By Lily Lyralin L. Tumalad, MD, FPDS, IPC Fellow 2021
Participants worldwide attended the 6th World Psoriasis and Psoriatic Arthritis Conference, an entirely virtual meeting broadcasted from Stockholm, Sweden, held from June 30 to July 3, 2021. The theme of this conference was CONNECTED, INFORMED, and UNITED to improve multidisciplinary care for people with psoriasis and psoriatic arthritis. This new format facilitated more global participation and interaction between clinicians, scientists, patients/patient representatives, wherein attendees could join the sessions virtually, without traveling. This successful meeting included the latest information on psoriasis and psoriatic arthritis researches, up-to-date management guidelines and treatments, comorbidities, personalized medicine, unmet needs, and challenges related to psoriasis – to improve global psoriasis health care. The following report presents summaries of the congress’ sessions.
Diamant Thaci, MD, IPC Councilor - University of Lubeck Session 1: “Looking Back and Looking Ahead” discussed by Professor Diamant Thaci, an IPC Councilor and dermatologist from the University of Lubeck, Germany, and Professor Kurt De Vlam, a rheumatologist from University Hospital Leuven, Belgium. Key points of the discussion are the following: 1) Not all psoriatic arthritis (PsA) treatment classes are effective across all critical domains of PsA; 2) Tolerability is the principal reason patients discontinue treatment; 3) No statistically significant differences can be found between active agents on the occurrence of severe adverse events; 4) IL-17 and IL-23 inhibitors have a lower risk for opportunistic infections compared to past treatment options; 5) Future treatment options may include a combination of biologics. Back to top
Kilian Eyerich, MD, PhD - Karolinska Institute, Sweden Laura Coates, PhD - University of Oxford Session 2: “Treatment strategies: Unmet needs of treating psoriasis and psoriatic arthritis patients” discussed by Professor Kilian Eyerich, a dermatologist from Karolinska Institute, Sweden, and Professor Laura Coates, a rheumatologist from the University of Oxford. Key points of the discussion are the following: 1) Clinical picture is still the most important diagnostic tool in both dermatology and rheumatology, and having a biomarker to predict those who will develop psoriatic arthritis would be helpful in the future; 2) There are changes in PsA subtypes over ten years, although it is difficult to predict who among the patients will have progression of symptoms; 3) There is a need for truly personalized medicine in psoriatic arthritis; 5) There is evidence that treatment with biologics (IL-17 antagonists and TNF inhibitors) may give 6-8% decrease in coronary plaque burden, but there is a need for more real-world evidence.
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Luigi Naldi, MD, IPC Councilor - Ospedale San Bortolo
Dr. Luigi Naldi from the Department of Dermatology, Ospedale San Bortolo, Vicenza, Italy, and IPC Councilor talked about lifestyle intervention programs in psoriasis. Smoking and obesity are two important environmental risk factors in psoriasis linked to dietary habits, which can also affect the severity of the disease and the development of comorbidities (“psoriasis march”). Obesity in early adulthood is also a risk factor for psoriatic arthritis. There is evidence that BMI influences the response to systemic treatment in psoriasis – reducing the activity of any treatment as the BMI increases (BMI <20 OR 1.2, BMI 20-24 OR 1, BMI 25-29 OR 0.8, BMI >29 OR 0.6). There is also an increased link between psoriasis and mortality compared to the general population. Lifestyle intervention is thus essential to decrease the burden of the disease and mortality, but not an easy task. A study by Naldi et al showed that diet and physical exercise reduce the PASI index irrespective of the treatment received, emphasizing the importance of reducing weight to improve psoriasis. As for future perspectives, there is a need to favor a holistic approach in managing psoriasis and develop a health education curriculum for dermatologists to familiarize themselves in helping patients change their habits.
Lone Skov, MD, PhD, IPC Councilor - University of Copenhagen Alexis Ogdie, MD, MSCE - University of Pennsylvania Josefin Lysell, MD, PhD - Karolinska University Hospital Professor Lone Skov, a senior consultant from Herlev and Gentofte Hospital, University of Copenhagen, Denmark, and IPC Councilor, discussed comorbidities in adult psoriasis focused on cardiovascular and liver diseases. Studies have shown that psoriasis increases the risk for myocardial infarction and stroke (Gelfand 2006, Ahlehoff 2011, Miller 2013). Obesity is considered an independent risk factor for psoriasis. There is evidence of a causal relationship between body mass index and psoriasis (Budu-Aggrey 2019). It is also suggested that obesity contributes to psoriasis's pathogenesis. They share the same chronic low-grade inflammatory markers (Th1 cells, TNF-alpha, IFN-gamma, IL-17, IL-6 Veg-F, Hs-CRP, Insulin sensitivity). Psoriasis is also linked to non-alcoholic fatty liver disease (NAFLD), a common cause of abnormal liver function tests. EULAR and Joint AAD-NPF guidelines recommend focus on information and screening for risk factors, treat risk factors, and lifestyle and medical treatment of cardio-metabolic diseases. Long-term weight loss in patients with psoriasis has long-lasting positive effects on the severity of psoriasis. Associate Professor Alexis Ogdie from the University of Pennsylvania discussed comorbidities in psoriatic arthritis. There is a higher prevalence and incidence of hypertension, diabetes, hyperlipidemia, and obesity in psoriatic arthritis patients than in the general population (Dubreuil 2014, Jafri 2017, Ogdie 2018). Obesity influences response to therapy in psoriatic arthritis wherein overweight (OR 0.66, 0.50-0.87) and obese (OR 0.53, 0.41-0.69) patients have decreased chance of achieving minimal disease activity. Weight loss improves therapy outcomes. Likewise, modification of body weight improves risk for PsA. There is evidence that individuals who lost weight had a reduced risk of developing psoriatic arthritis (Green, 2019). Shifting the care model is vital to help patients lose weight by having a trained person in practice or having a central program to take care of patients to control their risk factors. Dr. Josefin Lysell, a senior consultant from Karolinska University Hospital in Stockholm, discussed comorbidity in children and young adults. An 18-year follow-up cohort study by Glerup et al showed that 6.5% of the patients with juvenile psoriasis developed psoriatic arthritis with an average age of onset of 7.3 + 4.3 years. Sixty to eighty percent of children with psoriatic arthritis develop arthritis 2 to 3 years before skin findings. Adult patients tend to develop cutaneous manifestations of psoriasis first, on average 8.5 years before arthritis symptoms (Stoll, 2011; Lewkowicz, 2004; Ekelund, 2017). Since there are no biomarkers, dermatologists must pay attention, examine and ask about features of psoriatic arthritis, then refer to a rheumatologist/ophthalmologist when needed. Obese children are at higher risk of developing psoriasis (OR 2-3), and it predates psoriasis at least two years in >90% of children, with a mean delay onset of psoriasis of >4 years (Becker, 2014). In their retrospective cohort study, Tollefson et al (2018) concluded that while psoriasis is a small independent risk factor for the development of these comorbidities, obesity is a much stronger contributor to comorbidity development in children with psoriasis. Thus, it is essential to emphasize a healthy lifestyle and discuss weight loss. There is also an association between the quality of life and improvement in psoriasis severity and extent in pediatric patients wherein having over PASI 90 response has the most significant CDLQI reduction (Bruins, 2020).
Alexander Egeberg, MD, PhD - Dermatology and Allergy, Herlev and Gentofte Hospital Dafna Gladman, MD, FRCPC - University of Toronto
Session 3: “Prevention of Comorbidities” discussed by Dr. Alexander Egeberg, a dermatologist from Dermatology and Allergy, Herlev and Gentofte Hospital, Copenhagen, Denmark, and Professor Dafna Gladman, a rheumatologist from the University of Toronto, Canada. Key points of the discussion are the following: 1) Disease activity is an essential predictor of psoriatic arthritis in developing cardiovascular disease, with high ESR, WBC, and DAPSA score associated with more severe atherosclerosis (Eder, 2015); 2) Data on the effect of established psoriasis therapies remains questionable, and even if there is a benefit, the number-needed-to-treat would be high, and the risk/benefit ratio favors set cardiovascular risk reduction strategies. These will still only serve as an add-on to the established cardiovascular therapies (ie, statins).
Dr. Satveer Mahil, an IPC Councilor and dermatologist from St. John’s Institute of Dermatology, London, UK, discussed the findings from PsoProtect and PsoProtectMe. PsoProtect is a global registry for clinicians to report outcomes of COVID-19 in individuals with psoriasis. At the same time, PsoProtectMe is a worldwide registry for people with psoriasis to self-report their experiences during the pandemic. Most patients in the PsoProtect were receiving drugs that affect the immune system (71% biologics, 18% non-biologic), and more than 90% fully recovered from COVID-19. Hospitalization for COVID-19 was associated with male sex, older age, non-white ethnicity, those with other health conditions (ie, chronic lung disease), and patients on non-biologic immunosuppressants, compared to those on biologics. Nineteen percent (19%) of participants delayed or stopped their immunosuppressive medications primarily due to concern for complications. Those who discontinued treatment were more associated with worsening their psoriasis, anxiety, and depression than those who continued their immunosuppressive medications. These data helped partner organizations form consensus guidelines and provide relevant feedback to the community. Professor Peter van de Kerkhof from Radboud University and the International Psoriasis Council’s Chief Medical Officer discussed how COVID-19 affected the care of psoriasis patients, including telemedicine, and the impact of psoriasis-related cytokines in the course of COVID-19. Evidence has shown that COVID-19 has a tremendous effect on the mental (anxiety, depression, post-traumatic stress disorder) and physical (higher psoriasis severity scores and more frequent disease aggravations associated with alterations in the treatment and appointments) health of psoriasis patients. Telemedicine may be an essential “add-on” in psoriasis care but not a replacement. Existing data, with some exceptions, generally suggests patients with psoriasis and psoriatic arthritis have similar rates of SARS-CoV-2 infection and outcomes as the general population. Likewise, biologic use is associated with a lower risk of COVID-19 related hospitalization than with the use of non-biologic systemic therapies. There is some evidence that psoriasis and the development of cytokine storm in COVID-19 infection have some similarities in their IL-17 driven mechanisms, which deserve further studies. With this knowledge, current biologics for psoriasis may have a role in improving the course of COVID-19. IPC Councilor Professor Ulrich Mrowietz, dermatologist head of the Psoriasis Center at the University Medical Center Schleswig-Holstein in Germany, discussed COVID-19 vaccination in the context of psoriasis. Evidence shows that vaccination among patients with chronic inflammatory disease, including psoriasis, even during therapy (biologics, DMARDs), exhibits the same efficacy and safety as the healthy controls. The EuroGuiDerm Guideline 2021 has the following recommendations regarding COVID-19 vaccination: 1) It is recommended to vaccinate people with the psoriatic disease with the approved vaccines, 2) During the phase of vaccination, psoriasis treatment with any approved medication should not be interrupted (ie, methotrexate, cyclosporine), except if the physician sees a reason to temporarily discontinue them, 3) A complete protection from vaccination is not guaranteed for every person, 4) People with psoriasis should be receiving other vaccines such as against influenza and pneumococci as recommended.
COVID-19 and Psoriasis
Ignacio Cei-Cas, MD - Hospital Pte Peron, Buenos Aires Dr. Ignacio Cei-Cas from Hospital Pte Peron, Buenos Aires, Argentina, talked about the relevance of the gut microbiome to psoriasis. Altered metabolic pathways (TMA/TMAO, SCFAs, BA, uremic toxin pathways), as well as shifts in gut microbial composition (SCFAs-producing bacteria decrease, an abundance of microbial genes for LPS biosynthesis and TMAO generation increase), may induce gut microbiota dysbiosis, leading to a leaky gut, bacterial translocation and systemic inflammation that subsequently worsens the course of psoriasis. Treatment includes dietary fibers, probiotics/prebiotics, fecal microbiota transplantation (FMT), and pharmacological treatment. A study by Navarro-Lopez et al (2019) showed PASI-75 reduction in 67% of patients receiving probiotics (strains Bifidobacterium longum, B. lactis, and Lactobacillus rhamnosus once a day for 12 weeks) compared to 42% patients receiving placebo. Back to top
Jo Lambert, MD, PhD, IPC Councilor - Ghent University Hospital Lynda Grine, PhD - Ghent University Hospital
Professor Jo Lambert, an IPC Councilor, and Lynda Grine, PhD from Ghent University Hospital, Belgium, discussed psoriasis and diet. Based on currently available evidence, dietary changes ALONE do not cause a significant effect in psoriasis but may become an essential adjunct to current first-line treatments, demonstrated in several studies such as improvement of psoriasis following a very-low-calorie keto diet (Castaldo, 2015) and after an aggressive weight loss program (Castaldo, 2020). Also, in a randomized clinical study by Jensen et al (2013), patients who lost more weight after a low energy diet (800-1000kcal/day) achieved a more significant reduction in PASI (p=0.06) and more remarkable improvement in DLQI (p=0.02) than the control group on a routine diet. In a study by Michaelsson et al (2003), a gluten-free diet may positively impact the molecular level in psoriatic skin (decreased expression of transglutaminase and Ki67+ cells). In addition, aside from “what” you eat, “when” you eat also matters. In a real-life multicenter study by Damiani et al (2019), Ramadan fasting resulted in a significant decrease in PASI scores among moderate to severe psoriatic patients. Likewise, preliminary findings of an open randomized pilot trial (MANGO trial) showed that patients who underwent modified intermittent fasting had better subjective experience (p=0.025), significant improvement in PASI scores at weeks 6 and 12, and significantly improved itch at weeks 6 and 12. Metabolic parameters (BMI, weight loss, waist circumference) were also considerably improved in the fasting group (p<0.05). In conclusion, there was a modest improvement with diet interventions with the need to combat obesity-related comorbidities. Focusing on diet engages patients to look at themselves more holistically. Back to top
Alan Menter, MD, IPC Honorary Founder - Chief of Dermatology of Baylor Scott and White
Dr. Alan Menter, Chief of Dermatology of Baylor Scott and White, a clinical professor in UT Southwestern Medical School in Dallas, Texas, and an IPC Honorary Founder, discussed psoriatic arthritis for dermatologists. Dermatologists need to be at the forefront in diagnosing early psoriatic arthritis (PsA) as joint symptoms usually present 5-10 years after skin. Subtypes of psoriatic arthritis include 1) dactylitis, one of the cardinal features of early psoriatic arthritis, 2) enthesitis, a hallmark of PsA, triggered by overexpression of TNF-alpha, 3) asymmetric oligoarthritis, most commonly seen presentation, 4) symmetric arthritis, 5) DIP joint arthritis, 6) arthritis mutilans, which clinicians must prevent. X-ray findings (pencil in cup deformity) are also significant in detecting PsA. Nail involvement is an essential aspect of PsA. However, the study of Wittkowski et al in 2011 showed that the association between nail involvement and psoriatic arthritis was not statistically significant, except for DIP joint involvement. Treatment for PsA includes NSAIDs, leflunomide, sulfasalazine, corticosteroids, methotrexate, cyclosporine, and apremilast. Methotrexate, however, does not delay the radiographic progression of the disease. TNF- alpha antagonists give an early dramatic response and inhibit radiographic progression. Newer biologics, tildrakizumab, guselkumab, risankizumab (not yet FDA approved for psoriatic arthritis), which selectively block IL-23, may be used for psoriatic arthritis treatment. Back to top
Christopher Ritchlin, MD, MPH - University of Rochester
Professor Christopher Ritchlin from the University of Rochester discussed the unmet needs of psoriatic arthritis. The challenge is to achieve therapeutic outcomes in psoriatic arthritis similar to those observed with the newer biologic agents in psoriasis because psoriatic arthritis has multi-pathway involvement in the skin and synovio-enthesial tissue. To add to the complexity are the comorbidities of psoriasis. Suggested solutions include 1) improvement in the understanding of how CD8 tissue-resident memory (TRM) cells and arthritis associated tissue macrophages mediate inflammation and destruction; 2) preclinical intervention to treat psoriasis may ameliorate severity or present onset of psoriatic arthritis, including identifying “at-risk” for developing psoriatic arthritis (scalp and nail involvement, more severe plaque, obesity, having 1st-degree relatives, with ultrasound findings); 3) weight reduction programs and intermittent fasting viable treatment strategies in improving psoriatic arthritis activity (minimal disease activity achievement increased from 29% to 54%, p<0.002 in the study by Klingberg et al). Another suggestion was the role of a combination approach of biologic treatments to achieve PsA remission. Back to top
Alexander Nast, MD, IPC Councilor - Charity Hospital Arthur Kavanaugh, MD, IPC Councilor - University of California, San Diego
IPC Councilor Dr. Alexander Nast from the Charity Hospital in Berlin discussed the European guidelines for the systemic treatment of psoriasis vulgaris developed under the EuroGuiDerm system. They recommend initiation of systemic treatment in patients with moderate to severe psoriasis, with the initiation of ‘conventional’ systemic agents as first-line treatment. In the case of severe disease, where a good treatment success cannot be expected with the use of conventional treatment, the initiation of a biologic with a “first-line label” is suggested as first-line treatment. They recommend starting a conventional synthetic DMARD (MTX) early to prevent the progression of psoriatic arthritis. For inadequately responding patients after at least one synthetic DMARD, they recommend using biological DMARDs (TNF inhibitors, anti-IL17, and anti-IL12/23) as monotherapy or in combination with synthetic DMARDs. For psoriasis patients with inflammatory bowel disease, first choice biologics are the TNF-inhibitors (except etanercept), anti- IL12/23, and anti-IL17 are generally avoided. Psoriasis patients with a history of malignancies should take the burden of psoriasis and the risk of cancer worsening or recurring into account for shared therapeutic decision making. In patients with a current or recent diagnosis of cancer in the previous five years, case by case with cancer specialists and to reach an informed decision, respecting patient’s preference. Screening for hepatitis B (HBsAg, anti-HBAg, anti-HBcAg) as a standard measure is recommended before starting a treatment with cyclosporine, methotrexate, or biologics. In the case of latent TB, treatment with isoniazid can be recommended with treatment initiation one month before the start of the immunosuppressive therapy and should be continued for six months. IPC Councilor and Professor Arthur Kavanaugh from the University of California, San Diego, discussed the psoriatic arthritis treatment guidelines and best practices. Recommendations for treating psoriatic arthritis depend on the domains involved: peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, nail disease, inflammatory bowel disease (IBD), and uveitis. Revisions in the new GRAPPA Treatment Recommendations (3rd edition) published in 2021 include 1) ‘Comorbidities’ divided into ‘Associated conditions’ (uveitis and inflammatory bowel disease) and ‘Comorbidities’ which are important in the choice of treatment, 2) added a ‘Position Statement on Biosimilars’ on how clinicians can use these agents appropriately, and 3) added a ‘Position Statement on Tapering / Discontinuing Therapy.’ GRAPPA’s overarching principles state that future developments in psoriatic arthritis include the following: 1) Prediction and prevention of disease – predict which patients with skin or nail psoriasis will develop psoriatic arthritis and prevention of psoriatic arthritis inpatient with psoriasis; 2) Early treatment – identify and treat early psoriatic arthritis, alter the disease course by early intervention leading to better outcomes with ultimate tapering of treatment; 3) New treatment options – drugs with new mechanisms of action and combination therapy with different DMARDs and bDMARDs; and 4) Precision medicine – targeted therapy based on cellular and clinical phenotypes. Back to top
Kristian Reich - University Clinic Hamburg- Eppendorf Philip J. Mease, MD - University of Washington and Swedish Medical Center
Dr. Kristian Reich, professor of translational research in inflammatory skin diseases from University Clinic Hamburg- Eppendorf, discussed new treatments for psoriasis. There are two new IL-17AF inhibitors: bimekizumab and sonelokimab. Blocking IL-17A and IL-17F has been said to have a more robust response than just blocking IL-17A alone. Phase 3 head-to-head trial by Reich et al (2021) showed a 13% therapeutic difference between bimekizumab 320mg and secukinumab 300mg in giving PASI 100 response at week 16 (61.7% of patients on bimekizumab vs. 48.9% on secukinumab, p<0.001). The significant difference was maintained for one year (73.5% of patients at PASI 100 in the bimekizumab group vs. 48.3% in secukinumab). The phase 2b study by Papp et al (2021) showed that sonelokimab, an IL-17AF nanobody molecule, achieved PASI 100 response in 57% of patients after 24 weeks. Phase 2 trials also show that the rate of oral Candida infection is lower in the sonelokimab group (5.2%) vs. the bimekizumab group (13.4%) after 1-year treatment. It was also shown that TYK2 plays a significant role in the pathogenesis of psoriasis. In PSO-1 and PSO-2 clinical trials by Armstrong et al (2021), 69% (PSO-1) and 59.3% (PSO-2) of patients who received deucravacitinib, an oral TYK2 inhibitor, achieved PASI75 at week 24 vs. 38.1%, p<0.0001 (PSO-1) and 37.8%, p<0.0003 (PSO-2) in apremilast, and 12.7% (PSO-1) and 9.4% (PSO-2), p<0.0001 in placebo groups. Low safety signals for deucravacitinib were shown in these trials; there were a few herpes zoster cases, but none were serious, no serious infections that led to discontinuation, and no TB or opportunistic infection. Dr. Philip J. Mease, a clinical professor from the University of Washington and director for Rheumatology Research in Swedish Medical Center, Seattle, discussed the emerging treatments for psoriatic arthritis (PsA). A. New IL-17 inhibitors: 1) BE ACTIVE trial: Bimekizumab was effective for PsA with a significant dose-response for ACR50 vs. placebo (p<0.05) at week 12, and greater reduction for PASI 90 vs. placebo and resolution of enthesitis. No major safety signals were noted. 2) PATERA trial: Netakimab had also shown efficacy for PsA with an 82.5% ACR20 response rate at 24 wk vs. 9.3% with placebo. 3) Izokibep is a unique bispecific IL-17A small molecule with a very high-affinity binding for IL-17A. Its phase 2 PsA trial is underway in Europe. B. IL-23 inhibitors: 1) DISCOVER-2 trial: Guselkumab was safe and effective for PsA with 64% of patients who received 100mg q8wks achieved ACR20 response (vs. 32% placebo, p<0.001) at week 24. Also, there were resolutions of dactylitis and enthesitis in 59.4% and 49.6% of patients, respectively. Also, ASDAS-related endpoints improved at week 24 with guselkumab vs. placebo and were maintained through week 52. 2) Risankizumab 150 mg was effective for PsA with 57.3% of patients achieved ACR20 (vs. 33.5% placebo, p<0.001) at week 24. 3) Tildrakizumab 200mg every four weeks achieved the greatest ACR20 improvement of 79.5% response rate at week 24, which was maintained until week 52. C. Targeted synthetic DMARDs: 1) SELECT-PsA 1: Upadacitinib, a selective JAK1 inhibitor, 15mg, and 30mg showed better ACR20 response rate compared to adalimumab and placebo at week 12 (71% UPAD 15mg and 79% UPAD 30mg vs. 65% ADA vs. 36% PBO). Deucravacitinib showed efficacy for PsA with 53% (6mg) and 63% (12mg) of patients achieving ACR20 at week 16 (vs. 32% placebo, p=0.0134 with 6mg, p=0.0004 with 12mg). In summary, each of the drugs has unique features. They all show efficacy for PsA in getting patients to low disease activity and are relatively safe for use. Back to top
Professor Christine Bundy from Cardiff University in Wales and an IPC Councilor talked about self-responsibility and self-management using behavioral change techniques. As it is known, psoriasis may not be life-threatening but life-ruining. Patients living with psoriasis and psoriatic arthritis tend to have complex health needs and have poor psychological profiles. Patients often want to make health changes but need to be supported to do so. A different approach during a consultation is necessary to motivate behavioral change effectively, which should be done in a systematic way ‘with’ them by 1) simplifying the care of patients, 2) avoiding large volume of information given to them, 3) encouraging patient self-efficacy by decreasing their anxiety for them to process the information given to them effectively. Self-management begins with linking thoughts and feelings with behavior. One approach uses the evidence-based COM-B model that acknowledges the patient’s capability and opportunity to influence motivation and eventually affect behavioral change. Since consultation time is limited, clinicians need to engage patients, evoke information, and help patients set goals. Clinicians need training on these to support them to use effective methods and build their confidence. Back to top
Professor Jorg Prinz, IPC Councilor, from the Ludwig-Maximillian University of Munich, Germany, discussed psoriasis as an inflammatory disease- a new way of thinking. Psoriasis is a chronic inflammatory disease, requires long-term and potentially lifelong treatment. Numerous drugs with different properties are available, but efficacy must not be the sole criterion for a particular treatment decision. Treatment decision making is a permanent challenge that requires tailoring to the specific patient situation and life phases such as patient age, family planning, concomitant diseases, chronic infections and vaccinations, history of malignancy, need for surgery. Thus, it must be case by case and phase by phase in life with the following considerations: 1) if possible, do not use drugs that have a unique benefit in possible later stages in life (ie, certolizumab in women who might require it later during pregnancy); 2) try to adapt drugs to patient age (consider methotrexate in patients with cardiovascular disease); 3) consider the flexibility of dosing in an infectious environment or need for surgery (methotrexate, apremilast, etanercept, fumaric acid esters); 4) consider weight-based medications for overweight patients (infliximab, ustekinumab); 5) avoid IL-17 blockade if with a family history of IBD; 6) avoid TNF blockers if with a family history of multiple sclerosis; 7) use cyclosporine if rapid clearance is required; 8) do not interrupt biologic therapy unless required to avoid formation of anti-drug antibodies; 9) use phototherapy, acitretin or potentially apremilast if with history of malignancy. Back to top
Mr. Paul Mendoza, Vice President of Psoriasis Philippines and President of Psoriasis Asia Pacific, discussed the unmet needs of people with psoriatic disease based on their experience in the Philippines and how these can be addressed. According to Mr. Mendoza, most psoriasis patients have difficulty accessing treatment and doctors, particularly dermatologists and rheumatologists. Likewise, treatments available are expensive, and most are ‘out of pockets’ of patients. Also, currently, there are no health policies or health-related government services specific for psoriasis patients. Psoriasis Philippines, a patient support group, help fill in the gaps of these needs through their projects such as the ECARES program, ‘Caravan of Hope,’ the official proclamation of “National Psoriasis Awareness Week,” the inclusion of ‘Psoriasis’ as a psychosocial and orthopedic disability, collaborations and partnership with other organizations lobbying for health. Their suggested actions to further improve the care for people with psoriasis include continuous dialogues with the department of health to include psoriasis in the health plan, meetings with Congress to help create a health package for psoriasis, the inclusion of additional medicines for psoriasis (particularly biologics) in the national drug formulary, maintain a good relationship with doctors and stakeholders through consultative meetings to help push health policies for psoriatic disease. Back to top
Professor Ricardo Romiti, a dermatologist from the University of Sao Paulo and board member of the IPC, discussed health economics and access to treatment. Access to treatment is defined by its availability, affordability, and acceptability. Consider access in terms of whether those who need care get into the system or not. Different barriers should be considered, and patients’ needs and decisions to seek care are the first steps in accessing treatment. Financial issues and organizational barriers also play essential roles. There are different challenges in the healthcare systems worldwide (ie, affordability in Europe, disparities in healthcare resource use, and cost in the US). Data from the NPF survey panels (2013) showed that out-of-pocket healthcare expenses are the main reasons not seeing a specialist for psoriasis care. Biosimilars offer the potential for lower costs and increased access to biologics. Based on the Global Psoriasis Atlas (GPA) data, there are discrepancies in the access to care worldwide. There is more access to biologics in countries where they are provided for free. Back to top
Lone Skov, MD, PhD, IPC Councilor - University of Copenhagen
IPC Councilor Professor Lone Skov discussed the updated disease severity classification of psoriasis redefined by IPC in 2020. It underwent the Delphi process of 74 psoriasis experts. Their recommendation is as follows: psoriasis patients should be classified as either candidates for topical therapy or candidates for systemic therapy; the latter are patients who meet at least one of the following criteria: 1) BSA >10%; 2) disease involving special areas (face, palms, soles, genitalia, scalp, nails); 3) failure of topical therapy. This classification is simple, practical, and easy to use in daily clinics. However, it also has its limitations, such as no patient-reported outcomes, no definition of failure to topical treatment, no general dermatologist included, and no patient involvement in the process of developing it. The plan consists of creating a study to demonstrate the statement in real-world practice, focusing on educating regulatory bodies, clinicians, and patients on the new classification. Back to top
Alexander Navarini, MD, PhD, IPC Councilor - University Hospital of Basel
Professor Alexander Navarini, IPC Councilor and Chair of Dermatology at the University Hospital of Basel, Switzerland, talked about teledermatology's future. Twenty-five percent of the adult population needs annual dermatological treatment, and 70% of these cases can be treated by teledermatology. The demand for teledermatology rose during the pandemic, and it is the fastest-growing area of telemedicine globally, with an annual growth of 24.3%. Teledermatology systems are the store and forward (SAF) and live video conferencing (LVC). Requirements for efficient management of a dermatosis with teledermatology include: 1) unambiguous visual features, 2) diagnosis can be made without histology or labs, 3) low-risk differential diagnoses, 4) non-toxic treatments available, 5) straightforward treatment algorithms, and must NOT have: 1) features of low visibility, 2) neoplastic or infectious mimicker, 3) irreversible consequences. Armstrong (2019) showed that an online health model was equivalent to in-person care for reducing functional impairment and depressive symptoms in psoriasis patients. There were no significant differences in terms of PASI score improvements in both groups. Overall, psoriasis is a suitable tele-dermatosis. The potential future direction of teledermatology includes artificial intelligence brought directly to patients, decision support for non-dermatologists in the form of algorithms, and the DermaCompass app, which predicts invasion depth of lesions. Back to top
Robert Gniadecki, MD, PhD - University of Alberta Mona Stahle, MD, PhD - Karolinska Institute/ Department of Medicine Professor Robert Gniadecki from the University of Alberta, Canada, and Dr. Mona Stahle from Karolinska Institute/ Department of Medicine discussed treatment strategies with the concept of early intervention in psoriasis and psoriatic arthritis. Key points from this session: 1) Not all disease courses are the same in all patients. Psoriasis severity of an individual patient may not be a strong predictor of the activity of his psoriasis later. Based on the cohort study of Svedbom et al (2021), only 50% of severe patients continue to be severe, and half will become mild during the course. Thus, there may be patients that need the ‘hit hard approach,’ but this approach is far from being universal; 2) Comorbidities and risk factors (smoking, obesity, cardiovascular diseases) are essential factors to consider that affect the disease severity and disease course; 3) More clinical and molecular biomarkers may be needed. If there are more molecular basis of the disease, clinicians will choose which patients need a more aggressive treatment; 4) Full spectrum of the long-term effects of new treatments (ie, biologics) are still unknown. Back to top
Lars Iversen, MD, DMSc, IPC Board Member - Aarhus University Hospital Mark Lebwohl, MD, IPC Councilor - Icahn School of Medicine Wolfgang Wegener, MD - Dermatologist IPC Board Member Dr. Lars Iversen from Aarhus University Hospital, Denmark, discussed topical psoriasis treatment. In the 2021 joint JAAD-NPF guidelines, topical medications are the most common agents used to treat patients with mild to moderate psoriasis and frequently used adjunctive therapies for patients on phototherapy, systemic or biologic therapy. Topical steroids provide high efficacy and good safety and play a crucial role in treating psoriasis, especially localized diseases. Most patients on biologics have residual lesions on lower legs or elbows where topical treatments are applied, underscoring the importance of combining systemic plus topical treatment. The conclusion of available studies on topical drugs in combination with biologics showed a favorable effect of combination treatment, although not always significant, but may have some benefit. Individualizing topical treatment (ie knowing their preferred vehicle) is essential to enhance patient adherence. Dr. Mark Lebwohl from the Icahn School of Medicine at Mount Sinai, USA, and an IPC Councilor discussed new topical therapy for psoriasis. The study of Lebwohl et al (2021) (PSO-LONG trial) showed that the rate of relapses in patients with plaque psoriasis was proactively treated with twice-weekly topical calcipotriene/betamethasone dipropionate foam is reduced by 46% (CI: 37% - 54%) compared to the placebo group. The mean difference between the two groups in the number of remission in a year is 34.5 days. Overall, the number of treatment-related adverse events was relatively low and similar in both treatment arms. A phase 3 randomized trial by Gold et al (2021) showed that the new PADTM technology calcipotriol/betamethasone preparation improved efficacy compared to the topical suspension. Dr. Lebwohl also talked about the new steroid-sparing topical agents for psoriasis, such as 1) PDE4 inhibitors: crisaborole 2% ointment and roflumilast cream, 2) small molecule therapeutic AhR modulating agent (TAMA): tapinarof, and 3) Jak 1/ 2 inhibitor. A study has shown that crisaborole 2% ointment was highly effective for facial and intertriginous sites. DERMIS-1 and DERMIS-2 studies showed that 42.4% and 37.5% of patients, respectively, achieved IGA 0/1 and > 2-grade improvement from baseline at week 8 with roflumilast cream. In a Phase 2b trial, tapinarof significantly improved PGA response at weeks 8 and 12 compared with vehicle, and the efficacy was maintained after the end of treatment through week 16. A reported side effect of tapinarof was folliculitis-like eruption which was mild and well-tolerated. Dr. Wolfgang Wegener, a dermatologist from Austria, discussed treatment adherence. The World Health Organization (2003) defines adherence to long-term therapy in chronic disease as ‘the extent to which a person’s behavior… corresponds with agreed recommendations from a healthcare provider’. Five dimensions of adherence include socio-economic, healthcare system, disease, treatment, and patient-related factors. Usual reasons for non-adherence to topical drugs include less frequent application desired (38%) and greasy ointment (11%) (van de Kerkhof, 1998). A study by Caroll et al (2004) showed that adherence to topical therapy decreased during an 8-week psoriasis clinical trial. The more severe the disease is, the less adherent the patient is to the treatment. A study on the Topical Treatment Optimization Programme (TTOP) (2017) showed that a one-to-one conversation with the dermatologist and the nurse is the most critical element. Strategies to improve adherence include good patient-physician relationship, empathy for the patient, joint decision making, efficacious, safe and easy to use therapies, and interdisciplinary approach (rheumatologist, psychologist, psychiatrist, nurses). Back to top
Johan Gudjonsson, MD, PhD, IPC Board Member- University of Michigan Vinod Chandran, MD, PhD - University of Toronto Professor Johan Gudjonsson, a renowned researcher from the University of Michigan and IPC Board Member, presented new insights on the pathogenesis of psoriasis and remarkable novel findings. It was highlighted in the pathogenesis model integrating immunopathology and genetics of psoriasis that there are multiple different interactions and multiple different compartments critical in driving the disease and may act on various stages. However, this is still incompletely understood. Another way of looking at the pathogenesis of psoriasis is through its cytokine network that can shape and dictate clinical phenotype. The predominant cytokine noted in plaque psoriasis is IL-17, with a lesser contribution from IFN and IL-36. Clinical subtypes, paradoxical and pustular psoriasis, have type 1-IFN and IL-36 as their predominant cytokines, respectively. Most of the interactions in psoriatic skin occur between four cell types: keratinocytes, T cells, myeloid cells, and fibroblasts. Novel tools and technologies provide insights into psoriasis pathogenesis: 1) compartmentalization of specific immune response (ie IL-36 and IL-17A in the suprabasal layer of the epidermis), 2) contribution of fibroblasts in the pathogenesis of psoriasis, 3) CD8 T cells as a primary source of IL-17. Associate Professor Vinod Chandran, a rheumatologist and clinician-scientist from the University of Toronto discussed psoriatic arthritis's pathogenesis (PsA), focusing on the transition of psoriasis to transition to psoriasis synovio-enthesial inflammation. Genetic factors in developing psoriasis include the presence of the first-degree relative with PsA and the presence of the HLA-B27 allele. Factors such as trauma, comorbidities, biomechanical stress, and microbiome-related events may provide “second hits” in the development of PsA. The aberrant immune activation in the skin, gut, and enthesis through the activation of IL-23 – IL-17 axis and TNF production leads to the development of psoriatic arthritis. From recent studies, clonal CD8 T cell expansion, a predominance of monocyte/macrophage cells, and the presence of tissue-resident human enthesis γ𝛿T-cells were noted in PsA joints. Back to top
Christopher Griffiths, OBE, MD, FRCP, FMedSci, IPC Honorary Founder - University of Manchester Darren Ashcroft, BPharm MSc, PhD, FRPharmS, IPC Councilor - University of Manchester
IPC Board Member Christopher Griffiths and IPC Councilor Darren Ashcroft, both from the University of Manchester, discussed the Global Psoriasis Atlas (GPA) and the global burden of psoriasis updates. GPA collaborates with ILDS, IPC, and IFPA and is working in partnership with The University of Manchester. The GPA is a website launched on October 29, 2019. The mission of GPA is to ensure that people with psoriasis, wherever they live in the world, have access to the best available care. The prevalence of psoriasis is increasing while incidence is stable. At least 60 million people worldwide have psoriasis, the highest recorded in Scandinavian countries and low in Southeast Asia. In Latin America, access to dermatology cares widely varied, with a mean waiting time of 56 days. In Tanzania, of 57 million people, there were only 31 dermatologists. Misdiagnosis of psoriasis is common. They also have limited access to systemic medications, wherein methotrexate is the only systemic therapy available. The field survey was also done in Maasai Land. Clinical diagnostic criteria developed by Al-Tabik, et al published in BJD in 2021 for early psoriasis diagnosis help non-dermatologists, especially in low to middle-income countries. Currently, GPA focuses on epidemiology, early diagnosis, comorbid disease burden, and economic impact. There are future global research project plans and collaboration with Myanmar (webinars, workshops, establish a patient association), Greenland (pilot study on psoriasis prevalence, epidemiological study), Qatar (validation and cohort study on incidence/prevalence), and Newfoundland (large cohort study on epidemiology, comorbidities, economic impact). New epidemiological studies in Chile, Taiwan, and Malaysia and cohort studies on cancer comorbidity in UK, Denmark, Taiwan, Israel are underway. Back to top
Anthony Bewley, BA, MBChB, FRCP - Barts Health NHS Trust Andrea Evers, PhD - Leiden University Professor Anthony Bewley, a consultant dermatologist from Barts Health NHS Trust in London, talked about psoriasis, psychology, and cognitive behavior therapy. Ninety-eight (98) % of psoriasis patients struggle with emotional and psychological well-being. Many of them find it difficult to access psychological support. What can be done? 1) Have patient-centered communication by respecting and responding to patient’s wants, needs, and preferences so that patients can make choices in their care based on their circumstances; 2) Help patients access psychological treatment – eg relaxation techniques, mindfulness, cognitive behavior therapy, acceptance and commitment therapy, and group therapy. Professor Andrea Evers from Leiden University, Netherlands, talked about the placebo effects in psoriasis and psoriatic arthritis. Placebo and nocebo effects significantly impact different outcomes such as adherence to medication, reporting side effects, recovery, and morbidity and mortality. The placebo effect is a learning body through verbal suggestions (for short-term effects) and conditioning (for more stable, long-term effects). Clinical implications of optimizing placebo effect: 1) on patient – expectation-based treatments, 2) professional – doctor-patient interaction, 3) medication – pharmacotherapeutic conditioning. An interactive session on the role of advocacy groups was participated by Kathleen Gallant from IFPA, Paul Mendoza from Psoriasis Philippines, and Silvia Fernandez Barrio from AEPSO in Argentina. Advocacy groups have a substantial positive impact on patients’ mental health. They support patients by 1) letting them know that other people are going through the same situation and they can share their experiences with people who understand their struggles, 2) bridging the gaps between patients and doctors, 3) linking patients to the right doctors and proper treatment access, 4) organizing programs to help patients understand their disease more (ie PsorCoach, webinars). Back to top
April Armstrong, MD, MPH, IPC Councilor - Keck School of Medicine of USC Barbra Bohannan - International Federation of Psoriasis Associations (IFPA) Cristina Echeverria, MD, IPC Councilor - Argentinian Psoriasis Society Roop Saini , MD- Kenyatta National Hospital Dr. April Armstrong, an IPC Councilor and professor in dermatology from Keck School of Medicine of USC, discussed the interim results of the global psoriatic disease (PsD) survey capturing patient perspectives. The Global Psoriatic Disease Survey is a cross-sectional, quantitative online survey conducted in about 5000 patients >18 years old with BSA of >5% to <10% from 20 countries with moderate to severe plaque psoriasis with or without concomitant psoriatic arthritis. It aims to assess the patient’s understanding of psoriasis and psoriatic arthritis as part of systemic disease and describe the humanistic and physical burden of living with the condition. The interim results indicate that while a high percentage of patients had heard the terms ‘systemic disease’ and ‘psoriatic disease,’ they remain unaware of the systemic nature of PsD and the increased risk of associated comorbidities. The results highlight the disease burden from patients’ perspectives and underscore the need to recognize the systemic nature of the psoriatic disease and its various manifestations and comorbidities, as well as the humanistic and physical impact of living with PsD to ensure optimal management of patients. Ms. Barbra Bohannan, coordinator of policy, advocacy, and research of IFPA, discussed the survey findings from Sweden in improving treatment and care in the primary care setting. Healthcare in Sweden is a complicated system with many variables that can lead to unequal quality of care. The 2020 Psoriasisforbundet primary care online survey findings conclude that the responders felt that: 1) the delay to diagnosis is long, especially for psoriatic arthritis, 2) the treatment and care they receive is not enough, despite the deterioration in their condition or well-being, 3) it is difficult to get a referral to a specialist, 4) the knowledge about comorbidities is insufficient. Proposed options to create confidence and trust in psoriasis patients in a primary care setting include improved knowledge about the diagnosis and available treatment options and a holistic perspective on the patients’ health and well-being. Professor Cristina Echeverria, president of the Argentinian Psoriasis Society and IPC Councilor, discussed the latest therapeutic guidelines for managing psoriasis. Conclusions from her talk are the following: 1) National guidelines for the treatment of psoriatic patients are scarce all around the world, 2) Although different methodologies could be used, GRADE reduces the risk of bias in the development of recommendations, 3) High-quality guidelines based on evidence is essential, 4) Guidelines can be helpful not only to physicians but also to all the stakeholders, ensuring adequate treatment and facilitating access to the provision of care to patients. Dr. Roop Saini, a consultant dermatologist from Kenyatta National Hospital, Kenya, discussed learnings from Africa. Unmet needs in psoriasis experienced in Kenya are the following: 1) general lack of awareness about psoriasis, 2) gaps in specialized health care with a shortage of qualified dermatologists and rheumatologists, 3) limited healthcare resources, 4) lack of teledermatology services in rural areas, 5) need for current national clinical guidelines, 6) need to address language barriers, 7) lack of central patient registries, 8) paucity of data and research studies. Back to top
Curdin Conrad, MD, IPC Councilor - Lausanne University Hospital Professor Curdin Conrad, an active IPC Councilor and dermatologist from the Dermatology CHUV, University Hospital of Lausanne, Switzerland, discussed psoriasis and infectious agents. Conclusions from the first part of his talk are 1) Skin microbiota is essential for “optimal skin immune fitness” and stimulate protective immune responses; 2) Skin microbiota drives pustular psoriasis; 3) Dysbiosis might play a role in plaque-type psoriasis. Key points from his talk on the role of pathogens in targeted therapies are: 1) Not all Th17 cells are pathogenic. Non-pathogenic Th17 cells have physiological functions, including protection against extracellular pathogens; 2) IL-17 inhibition but not IL-23 inhibition is associated with candida (fungal) infections; 3) Risk of tuberculosis reactivation for non-anti-TNF biologics (IL-23 and IL-17 inhibitors) is negligible. Back to top
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