Psoriasis/Psoriatic Arthritis Update:

A Team-Based Approach to Elevated Care

Supported by educational grants from AbbVie Inc. and Janssen Biotech, Inc.,
administered by Janssen Scientific Affairs, LLC
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Faculty
April W. Armstrong, MD, MPH Philip Mease, MD, MACR
Professor of Dermatology and Associate Clinical Professor
Dean of Dermatology University of Washington
Keck School of Medicine of USC School of Medicine
Director
Associate Dean for Clinical Research
Rheumatology Research
Department of Dermatology Swedish Medical Center
Director, Clinical Research Support, Southern Providence St Joseph Health
California Clinical and Translational Science Seattle, Washington
Institute (SC CTSI)
Vice Chair and Director, Clinical Trials and
Outcomes Research
Director, Psoriasis Program
Los Angeles, California
Disclosures
The faculty reported the following financial relationships or relationships to products or
devices they or their spouse/life partner have with commercial interests related to the
content of this CME/CE activity:
April W. Armstrong, MD, MPH, has disclosed that she has received consulting fees from
AbbVie, Aslan, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavent, Dermira, EPI Health,
Incyte, Janssen, Leo, Lilly, Novartis, Ortho, Parexel, Pfizer, Regeneron, Sanofi, Sun, and UCB
and funds for research support from Bristol-Myers Squibb, Dermavent, Dermira, Lilly, Leo,
Pfizer, and UCB.
Philip Mease, MD, MACR, has disclosed that he has received consulting fees from AbbVie,
Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Galapagos, Gilead Sciences,
GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, Sun, and UCB; funds for research from AbbVie,
Amgen, Bristol-Myers Squibb, Galapagos, Gilead Sciences, Janssen, Lilly, Novartis, Pfizer, Sun,
and UCB; and fees for non-CME/CE services from AbbVie, Amgen, Janssen, Lilly, Novartis,
Pfizer, and UCB.
 Epidemiology, Burden, and
Clinical Features of Psoriatic Disease
 Clinical Burden of Psoriatic Disease in the United States
▪ Chronic, multisystem inflammatory disorder1
▪ Affects >8 million individuals 2
‒ 10% to 30% develop PsA2,3
▪ Symptoms usually develop by 20-30 yr of age but can occur at any time2
▪ ~25% of patients have moderate to severe disease2
‒ Extensive involvement on hands, feet, scalp, or genitals3
▪ Negatively affects QoL, productivity, daily function2
▪ Risk factors include smoking, obesity, stress, genetics4

1. Elmets. J Am Acad Dermatol. 2021:84;432. 2. www.psoriasis.org/content/statistics. 3. Menter. J Am Acad Dermatol.

2019;80:1029. 4. www.mayoclinic.org/diseases-conditions/psoriasis/symptoms-causes/syc-20355840?p=1. Slide credit: clinicaloptions.com
 Psoriasis Epidemiology
▪ Equal frequency in both sexes1
▪ 70% have onset before age 402,3
▪ Adults: 2 peaks of onset4
‒ At 20-30 yr (most)
‒ At 50-60 yr
▪ Children4:
‒ Onset between 8 and 12.5 yr
‒ Prevalence between 0.5% and 1.1% in children younger than 16 yr of age

1. Rachakonda. J Am Acad Dermatol. 2014;70:512. 2. Queiro. Rhuematol. 2014;53:1178.

3. Griffiths. Lancet. 2021;397:1301. 4. Burden-Teh. Br J Dermatol. 2016;174:1242. Slide credit: clinicaloptions.com
 Inflammation in Psoriasis

Reproduced with permission from Armstrong. JAMA. 2020;323:1945. Copyright©2020 American Medical Association. All rights reserved. Slide credit: clinicaloptions.com
 Psoriasis Classification: Subtypes1-3
▪ Morphology-based ▪ Location-based classification:
classification:
‒ Inverse/intertriginous
‒ Plaque (most common; 80%)
‒ Palmoplantar
‒ Guttate
‒ Nail
‒ Erythrodermic
▪ Overlap
‒ Pustular (generalized, localized)
▪ Change from one subtype to
another

1. www.psoriasis.org/locations-and-types/.
2. Rendon. Int J Mol Sci. 2019;20:1475. 3. Griffiths. Lancet. 2021;397:1301. Slide credit: clinicaloptions.com
 Plaque Psoriasis
▪ Most common morphology
(80%)
▪ Well-demarcated plaques
with varying degrees of:
‒ Erythema (pink to red)
‒ Scale (desquamation)
‒ Induration (thickness)

Reproduced with permission from Armstrong. JAMA. 2020;

323:1945. Copyright©2020 American Medical Association. All rights reserved.
 Prevalence of PsO and PsA

Prevalence of PsO in the general

US population: ~3.2% 1

Prevalence of PsA in patients with PsO in

North America and Europe: 10%-30%2

Expected prevalence of PsA in US:

0.32%-1.0%

1. Rachakonda. J Am Acad Dermatol. 2014;70:512. 2. Mease. J Am Acad Dermatol. 2013;69:729.

 PsO and Musculoskeletal Pain: A Challenging
Differential
OA + Gout
PsA + Gout 1%
1% Indeterminate
Gout 13%
2%

PsA
41%

OA
27%

PsA + OA
15%

Qureshi AA. Semin Cutan Med Surg. 2005;24:46. Slide credit: clinicaloptions.com
 Psoriasis Epidemiology Screening Tool
▪ PEST comprises 5 questions:
‒ Have you ever had a swollen joint (or joints)?
‒ Has a doctor ever told you that you have arthritis?
‒ Do your fingernails or toenails have holes or pits?
‒ Have you had pain in your heel?
‒ Have you had a finger or toe that was completely swollen and painful for no apparent
reason?

▪ Answering “yes” to ≥3 of the 5 questions suggests PsA

▪ PEST questionnaire has 91% sensitivity and 84% specificity

Ibrahim. Clin Exp Rheumatol. 2009;27:469. Slide credit: clinicaloptions.com

Patient Vignette:
42-Yr-old Man With 4-Yr History of Plaque Psoriasis
▪ ̴4% body surface area affected: scalp, elbows, and knees, but no nail findings
▪ Currently on betamethasone/calcipotriene foam
▪ When asked about joint pain:
‒ No history of arthritis
‒ Reports intermittent pain in the fingers for the past 2 mo
‒ Swelling of one entire finger digit
‒ No heel pain
▪ Should this patient be evaluated by a rheumatologist?
Guideline Recommendations
 NPF Treatment Target for Psoriasis:
≤1% of BSA During Maintenance Therapy
Preferred
Initiation Maintenance
Assessment
Body Surface Area Phase Phase

Therapeutic Benefit
Instrument in
Clinical Practice
Either BSA ≤3% or BSA
Acceptable
improvement ≥75% from
response after tx
baseline at 3 mo after tx
initiation
initiation
Target response BSA ≤1% at 3 mo after tx
after tx initiation initiation Time
Target response
BSA ≤1% at every 6-mo
during
assessment interval during
maintenance
maintenance therapy
therapy

Armstrong. J Am Acad Dermatol. 2017;76:290. Slide credit: clinicaloptions.com

 Calculating the Extent of Psoriasis:
1% = Surface Area of the Hand
Psoriasis Coverage and Severity

1%
Mild Moderate Severe
<3% 3%-10% >10%
of the body of the body of the body
has PsO has PsO has PsO

Menter. J Am Acad Dermatol. 2019;80:1029. www.psoriasis.org/sites/default/files/npf_pocketguide_2018_0010.pdf. Slide credit: clinicaloptions.com

 AAD Recommendations: Psoriasis Management

With PsA Without PsA

Psoriasis

Limited Moderate to
Biologic severe disease
± MTX disease

Topicals/
UVB/ Oral
targeted Biologic
PUVA systemic
phototherapy

Lack of effect
Adpated from Menter. J Am Acad Dermatol. 2008;58:826. Slide credit: clinicaloptions.com
 Overall Treatment Approach for Plaque Psoriasis

.
Reproduced with permission from Armstrong. JAMA. 2020;323:1945. Copyright©2020 American Medical Association. All rights reserved. Slide credit: clinicaloptions.com
 ACR/NPF Recommendations:
Management of Patients With Active PsA
Treatment-naive Begin with TNFi over oral small molecules,
active PsA IL-17i, or IL-12/23i

Persistent active disease?

Switch to different TNFi*

Persistent active disease?

Switch to IL-17i*
Persistent active disease?

Switch to IL-12/23i*

*Biologic therapy is recommended over biologic + MTX combination therapy.

▪ Methotrexate or other oral small molecule agents can be employed if indicated

by cost or other reasons (eg, to bolster effect or combat immunogenicity)

Adpated from Singh. Arthritis Rheum. 2019;71:5. Slide credit: clinicaloptions.com

 GRAPPA: Management of PsA
Peripheral NSAIDs, Biologic (TNF, IL-12/23, IL-17,
Switch biologic, JAK, or PDE4
arthritis csDMARDs IL-23, CTLA4-Ig) JAK, or PDE4

Axial disease NSAIDs Biologic (TNF, IL-17) or JAK Switch biologic or JAK

MTX, biologic (TNF, IL-12/23,

Enthesitis NSAIDs Switch biologic, JAK, or PDE4
IL-17, IL-23, CTLA4-Ig), JAK or PDE4

MTX, biologic (TNF, IL-12/23,

Dactylitis NSAIDs Switch biologic, JAK, or PDE4
IL-17, IL-23, CTLA4-Ig), JAK, or PDE4

Topicals (keratolytics, steroids, Photo Tx or csDMARD,

Psoriasis vitamin D analogs, emollients, biologic (TNF, IL-12/23, Switch biologic, JAK, or PDE4
calcineurin inhibitor) IL-17, IL-23), JAK, or PDE4

Topicals, pulsed dye laser, Biologic (TNF, IL-12/23,

Nail disease Switch biologic or PDE4
csDMARDs, acitretin, JAK IL-17, IL-23) or PDE4

IBD1,2 TNF (not ETN), IL-12/23, IL-23, JAK, MTX

Uveitis 3 TNF (not ETN), CyA

Adapted from Coates. EULAR 2021. Abstr OP0229. 1. Whitlock. J Am Acad Dermatol. 2018;78:383. 2. Chimenti. Ther Adv Musculoskel Dis.
2021;1759720X20977777. 3. Fotiadou. Psoriasis (Auckl). 2019;9:91. Slide credit: clinicaloptions.com
 Biologics and Targeted Synthetic DMARDs
Approved for Treatment of Psoriatic Disease
Indication
Class Treatment Option 1 Approval
Psoriasis Psoriatic Arthritis
Adalimumab 2008 X X
Certolizumab 2018 X X
TNF inhibitors Etanercept 2004 X X
Golimumab 2009 X
Infliximab 2006 X X
IL-12/23 inhibitor Ustekinumab 2009 X X
Brodalumab 2017 X
IL-17 inhibitors Ixekizumab 2016 X X
Secukinumab 2015 X X
Guselkumab2 2017/2020* X X
IL-23p19 inhibitors Risankizumab 2019 X
Tildrakizumab 2018 X
JAK inhibitor Tofacitinib3 2017 X
PDE4 inhibitors Apremilast 4 2014 X X
*FDA approved guselkumab for treatment of patients with active psoriatic arthritis in July 2020 .

1. Menter. J Am Acad Dermatol. 2019;80:1029. 2. Guselkumab PI. 3. Tofacitinib PI. 4. Apremilast PI. Slide credit: clinicaloptions.com
 Guselkumab: MDA, ACR, and PASI Responses Achieved
at Wk 24 and 52 in Phase III DISCOVER-2
1 10 ACR 20 Response2 *P <.05; † P <.01; ‡ P <.001;
MDA at Wk 24 0 §
Adjusted P <.0001
PBO (n = 246) 80 7
GUS 100 mg Q8W (n = 248) ‡
6§
57

Patients (%)
GUS 100 mg Q4W (n = 245) ‡ 4
60 PBO GUS 100 mg Q4W (n = 246) 60 ‡ § 61
‡
‡ 6
→
Patients (%)

‡ ‡ 4
40 4
40 ‡
GUS 100 mg Q4W (n = 245)
†
25 3 GUS 100 mg Q8W (n = 248)
20 19 20 3 PBO GUS 100 mg Q4W (n = 246)
* *
6 * →
0
0 0 2 4 8 12 16 20 24 28 36 44 52
1,2
Wk
10 PASI 75 Response Wk 24 1
MDA at Wk 52 0 86. Wk 52 2
60 78. 4 79. 85. 83.
80 3 0 8 1
Patients (%)

Patients
40 31 34 60
30

(%)
* * 40
20 23.
20 0
0 0 GUS GUS PBO → GUS
*Unadjusted P <.0001 100 mg Q4W 100 mg Q8W 100 mg Q4W
(n = 184) (n = 176) (n = 183)
1. Mease. Lancet. 2020;395:1126. 2. McInnes. Arthritis Rheumatol. 2021;73:604. Slide credit: clinicaloptions.com
Patient Vignette: PsA Diagnosed
▪ 42-yr-old man with 4-yr history of plaque psoriasis
▪ ~4% body surface area affected: scalp, elbows, and knees, but no nail
findings; intermittent pain in fingers; swelling of one entire finger digit
▪ Currently on betamethasone/calcipotriene foam
▪ Rheumatologist diagnoses PsA
‒ Therapy recommendations?
‒ Shared decision-making with the patient?
‒ Coordination with dermatologist?
Emerging Agents for PsO and PsA
 Examples of Emerging Treatments for PsO and PsA

MoA Generic Name Disease State Status

Bimekizumab1 PsO Phase III; PDUFA, 7/22/2021
IL-17AFi
Bimekizumab2 PsA Phase III
TYK2i Deucravacitinib3,4 PsO, PsA Phase III
Risankizumab5, 6 PsA NDA filed 04/21
IL-23p19i Tildrakizumab7 PsO, nail Phase III
Tildrakizumab8 PsA Phase IIb
JAK1i Upadacitinib 9 PsA Phase III; PDUFA pending
Apremilast10 PsO, mild to mod Phase III
PDE4i
Roflumilast11 PsO Phase IIb
Aryl hydrocarbon
Tarpinarof12 PsO Phase III
modulator

1. NCT03410992. 2. NCT03896581. 3. NCT03624127 4. NCT03611751. 5. NCT03675308. 6. NCT03671148.

7. NCT03897075. 8. NCT02980692. 9. NCT03104374. 10. NCT03721172. 11. NCT03638258. 12. NCT03983980 Slide credit: clinicaloptions.com
 Deucravacitinib POETYK Trials:
PASI 75 Response at Wk 16 and Through Wk 24
POETYK PSO-1 POETYK PSO-2
100 Primary endpoint 100 Primary endpoint
PASI 75 Response Rate (%)

PASI 75 Response Rate (%)

80 69.0 80
58.7 % 59.3
60 % 60 53.6
%
%
38.1 40.2 37.8
40 35.1 40
% % %
%
20 12.7 20
9.4
% %
0 0
0 1 2 4 8 12 16 20 24 0 1 2 4 8 12 16 20 24
W W
k
Deucravacitinib 6 mg QD Apremilast 30 mg BID Placebok

▪ Durable response for deucravacitinib patients achieving PASI 75 at Wk 24

Armstrong. AAD VMX 2021. Oral presentation. Slide credit: clinicaloptions.com
 Safety of Deucravacitinib: Adverse Events Wk 0-16
Deucravacitinib Apremilast PBO
AEs, n (%)
(n = 842) (n = 422) (n = 419)
Any AEs 469 (55.7) 243 (57.6) 208 (49.6)
Serious AEs 15 (1.8) 5 (1.2) 12 (2.9)
AEs leading to d/c 20 (2.4) 22 (5.2) 16 (3.8)
Deaths 1 † (0.1) 1 † (0.2) 1* (0.2)
Most common AEs ( ≥5%) in any
active treatment group:
76 (9.0) 37 (8.8) 36 (8.6)
▪ Nasopharyngitis
46 (5.5) 17 (4.0) 17 (4.1)
▪ Upper respiratory tract
38 (4.5) 45 (10.7) 19 (4.5)
▪ Headache
37 (4.4) 50 (11.8) 25 (6.0)
▪ Diarrhea
14 (1.7) 42 (10.0) 7 (1.7)
▪ Nausea
*Sudden cardiac death due to hypertensive CVD occurred in a 57-yr-old female patient receiving PBO. †1 patient d/c deucravacitinib after 4 days
of tx due to use of prohibited medication (leflunomide) and died 9 days later of sepsis and HF. ‡1 patient d/c apremilast due to lung cancer after
3 mo and died from lung cancer and gastrointestinal bleed 1 mo later.
Armstrong. AAD VMX 2021. Oral presentation. Slide credit: clinicaloptions.com
 BE VIVID: Bimekizumab vs Ustekinumab,
Wk 16 PASI 90 and IGA 0/1
▪ Randomized, double-blind phase III trial to compare efficacy and safety of BKZ vs PBO and
ustekinumab in patients with plaque psoriasis (N = 567)
▪ Coprimary endpoint: superiority of BKZ vs PBO; key secondary endpoint: superiority of BKZ vs UST
Wk 16 PASI 90 Wk 16 IGA 0/1
P <.001 P <.001 P <.001 P <.001

Patients Achieving IGA 0/1 (%)

Patients Achieving PASI 90 (%)

100 100
85.0% 84.1%
7 7
5 5 53.4%
49.7%
5 5
0 0
2 2
5 4.8 5 4.8
0 % 0 %
Placebo BKZ 320 mg UST Placebo BKZ 320 mg UST
(n = 83) Q4W (n = 163) (n = 83) Q4W (n = 163)
(n = 321) (n = 321)
Reich. Lancet. 2021;397:487. Slide credit: clinicaloptions.com
 BE RADIANT: Bimekizumab vs Secukinumab,
PASI 100 Over 48 Wk
▪ Phase IIIb trial to assess efficacy and safety of BKZ vs SCK in patients with moderate to severe
plaque psoriasis (N = 743)
‒ Primary endpoint: PASI 100 at Wk 16; secondary endpoint: PASI 100 at Wk 48
PASI 100 (ITT) PASI 100 (Maintenance)*
Bimekizumab Q4W (N = 373)
Bimekizumab Q4W (n = 147)
Bimekizumab Q4W or Q8W (N = 373)
Bimekizumab Q4W/Q8W (n = 215)
Secukinumab Q4W (N = 370)
Patients With PASI 100 (%)

Secukinumab Q4W (n = 354)

100 100
P <.001 P <.001
80 67. 80 73.5%
61. 0 66.0%
60 7 60
48. 46.
9 2 48.3%
40 40
20 20
*aRD: P < .001 BKZ vs SCK
0 1 4 0 1 16 20 24 2 3 4
6 Wk 8 0 4 8 2 Wk 8 2 36 40 44 8
Reich. NEJM. 2021;[Epub]. Slide credit: clinicaloptions.com
 Bimekizumab: Safety

▪ Bimekizumab well tolerated overall1-4

▪ During placebo-controlled period, rates of serious AEs for
bimekizumab not higher than placebo in both pivotal studies2,3
▪ Low rates of oral candidiasis did not lead to discontinuation of
bimekizumab3
▪ During placebo-controlled period, no inflammatory bowel disease
observed in BE READY; 1 case observed in BE VIVID4,5

1. Glatt. Br J Clin Pharm. 2017;83:991. 2. Glatt. Ann Rheum Dis. 2018;77:523.

3. Papp. J Am Acad Dermatol. 2018;79:277. 4. Gordon. Lancet. 2021;397:475. 5. Reich. Lancet. 2021;397:487. Slide credit: clinicaloptions.com
 KEEPsAKE 2: Risankizumab in Active bDMARD-IR
or csDMARD-IR PsA
▪ Randomized, double-blind phase III trial to assess efficacy and safety of RZB vs PBO (N = 443)
▪ Primary endpoint: ACR20 at Wk 24
RZB 150 mg (n = 224)
PBO (n = 219)
10 10 10
08 08 1° endpoint 08
Patients (%)

0
6 0
6 0
6
51.3* 55.0*
0
4 0
4 0
4
0 25.6* 0 26. 0
2 11. 2 5 2 10.
0 4 0 0 2
0 0 0
MDA ACR20 PASI 90 (n = 119 and 123)
*P <.001 vs PBO
▪ BL disease characteristics comparable across tx arms: mean SJC: 13.3; mean TJC: 22.6; mean PsA
duration: 8.2 yr; patients with inadequate response to biologic therapies: 46.5%
▪ SAEs: 4.0% in RZB arm vs 5.5% in PBO arm; serious infections: 0.9% in RZB arm vs 2.3% in PBO arm
Ostor. EULAR 2021. OP0228. NCT03671148. Slide credit: clinicaloptions.com
 SELECT-PsA 2: MDA, ACR, and PASI Responses
for Upadacitinib at Wk 16 and 24
MDA (Wk 24) ACR20 (1° Endpoint)
100 PBO PBO, n = 212
80 UPA 15 mg QD 100
UPA 15 mg QD, n = 211

Responders, % (95% CI)

60 UPA 30 mg QD UPA 30 mg QD, n = 218
80 * *
Responders, % (95% CI)

25 29 6 † †
40 * † † 4 6
* 60 * † *1
20 † 5 †
† 5
3 † 7 9
0 40
† 2
100 4 2
PASI 75 (Wk 16) 20 0
80 56
52 *
60 * 0 1
0 2 4 8 2 16 20 24
40
1 W
20 6 k
*P ≤.05 for UPA 15 mg and 30 mg QD vs PBO.
0 13 13 13
†
P ≤.05 for UPA 15 mg and 30 mg QD vs PBO.
N 1 0 1
Mease. Ann Rheum Dis. 2021;80:312. NCT03104374. Slide credit: clinicaloptions.com
Comorbidities and the Need for Collaborative Care
 Conditions and Comorbidities Associated
With Psoriatic Disease

Depression/anxiety 1 Malignancy 1
Uveitis1
1 COPD1
Obstructive sleep apnea
CVD 1
Hypertension 1
Fibromyalgia3,4
Kidney disease1 Obesity 1
Fatty liver (NAFLD) 1 Dyslipidemia1
IBD1
Diabetes/metabolic
syndrome1
Osteoporosis2

1. Elmets. J Am Acad Dermatol. 2019;80:1073; 2. Shah. J Am Acad Dermatol. 2017;77:287.

3. Brikman. J Rheum. 2016;43:1749. 4. Graceffa. Clin Exp Dermatol. 2015;40:136. Slide credit: clinicaloptions.com
 GRAPPA: Comorbidities in PsA Influence Treatment Selection
NSAI Gl Cy
Sul Me
Ds uc Lef clo
fas th
oc HC lun sp
Comorbidity ala otr
ort Q om ori
zin ex
ico ide ne
e ate
ids
Cardiovascular disease C ?
Congestive heart failure C C C Reason for caution*
Obesity C ** Requires special monitoring
Metabolic syndrome C C ? Data insufficient, concerns raised
Diabetes C C P Preferred therapy*
Inflammatory bowel disease ? † ‡
Uveitis P
Osteoporosis C
Malignancy
Fatty liver disease C C C C
Chronic HBV or HCV C C C
HIV
*Consult with specialists when treating patients with chronic
Chronic kidney disease C C ? ** infections that can affect the liver. †Off-label use in Crohn
Depression disease. ‡Off-label use in ulcerative colitis.
Adapted from Coates. Arthritis Rheumatol. 2016;68:1060. Slide credit: clinicaloptions.com
 GRAPPA: Comorbidities in PsA Influence Treatment Selection (cont’d)
Cer
toli
Ad zu Ust
Eta Infl
ali ma eki Apr
ner ixi
Comorbidity mu b, nu emil
ce ma
ma Go ma ast
pt b
b lim b
um
C Reason for caution
ab
** Requires special monitoring
Cardiovascular disease ?
? Data insufficient, concerns raised
Congestive heart failure C C C C
P Preferred therapy*
Obesity
Metabolic syndrome
Diabetes
Inflammatory bowel disease † † ‡
Uveitis ? P P
Osteoporosis
Malignancy C C C C ? *Consult with specialists when treating patients with chronic
infections that can affect the liver. †Approved for primary therapy of
Fatty liver disease the comorbid condition. ‡CZP approved for Crohn disease; GOL
Chronic HBV or HCV **/ approved for ulcerative colitis.
** ** ** ?
P
Adapted from Coates. Arthritis Rheumatol. 2016;68:1060. Slide credit: clinicaloptions.com
HIV ** ** ** ** ?
Potential Members of the PsO/PsA Management Team
▪ Coordination of care can
bring different perspectives
together, sharpen treatment Dermatologist Rheumatologist

plans, and improve care

Psychiatrist/ Primary care
psychologist provider
Patient
with
Cardiologist PsO/PsA Nurse

Ophthalmologist Endocrinologist
Gastroenterologist

Slide credit: clinicaloptions.com

 Collaborative Care in Psoriatic Disease:
Real-World Challenges
▪ Multisystem systemic disorder
▪ Skin and joints are both important to patients
‒ Dermatologists may not be familiar with articular
aspects
‒ Rheumatologists may not be familiar with dermatologic aspects
▪ Despite progress with treatment options, there is considerable variation in
quality of care regarding:
‒ Diagnosis
‒ Time to referral and treatment
‒ Follow-up
Husni. ACR 2017. Abstr 358. www.psoriasis.org/treatment-and-care. Slide credit: clinicaloptions.com
 Challenges for Dermatologists
▪ Screening for PsA ▪ Unfamiliar/uncomfortable with PsA
management
‒ What’s the rationale? Maybe the PCP is
doing it? ‒ What works in various domains (axial,
enthesitis, etc)
‒ Screening for inflammatory or
noninflammatory arthritis? ‒ Systemic therapies and monitoring
‒ How often? What is the time ‒ Vaccination considerations
commitment?
‒ Comorbidities
‒ Where (waiting room, exam room,
online)? ‒ Medication complications, combination
therapy
▪ PsA workup
‒ Unfamiliar with MSK history and exam,
serologic testing, differential diagnosis
www.psoriasis.org. Slide credit: clinicaloptions.com
 Challenges for Rheumatologists
▪ PsO workup
‒ May not be familiar with multiple presentations of PsO and differential diagnosis of
skin lesions
‒ Especially nonplaque or nonobvious PsO
▪ PsO management
‒ Use of topical and combination therapies to control skin when joints well controlled
‒ What to do about drug-induced eruptions/skin complications
‒ May underestimate importance of skin disease activity
▪ May fail to appreciate the impact of PsO on QoL

www.psoriasis.org. Slide credit: clinicaloptions.com

 One Solution: Rheum-Derm Clinics
▪ Academic or community setting
‒ Both specialties in one office at same time
▪ Virtual
‒ More feasible with rise of telehealth
▪ Postvisit conferences/collaboration
▪ Improved routine communication
‒ Consultation letters, EMR notes, routine phone contact, etc

www.psoriasis.org.
Patient Vignette: Comorbidities and Coordination of Care

▪ 42-yr-old man with 4-yr history of plaque psoriasis

▪ ~4% body surface area affected: scalp, elbows, and knees, but no nail
findings; intermittent pain in fingers; swelling of one entire finger digit
▪ Rheumatologist diagnosed PsA; patient being treated for PsO and PsA
▪ What comorbidities should we be looking for?
▪ Coordination with primary care, other specialists?
▪ Who does what?
 Go Online for More CCO
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CME/CE-certified on-demand webcast (coming soon!) from the live program
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in the holistic management of patients with psoriasis and PsA (coming soon!)

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