. But otherwise, I don't do additional workup specifically for malignancy or IBD unless those things come up.

Dr Helliwell: I think that's more or less our experience as well. This is turning out to be quite a complex case with a lot of additional features. As we had learnt at the start, he's had topical treatment and intermittent phototherapy. What sort treatments would we be looking at now for this man with moderate to severe psoriasis and a significant number of comorbidities that might affect your treatment choice, I suppose?

Dr Merola: We've already heard that this is a patient who has tried topicals. And to be honest, he's really in the moderate to severe category, where one could make a case that that's really outside of the scope of what topicals would treat well for most patients. They wouldn't really want to, necessarily, be applying it to such a large area. Phototherapy is a reasonable choice, and it sounds like this patient has tried phototherapy. At least in the US for some of our patients, increasingly it's a bit of a burden also because of copays. Patients wind up having to pay each time they go to phototherapy treatment, which is 2 to 3 times a week in many cases. And so that can be a burden both on time and cost. Of course, home phototherapy may be an option or an opportunity there.

But I think he's certainly someone who is quickly facing a systemic therapy discussion. Obviously that could take up our whole time to talk about, but I think there are some oral options we might discuss. Historically it might have been a discussion about something like methotrexate, but again, this patient enjoys, it sounds like, some cocktails with friends more frequently, has some overweight, and some other issues. We know that methotrexate may not be among our most effective therapies from a number-needed-to-treat standpoint, among others. So that may be more historic, but it could come up as a discussion. We have drugs in classes like apremilast, other oral agents.

And then I think a variety of systemic agents and biologics, including some of our most highly effective classes, IL-23 inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, and then of course, anti-tumor necrosis factor (TNF) therapy, as well. At the current time, I think we have just really a multitude of options to treat the patient, all of which I think from a skin standpoint would be very reasonable at this point. I think it would be influenced very much by comorbidities and by other potential discussions that we're likely to have here. I do think we would have a pretty robust discussion, lots of stuff to offer this patient at this point.

Dr Helliwell: I guess methotrexate would not be a good choice in his case?

Dr Merola: I will say in the dermatologist armamentarium, it's really fallen very much out of favor. I know in rheumatology, obviously, it's still a go-to for so many of our inflammatory arthritides. But I will say, increasingly, it's something that we don't really consider at the top of our list in the psoriasis discussion, which is a big change.

Dr Helliwell: What educational approach would you take with him? Clearly we've heard that he's got significant comorbidities. He needs to have some lifestyle changes, which Dr Ogdie has already outlined. And I guess you need to give him some expectations about the effect of his treatment. What do you tell your patient about starting treatment with the biologic and their skin?

Dr Ogdie: I give people the 12-week mark to see changes, and hopefully they see some changes early on. But then they feel better when they start to see earlier changes, knowing that the full changes won't come for a while.

Dr Merola: I will say that the rapidity of onset does differ a little bit by mechanism. I do set those expectations for patients, as well. I think some mechanisms do take a little bit longer, and this is a long game. It's about getting people clear and then keeping them clear hopefully for a long time. I agree with what Dr Ogdie has said. I think we set expectations on several-month timelines, but the truth is with many of our newer therapies, people can start to see pretty substantial changes as early as a few weeks in. And we also know that that often does predict longer-term responses, so that can be helpful and encouraging to share with patients.

Dr Helliwell: And I'm aware that you 2 are international experts. But Wendy, what's your experience? What would you have liked to have been told when you were first diagnosed with psoriasis?

Ms Olsder: Yes, I fully agree with what's been said so far. I think setting the stage right for the treatments and not getting too much expectations is a good idea. But what I would've liked to have been told as well is a little bit more about other symptoms and comorbidities, as I was developing some nail problems later on, but I never realized that they were actually related to the psoriasis. And that could, of course, also happen with other comorbidities. Of course you as the doctors are looking out for it, but if we are educated about it, then we can also recognize it and come to you earlier, and appropriate interventions can be used in time.

Dr Helliwell: Yes, thank you for that. Well, let's move on with the case then. In fact, he does get treatment, systemic treatment, and he actually does very well. But he comes back a year later, and he's getting a few aches and pains. We now have to think about whether he's developing psoriatic arthritis. And clearly the dermatologist is often the first point of call. Although I must say my experience is that patients who get aches and pains don't tell their dermatologist in the UK because they're a dermatologist -- they're a skin doctor and they've got a joint problem. But it is clearly a role for a dermatologist to ask these questions. What do you think dermatologists should be doing on a regular basis, Dr Merola?

Dr Merola: You already hit the nail on the head. I think it's wonderful when patients are aware of the risk. And obviously, some of... Honestly, even some of the direct-to-consumer and direct-to-patient stuff in the US I think in some ways helps that knowledge. But the dermatologist has to own this, clearly to your point. We are seeing the at-risk patients. We're seeing the patients who are going to develop psoriatic arthritis. I think, minimally, dermatologists can be utilizing validated screening tools. It really is of minimal burden on the office to do so, because they're patient-phasing. I think we'll get into this a little bit more, but simple questionnaires like the PEST, a simple 5-question screening tool, can be given to a patient while they're waiting in the waiting room to see you, while they're sitting on the exam table, or even in advance of a visit, potentially. We're increasingly doing it through our patient gateway electronically.

It really is very low burden on the office then to have screened a patient for psoriatic arthritis and do the right thing by the patient in terms of following up -- either the dermatologist then working through the diagnosis or minimally referring to a rheumatologist for a proper workup. I really do feel strongly that the dermatologist needs to own that screening piece, minimally. And for some dermatologists, I think we can get comfortable with diagnosis, even basic physical diagnosis, of psoriatic arthritis and potentially, honestly, even treatment. If I'm going to choose A vs B and I suspect psoriatic arthritis, I think I could make a decision as such. But the screening is the bare minimum.

Dr Helliwell: Any tests that a dermatologist should be doing before they refer to a rheumatologist, apart from the screening questionnaires?

Dr Ogdie: That's a great question. Locally, we have our derm-rheum collaboration, and we have this setup where if they're going to send us a patient that they think has psoriatic arthritis, we have them send all the basic labs, like CBC, complete metabolic panel, C-reactive protein, sometimes a rheumatoid factor and CCP if they have polyarticular disease, and then their QuantiFERON Gold, because we might be talking about therapy initiation, so we might just have that all done. And then we don't necessarily have them get x-rays, but sometimes if there is some significant swelling, we might have them get x-rays if it's a finger, for example, both hands. But that way it just speeds up the process, so once they're sitting in front of you, you can make some decisions without having to wait around for the lab tests.

Dr Helliwell: I think that's very relevant. I'm increasingly being asked at meetings whether ultrasound should be done prior to referral, particularly of entheses. And I usually counsel that dermatologists should look at only one enthesis at the heel, the Achilles insertion. And if that's swollen, tender, by all means get an ultrasound, but you probably don't need it if it's swollen and tender. Yes, I would agree with you there.

What about the screening tools we've got? You've mentioned the PEST already. We've got several available. Do you want to tell us a little bit about them, or shall we leave it at the PEST, since the PEST is best?

Dr Ogdie: I do happen to think that the PEST is best and it's easiest. I think that while there are many questionnaires, I think that's just an easy questionnaire. There's only 5 questions. It also helps inform dermatologists about what's important to ask about. We can tell you that there are multiple tests, you can read about them, but I think the PEST is easy, and the National Psoriasis Foundation has it on their website, so you can easily find it, too.

Dr Helliwell: And it's on the GRAPPA app, of course, isn't it?

Dr Ogdie: Yes.

Dr Merola: I was going to also add it's available on the GRAPPA app, as you said, in multiple languages, too, which facilitates for us in the clinic, and I was going to even go on record saying our own institution developed other screening tools, and we very much use the PEST. I also think the PEST is really just so easy to have just 5 questions facing a patient. It just really makes it easy for everyone involved.

Dr Helliwell: Coming back to this patient. He scored 4 out of 5 for his PEST. The cutoff is 3 for suspicion of psoriatic arthritis. He was referred to a rheumatologist, who found that his fingers were tender, but he had a swollen distal interphalangeal joint, and his knee was swollen. And furthermore -- a big giveaway sign -- he had dactylitis of his right fourth toe. This man looks as though he has psoriatic arthritis. He's been referred to rheumatology. Should we continue to manage him as a joint referral between dermatology/rheumatology? Should I be doing the treating of the skin, as well? What do you think?

Dr Ogdie: We often do work in collaboration with our dermatology colleagues across the hall. In this particular case, he's on a medication for his skin, but he's not doing well from a joint perspective. So we're going to have to switch therapy. It becomes really difficult when you have one piece doing well, and one piece not doing well. And this just really highlights the importance of having that collaborative relationship where you can discuss the risks and benefits of changing vs adding something, for example.

Dr Helliwell: Agreed. And I think it's an important that each of us should assess the other's specialty, just for a point of view of treatment choices, as Dr Merola has already pointed out. Wendy, what's been your experience of going to different specialists? What was the path you took to finally get your diagnosis of psoriatic arthritis?

Ms Olsder: Well, I had my first symptoms when I was 14. And then I saw many pediatricians and orthopedists because I had inflammation in my hips and in my neck. But unfortunately it took more than 2 years before I finally got my diagnosis of juvenile arthritis. And then after a couple of years, I also started to develop plaques on my elbows and knees. And then I also got diagnosed with psoriatic arthritis. It took a long time for my diagnosis, but now I really have a good team of healthcare providers to manage my psoriatic arthritis.

Dr Helliwell: Thank you for that. We've just covered a case. We've heard the first case with skin developing into psoriatic arthritis. We just heard Wendy's story. It's important to remember that about 15% of our patients with psoriatic arthritis will develop the arthritis before the psoriasis, which can be a real problem in the clinic. Of course, there'll be a few who've got hidden psoriasis that we don't ever see until finally a dermatologist helps us out. But it's important to remember that you can have psoriatic arthritis without actually having psoriasis.

That brings us to the end of this case-based discussion. It just leaves me with the task of giving you some takeaway messages. Let's not forget that psoriasis is more than the skin. There are lots of important comorbidities, including the very important one of psoriatic arthritis. The disease, the skin disease, has a much wider impact than you will see from the skin itself, both psychologically and physically. It's important to spot psoriatic arthritis early because it's an important comorbidity that if not treated early will lead to subsequent damage. In treating these patients, we have to remember that they have 2 important systems, and to work collaboratively is always important in these cases. I'd like to thank everybody -- Wendy, Alexis, and Joe -- for a very interesting and thorough discussion.

I'd like to thank the audience for participating in this activity. I'd like the audience to continue on to answer the questions that follow and then complete the evaluation.

This is a verbatim transcript and has not been copyedited.