Psoriasis & Psoriatic Arthritis – So Now What Do I Do?
James Elder Professor and Chair of Dermatology
University of Alabama at Birmingham
Chief, Division of Dermatology
David Geffen School of Medicine at UCLA
Los Angeles, CA
Joseph B. Chastain Chair of Dermatology
Tulane University Health Sciences Center
New Orleans, LA
In this 4-part lecture, Boni E. Elewski, MD, April W. Armstrong, MD, MPH, Erin E. Boh, MD, PhD, and Kristina Callis Duffin, MD, provided the audience with clinical pearls for treating patients with psoriasis who also have psoriatic arthritis. Dr Elewski began with a tip for treating college students with psoriasis. Interleukin-23 blockers, such as guselkumab, risankizumab, and tildrakizumab, offer reliable, high-efficacy, and convenient dosing schedules for patients who will be away at school. With a proven safety profile, including no contraindication for irritable bowel disease, these medications are a great choice for college students. IL-23 blockers have also been proven effective for psoriatic arthritis in clinical studies.
Dr Armstrong continued the discussion with a pearl for treating erythrodermic psoriasis with severe joint pain. Erythrodermic psoriasis, while rare, can commonly result in nail dystrophy, arthralgias, and lab abnormalities. Ixekizumab, an IL-17 inhibitor, has rapid and robust efficacy in psoriasis, as well as a pediatric indication for psoriasis down to 6 years of age. Ixekizumab was also shown to inhibit radiographic progression of psoriatic arthritis in clinical trials and is effective for both peripheral and axial disease. If complete clearance of erythrodermic psoriasis is not achieved after 3 months, Dr Armstrong recommended adding deucravacitinib to boost efficacy.
Moving on to oral agents, Dr Boh reviewed efficacy data for apremilast and deucravacitinib. Apremilast is an oral phosphodiesterase-4 inhibitor approved for both psoriasis and psoriatic arthritis, with no lab monitoring required except in patients with end-stage renal disease. Apremilast exhibited durable treatment responses in clinical trials, with 44% of patients maintaining PASI-75 responses at Week 206. Deucravacitinib is an oral TYK-2 inhibitor that blocks downstream IL-23 signaling and is approved as a once-daily pill for psoriasis. Exhibiting robust efficacy, deucravacitinib 6 mg led to PASI-75 rates of 53% to 58% at Week 16 in clinical trials. To conclude, Dr Boh provided tips on how to use both of these oral medications in combination with biologic therapies.
To finish the session, Dr Duffin discussed indications and efficacy data for the oldest class of biologic medications, TNF-a inhibitors. With over 20 years of history for this class of medication, TNF-a inhibitors are a pillar of psoriasis and psoriatic arthritis treatment. While IL-23 inhibitors and IL-17 inhibitors may have higher rates of skin clearance, TNF-a inhibitors consistently show the highest rates of joint disease control among the approved biologic medications and should be considered as first-line treatments for axial psoriatic arthritis. TNF-a inhibitors have a few unique characteristics to remember, including the youngest indication (etanercept down to age 4) and proven safety in pregnancy and lactation with certolizumab pegol.