The Evolving Psoriasis Treatment Landscape and Managed Care Considerations

Welcome to Unscripted, the AMCP podcast, a look inside managed care pharmacy.

Steve: What if treating psoriasis as just a skin disease is causing us to miss the bigger picture? As we recognize World Psoriasis Day on October 29th, we're exploring the broader impact of this complex condition and what it means for patient care. Welcome to Unscripted, the AMCP podcast. I'm Steve Kheloussi. I'm the principal consultant with Kheloussi Consulting and a managed care pharmacist by background.

This episode of Unscripted is sponsored by AbbVie Inc. AbbVie, they find answers that make life better for patients and our world. Joining us today is Dr. Harrison Nguyen. Dr. Nguyen is a double board certified dermatologist, Mohs micrographic surgeon, and clinical researcher in Houston, Texas. He serves as managing director at Harrison Dermatology and Research Group, clinical associate professor of dermatology and health economics at the University of Houston College of Medicine, and clinical assistant professor of dermatology at the Baylor College of Medicine.

Dr. Nguyen, welcome. We're so happy to have you. 

Dr. Nguyen: Steve, thanks so much for having me. Thrilled to be on here and talk about psoriasis. 

Steve: Fantastic. And so, yeah, let's jump right in. Psoriasis is increasingly being recognized as more than a skin condition. Can you explain how the inflammatory pathways that drive psoriasis also contribute to comorbidities such as psoriatic arthritis, inflammatory bowel disease, cardiovascular disease, and metabolic syndrome?

Dr. Nguyen: Absolutely. And this is so important for me to explain to patients when I first meet them and render the diagnosis psoriasis, or even if they're coming to me after years of having a diagnosis of psoriasis that maybe no one's ever talked to them about it. I have to explain to patients that psoriasis is a systemic inflammatory condition.

It's a chronic systemic inflammatory condition. Chronic meaning we don't have a cure, systemic meaning that it's happening within the body, and inflammatory meaning, of course, there's inflammation going on inside the body. And what we see on the skin is often just the tip of the iceberg, right? And so I have two, kind of major goals as a dermatologist taking care of my psoriasis patients.

First, of course, is to make sure that the psoriasis isn't impacting their quality of life. That often comes in terms of making sure that we can clear their skin, making sure their skin's not itchy. But second, to also make sure that patients understand the systemic inflammatory nature of psoriasis and making sure that we are both managing and monitoring for that.

So what does that mean? It means that psoriasis can affect beyond just the skin. In about 30% of patients, it can affect the joints. That's called psoriatic arthritis. It can also affect the, the stomach and the gut. That's manifested as inflammatory bowel disease. It can also affect the heart and the vessels.

We know that patients with psoriasis are at increased risk for cardiovascular events, so things like heart attack and stroke. And so, it's just important for me to explain to patients that, look, like, look, I'm, as a dermatologist, I'm focused on making sure that you're not itchy, that we're going to clear your skin, but also that we're going to look out for other things, and making sure that you understand about your condition and making sure that we are able to, you know, monitor your health with a diagnosis of psoriatic disease.

Steve: Yeah. No, you raise such a good point, especially around your first goal. I feel like a lot of people underestimate the psychosocial burden and how this disease can impact quality of life. So how do things like depression, anxiety, and stigma affect patients' overall health outcomes? And, you know, how should clinicians account for these impacts when developing treatment plans?

Dr. Nguyen: Yeah. So there, there are patients with psoriasis are at increased risk for developing depression, anxiety. There's a couple schools of thought, and I think that there's probably truth to both of them as to why that's the case. So remember that psoriasis is a systemic inflammatory condition, and so the inflammation happens, beyond, the skin, including the nervous system, we believe.

And so we believe that psoriasis the inflammation of psoriasis can lead to the manifestations of things like depression, anxiety. But we also know that because psoriasis is often often affects visible areas or can affect areas that are impactful to the patient. It can affect the hands, it can affect the face, it can also be very itchy, it can affect the scalp, and so patients are itchy and they're flaky.

And because of those symptoms that they're it can impact the way a patient presents themselves to the world, right? And so that's something that we know that skin, you know, represents our, how we present ourselves to the world and can affect our self-confidence. And when we are and our skin is impacted it can lead to psychiatric comorbidities like depression, anxiety.

So I think there's kind of truth to both of those and it's important for us to be able to be able to monitor for that, to be able to educate our patients about that, and to be able to make sure that we're addressing those comorbidities appropriately for our psoriasis patients.

Steve: Yeah, absolutely. So much more than just a skin condition. And you mentioned that the treatment focuses not only on the, the skin manifestations but also the comorbidities. So I want to talk a little bit more about treatment. And so, historically, psoriasis treatment, you know, it frequently follows a stepwise escalation approach, right?

So how has the treatment paradigm changed over time towards treating earlier and aiming for outcomes such as clear or near clear skin? 

Dr. Nguyen: Well, treatment of psoriasis of the skin has been one of the greatest success stories in all of medicine. You know, we are able to administer in modern medicine both effective and safe therapies that can clear 90 to 100% of psoriasis on the skin.

And I differentiate that because psoriasis on the skin, we've gotten very good at treating. We have a lot of really good treatment options. However, psoriasis of the joint, psoriatic arthritis, lags behind in that, so that it is an important differentiator. Now, you mentioned we have different tools and, you know, my job as a doctor is to make sure that I find the right treatment plan that fits into the patient's preferences and patient's lifestyle and patient goals, but also addresses aspects of their health that they may not be aware of.

So it's what we call shared decision-making in medicine, making sure that I understand the patient's burden on their quality of life, understand their preferences, and then design a treatment plan that addresses the things that I know to be true or probable about their disease that integrate best with that patient's goals and preferences, okay?

And so we have things like creams that we can use, creams and topical options like foams that we can use to treat psoriasis of the skin. We have pills that we can use to treat psoriasis as well as injections or biologics, right? And so each one kind of presents different unique advantages.

And so, you know, depending on the patient, we find the right treatment plan for that. And you mentioned another important thing, Steve, about step therapy. We don't like that terminology in dermatology. We don't like having to necessarily follow an algorithm where we have to take step one before we get to step two, before we get to step three.

That step therapy is often mandated by insurance plans, mandated by payers, and they aren't really often focused and designed around the patient needs and things that are important to the patient and their health. And so, you know, as dermatologists and dermatology clinicians, we're trained in finding the right science, the right treatments for the patient in front of us.

We believe that we should be able to go to step three if that's what is warranted for the patient at that time in front of us, right? We shouldn't have to, let's say, we have a patient with 50% coverage of their skin, we shouldn't have to start with, let's say, the doing only topical treatments, then failing topical treatments to then get them to more advanced therapies when we know that what they need from the get-go is likely a, the advanced therapy.

So, I think a couple points just to summarize is that we have a lot of great treatment options. Psoriasis has been a true success story in science and in medicine. You know, sometimes we have our hands tied by things like access and things like insurance. But that being said, it's a joy to take care of our patients and, you know, understanding what their experiences, what their preferences, and then finding the treatment regimen that is best for them.

Steve: Yeah. You raise a, a really good point about step therapy, and I want to, pause on this for a moment because our audience is payers and, you know, the payers, recognize the importance of appropriate treatment, while also struggling to balance sometimes appropriate use of resources and all of that.

And, I want to go back to something that you said earlier. You noted that there are, certain patients who we need to set realistic expectations, such as clear skin and getting them on therapy early in the disease. What evidence, what clinical experience do we have that supports this idea of achieving high levels of skin clearance early in the disease, and how that will impact long-term patient outcomes?

Dr. Nguyen: We have multiple levels of evidence to show that skin clearance or complete skin clearance should be our goal, right? We know that early intervention can change the trajectory of disease, that early intervention in the disease course can reduce inflammation and prevent progression.

It can, it, our treatments often work better. And then, second is that when we aim for complete clearance, so 100% clearance of psoriasis of the skin, it reflects a better impact on quality of life improvement, right? In that patients care about the difference between 5% BSA versus 0% BSA.

That makes a big difference. I know it may not sound like we're talking about just one or two percentage points, but when we've looked at quality of life impact and impact socioeconomically of, interventions, we see a significant improvement when we strive and achieve complete clearance.

Steve: Yeah. That's a great summary. And so do we tend to see differences in outcomes if we're thinking about durable disease control as opposed to patients who continuously flare and then go back into remission and flare back into remission? 

Dr. Nguyen: Yes. So durability is important. We want to try to identify treatments that are effective, safe, and durable, where we're able to maintain control over a long period of time.

Remember, psoriasis is a chronic condition. It's not a, word, it's not like a, you know, a cold that we can just treat and it goes away. This is something we have to treat over the long term. And so, fortunately, our advanced therapies nowadays, we are able to achieve very good clearance with a very favorable safety profile with very strong durability And also the nice thing is that, you know, in our more advanced treatments, so like IL-23 inhibitors, IL-17 inhibitors, there is almost no risk for development of clinically significant drug antibodies, right?

And so why is that important is because historically our first kind of main systemic treatment or biologic treatment for psoriasis were TNF alpha inhibitors, which of course were important at the time, but they have high risk for anti-drug antibodies, right, and neutralizing antibodies. And so patients lost access to the medication or they came off it for any reason, that could have really important consequences for long-term response and long-term control and durability of their treatment.

And so, you know, fortunately with our, 23s and our 17s nowadays, we're able to achieve durable response and, but if there is a gap in coverage, which certainly is not ideal from a disease control standpoint. Fortunately, if we are able to restart the medication, we are more than not able to recapture response.

Steve: And I think you highlight such an important point here is that the treatment landscape has expanded considerably in recent years. So as the number of treatment options continues to grow, how do you determine which therapy is going to be the right fit for a particular patient, and what kind of patient-specific factors do you consider beyond the efficacy decisions alone?

Dr. Nguyen: Well, we take into account multiple factors. The patient's manifestation of psoriasis, each patient is different. So what particular areas are affected on the skin or on the nails or on the scalp? We have some medications which show stronger data for certain anatomical involvement, right? Number two, what is the risk for joint involvement?

If the risk for joint involvement is higher, and we have sometimes different predictors of that. For example, we know nail psoriasis, three times greater risk for developing psoriatic arthritis. Scalp psoriasis is four times greater risk of developing psoriatic arthritis. So we look at different kind of indicators of that, and depending on whether those are in place, then we say, "Okay, we need to protect the joints," and we may go after different medications which, with different levels of joint data.

And then so those are my two, I think, driving factors. Obviously, I want to choose a efficacious agent that can protect the joints, in particular patients. But then we also look at things like comorbidities, right? And what other things are patients, have they been diagnosed with, because based on comorbidities, we may lean towards, certain classes over others.

And then finally, patient preference, right? So, does a patient prefer a once a day medication, once a day oral medication versus doing a injection every two or three months, right? And so then we integrate all that to help us formulate what we believe to be the best treatment plan for the patient.

And, you know, typically, we give it about three to four months for a medication, a biologic or a systemic agent to kick in, in psoriasis. And we usually believe we get it right the first time, but we don't always get it right the first time. Sometimes we have to see response and if it doesn't respond the way that we think, then we then we have to switch to a different agent.

And so that's all to say is that we take into, it's a global assessment. We take into multiple factors when choosing the right agent, and that's also why, going back to our discussion, Steve, about step therapy, why we believe it's important for us to maintain some degree of, autonomy in choosing the treatments.

We know that, I know there's a lot of factors in which medications you can get access to and others, but it's important to maintain some autonomy because when we make a decision that drug X is best for the patient, it's usually for a reason, right? It's because of taking into the global assessment for why that treatment is the best treatment for the patient in front of us, as opposed to another treatment 

Steve: Yeah, it goes back to this idea that shared decision-making is between the provider and the patient, right?

Not necessarily the insurance company. But, you know, one of those factors that often does weigh in to those decisions is insurance coverage. You know, these are not inexpensive medications, and so, it's important that these patients are able to fill their prescriptions once they leave the, the provider's office.

So from your perspective, what is something that you think that's, you know, important for payers to know about how dermatologists are viewing the growing number of effective therapies? 

Dr. Nguyen: It's important for payers to understand when we treat psoriasis, it is more than just a skin condition, right?

Of course, we're, we are keyed into the skin, quality of life impact, but we're treating a systemic inflammatory condition. So it's important for us to have access to advanced systemic therapies. But it's also important for us to have access to multiple advanced systemic therapies because they are differentiated.

Not all IL-23s are the same, not all IL-17s are the same, right? And so, even within a class, we need to really need to maintain access to multiple agents within a class because the psoriasis patient in front of us may be different than the next one. And so it's important for us to be able to choose the best treatment for that patient so that we can restore quality of life, but also reduce systemic inflammation and making sure that reduce risk of things like joint involvement and inflammatory bowel disease, et cetera, of other manifestations of psoriasis.

Steve: Yes that's a really good summary, and I think something that payers need to recognize as they're designing their formularies and, you know, they're making their coverage decisions is think about that individual patient, which is sometimes a little bit challenging, you know, when working remote, not face-to-face with the patient and so on.

Now, I want to switch gears just a little bit here. We are anticipating new guidelines from the American Academy of Dermatology in the third quarter of 2026. What are you expecting to see in these guidelines and what would you like to see in these guidelines? 

Dr. Nguyen: Yeah, we continue to, evolve and grow in dermatology and the treatment options that we have.

It's going to be important to integrate the new treatment options. To make sure they have a clear place in our treatment regimens. What I'll also be very, keen to see is the importance of educating the patient on other comorbidities of psoriasis because, you know, yes, we're in dermatology, we're focused primarily on the skin, but it's also our job to educate on the other aspects of the patient's disease.

Furthermore, I'll be keen to make sure that, it's being communicated that complete clearance is our target. We should try to strive for complete clearance on the skin, treating to target. And then the final thing, Steve, that I will be very, keen to to see is the, impact of emerging treatments and the role of treating psoriasis and systemic inflammatory conditions.

Steve: Now, as it relates to these, guidelines that we're anticipating, payers are going to react to them, right? They're going to review their formularies, they're going to review their prior authorization requirements. And so from your perspective, what should payers keep in mind as they review these new guidelines when they become available?

Dr. Nguyen: Keep in mind that we have many treatment options for psoriasis and that they're differentiated. And that, you know, the guidelines, they tend to be a snapshot. They tend to be a summary of recommended approaches to psoriasis and different manifestations of psoriasis.

But they, just because of the complexity of psoriatic disease, the guidelines don't always have the bandwidth and the room to be extremely nuanced in how different manifestations of psoriasis are best treated. So I would just say to payers, please read the guidelines. Please integrate them.

But just also bear in mind our discussion point earlier that, you know, it's important to have access, to multiple treatments, advanced treatments in psoriasis because oftentimes when we are choosing a particular IL-23, it is for that reason for the, that we're choosing the IL-23, or choosing an IL-17, we're choosing for that reason the IL-17.

And the guidelines don't always get so nuanced into the differentiated aspects of those, but just know that we do have a lot of data to show that the differentiation among the different treatments. 

Steve: Yeah. Excellent points, and, I think that's something that we need to remember as we review guidelines, right?

We call them guidelines because they're a guide, not necessarily because they're going to be appropriate for every patient, and that's something that we struggle with on the managed care side is applying population level care to individual patient level scenarios and this is a perfect example of that.

So Dr. Nguyen, thank you so, so much. 

Dr. Nguyen: Thanks so much for having me on, Steve. 

Steve: And thank you to our audience for listening to this episode of Unscripted, the AMCP podcast. This episode was sponsored by AbbVie Inc. For more information about AbbVie, go to abbvie.com.