Transitions and Changes That Impact Psoriatic Disease

Shiva: My name is Shiva Mozaffarian and I’m here today with dermatologist Dr. Clive Liu for a discussion about treatment transitions and circumstances that may necessitate going off of your psoriasis treatment and what to expect. Dr. Liu is the Director of the Psoriasis Treatment Center at Bellevue Dermatology where he established an acclaimed center for the research and treatment of psoriasis and other inflammatory skin conditions. Dr. Liu is a member of the adjunct faculty at University of Washington’s Division of Dermatology and a President’s Council member of the National Psoriasis Foundation where he also serves as a member of the Foundation’s Medical Board. In 2021, Dr. Liu received the Outstanding Physician-Clinician in Dermatology award for his achievements in improving psoriatic disease clinical practice which improves the quality of life of those living with psoriatic disease.

Welcome Dr. Liu! Thank you so much for joining us today! So let’s start with a discussion about remission. We know flares of psoriasis tend to come and go, and people may see clear or nearly clear skin for periods of time meaning their disease is under control. Is there a set definition of remission in psoriasis and psoriatic arthritis?

Dr. Liu: Well, that is a great question. And the interesting thing is there actually is no standard definition “what is considered remission”. By the strict definition, remission should be something that continues to clear the disease without treatment. As you may know, the main goal of the National Psoriasis Foundation is a cure. A cure is a permanent remission. Essentially the disease going away permanently without therapy. Now a temporary remission, meaning going away for a while without therapy can be quite helpful for many of our patients. That has been a challenge because we do not have a cure for psoriasis at this point. Some people consider remission when their disease is clear or almost clear while on therapy, and that can be found to be another definition of remission. Now, how long can remission last? Well without therapy, as short as one week for some of the topical steroids to sometimes months. And if you're very lucky, many months. Fortunately, these new therapies keep you clear and almost clear while staying on these new therapies.

Shiva: And so, during these periods of clear skin, is it OK for someone to just stop taking their psoriasis treatment?

Dr. Liu: Generally no. Theres a few reasons why we recommend against just stopping. One of course, is that your disease can come back and flare. In addition, some of these newer therapies that we have including these injectable biologics are technically proteins and our body can develop an immunity against these proteins over time. So that when you go on and off these therapies it slowly stops working. So we generally recommend that you stay on therapy as long as possible. Now we did talk about, a little bit about remission and how do we know when the remission should occur and that's a great question. So for some of my patients, if they have been clear on therapy for quite a while, I will attempt like say, say dip my toes in the water to try to go slowly off the medication. And if we do that, it is hopeful that we can get as low of a dose as needed to keep them clear, or if we're lucky enough go into remission.

Shiva: So Psound Bytes™ recently addressed erythrodermic psoriasis in Episode 183. Isn't it true that some treatments, if stopped, immediately can cause psoriasis to rebound, leading to pustular or erythrodermic psoriasis?

Dr Liu: Wow, that is interesting and it is true. I am old enough to remember a time when these used to happen and most of these patients were admitted to the hospital. Fortunately, we don't see it as much anymore. They usually were patients who are given either oral or injected steroids or would call cortisone. And while these medications do work well and making disease clear relatively quickly. Often when tapered off the medication or going off the medication, their disease comes back even more severe than previously. And when doing repeated cycles of this, what happens is they develop these severe what we like to call it erythrodermic or pustular psoriasis. Unfortunately erythrodermic psoriasis can be life threatening. And with the advent of newer therapies, we just don't see this as much anymore.

Shiva: And is treatment dissatisfaction a factor in the willingness to continue treatment and what should someone do if they’re dissatisfied with their treatment?

Dr. Liu: Yes, I think psoriasis is one of those diseases where treatment satisfaction is probably the most important aspect of the disease that I care about. I have this young lady who was going to college, just had a plaque on her arms and was moving into a dorm room and that was enough to make her horrified about her therapy. Some may think, well, that's very minor and you should keep on the current therapy. My opinion in these cases is we should treat it to the patient's ultimate goal of quality of life, efficacy and clearance of disease.

Shiva: I love that point of view. Thank you. Under what circumstances should treatment be stopped? We've talked about how treatment needs to continue.

Dr. Liu: Ah, that's a great question. There are many reasons why we stop, including insufficient efficacy, and this includes quality of life issues, side effects ( if you have any side effects from the medication that you suspect may be related, you should consider stopping), infections. We all know some of these therapies may increase your risk of infection and while you are sick, you should consider holding your dose until you get better. I also believe that we should have a low-level suspicion. If you're having something that you don't know what's going on, hold the medication, call your doctor. It's better to be safe than sorry. Now there are other reasons you might go off therapy that includes pregnancy. It includes also surgery that sometimes your doctor would want you to hold therapy before the surgical procedure.

Shiva: So let’s talk about some of those circumstances. You mentioned pregnancy, we know not all treatments are safe to use during pregnancy. What are those treatments and what's the best way to transition treatments to something that’s safe when planning to start a family and treating psoriasis during pregnancy?

Dr. Liu: Yes, there are certain medications that are contraindicated during pregnancy. These include retinoids, which are vitamin A derivatives, and methotrexate. Now, if you're on these medications and you are thinking of having children, I think it is important to speak to both your dermatologist and possibly your rheumatologist. The idea is to prepare for when this situation should occur, and this includes transitioning to other therapies that might be successful at keeping your disease under control without medications that could affect the developing baby. We sometimes just transition topical therapy. If that is enough for the skin, we sometimes do light therapy and there are biologics that have been studied in patients who have been pregnant. Certolizumab is one of them. But interesting while there are other biologics that have not been studied for pregnancy, some have been continued and have had healthy babies who were delivered. So it is something you should speak clearly with your dermatologist or rheumatologist.

Shiva: That’s a great point. And doesn’t psoriasis tend to improve during pregnancy and flare shortly after delivery? How do you typically approach treating flares of the disease postpartum?

Dr. Liu: That's a great question because it is true. Often during pregnancy many of my patients actually don't even need therapy, and they can be controlled with a mild topical steroid or topical treatments. Now the post pregnancy flare is relatively common and is a tough time for the mother because of course she has significant responsibilities at that time, and they often neglect their own health. I usually like to speak with them and prepare them for this. Whether getting ready with the limited topical steroids, we also discuss whether they are planning to breastfeed because that could determine which therapy we do. Light therapy is often one of the treatments that we use for mothers who are considering breastfeeding because of course it doesn't affect anything in the breast milk and again as we said before there are certain biologics that seem to be not excreted in the breast milk like certolizumab. But there is also some belief that the other biologics while excreted in the breast milk probably isn't absorbed in significant enough amounts to affect the baby. Again, this is something you should speak clearly with your doctor and determine the risk and benefits of staying on, trying new therapy or going off.

Shiva: So another circumstance where treatment may need to stop is surgery. Should biologics or other immunosuppressants be stopped prior to major surgeries, and if so, why?

Dr. Liu: Oh, that is another interesting and challenging question. There have been many studies on some of these systemic therapies, including some of the biologics, that seem to be safe to do while getting a surgical procedure and many cases I do recommend that they continue. However, there's also concerns about increased rates of infection with these and for many of the surgeons that is their biggest concern. So generally I discuss it with the surgeon. If they feel that it is important enough, I do hold therapy and wait till the surgical site is completely healed or healed enough to restart treatment.

Shiva: And is there a risk of the Koebner phenomenon occurring post-surgery?

Dr. Liu: Yes, that is true. It is something well known named after Dr. Koebner, who noted that after any kind of trauma or surgery to the skin, the resultant inflammation can cause psoriasis to flare. Fortunately, most of the therapies we have these days do seem to keep people clear or as we like to say, remission for enough time after cessation of therapy that we don't see this nearly as often.

Shiva: Another reason that could cause a treatment transition is loss of treatment persistence or effectiveness. Why does loss of treatment effectiveness occur, and what should someone do when this happens?

Dr. Liu: This is one of the mysteries about psoriasis. We see medications that work and over time it stops, and there's many theories of why that happens. Sometimes as I stated before, our body does develop an immunity or what we like to call neutralizing antibodies against the medication we use, the biologics we use. And that can result in loss of efficacy. Of course, there are many things that can cause your psoriasis to flare. Stress, infections can cause it to flare. There's actually one unknown theory that has been fascinating people. Does the body develop kind of a response against our therapies in many ways like a bacteria developing response against antibiotics. There is no data to prove that, but it is a fascinating subject we think about. In these cases again, speak to your physician. We can switch therapies. Sometimes what you need is a combination of different therapies to keep your disease under control, depending on how much your psoriasis has flared. So we have many choices, and we can usually find a path that works best for you.

Shiva: And what works best in one person may not work in another.

Dr. Liu: That is so true. And there is actually research in this area. We have a registry now that is being conducted that kind of looks at people's responses to various therapies and maybe we can gleam out some information of maybe what sort of individuals do better with which therapies. Other than a cure which my hope is within my lifetime that will occur, a more targeted individualized therapy is another goal that we hope to achieve.

Shiva: So, sometimes we hear from people who change insurance that their treatment is no longer covered. How do you as a dermatologist approach such circumstances? Do you try to find other treatment options?

Dr. Liu: This is an interesting question in our society, not only do we change insurance, but I think with changing economic circumstances, at times lose insurance. As a dermatologist, I always like to tell my patients that we are your physicians. Our goal is always to keep you clear despite the changes in insurance. And I think you should not do this by yourself if you lose insurance and if you change insurance, of course, get the information to your dermatologist as quickly as possible. I've done many things to transition these cases. If they have no insurance, we do try to get samples to try to keep you clear until we can figure things out. There are programs out there for those who lack insurance that we can subscribe to and maybe get you on. And if you change insurance, if you wanna stay on the therapy we can try to appeal to your insurance company to try to stay on the current therapy. But at times there are requirements that we switch to different therapies based on the insurance criterias and while we find that less than optimal, we do sometimes go that route too. Our system requires different steps or hurdles to go through before we go to the medication that the patient and the doctor decide upon. That is in many ways a reality, and fortunately, the National Psoriasis Foundation has been a leader in trying to set legislation that tries to diminish a burden of these step edits.

Shiva: Thank you Dr. Liu for including the issue of step therapy! We've spoken about many reasons where transitions of treatment may need to occur. While treatment may need to transition, ultimately why is it important to continue treating psoriatic disease? And what are the risks associated with not treating the disease?

Dr. Liu: Yes, That's another great question. First, I should point out psoriatic arthritis is one big reason to continue. When you have inflammation in a joint and it results in any damage to the joint that is permanent. So our goal is try to prevent any progression of damage to joints because that is a big part of quality of life. Of course we want to try to prevent the recurrence or flare of your psoriasis. I think finally we should talk about inflammation. We have all known now the inflammation is not good for the body. There is discussions about things like an anti-inflammatory diet that has been helpful for many health measures. We do know that inflammation plays a big role in many things. There is now increasing data showing that inflammation can really result in increased cardiac disease. Myocardial infarction or we like to say heart attacks. And the prevention or decrease of inflammation can improve that. We also know that inflammation could result in increased rates of diabetes and metabolic syndrome, which are all other diseases we hope to prevent. There's other theoretical reasons why. Maybe early treatment of psoriasis and continue with treatment of psoriasis may prevent it from becoming more severe. We don't have data to confirm that at this point. And we have no data to show that we can place people into remission. But the chance of that happening with continuous therapy is probably much better. So keeping on therapy and preventing inflammation is now a very important aspect of our treatment program and even for my patients with psoriasis or those with other inflammatory diseases, my ultimate goal is to diminish inflammation.

Shiva: And do you have any final comments you'd like to share with our listeners?

Dr. Liu: Well, I think transition of therapies is a fascinating area. It's a question that marks us mainly because we as humans change whether we get pregnant, we need surgery, whether we are traveling, and this area is gonna happen to most of you at some point in your life. Our hope is of course that you know we could find an approach that keeps you clear as long as we need and if possible, find a therapy that can put you into remission.

Shiva: Thank you Dr. Liu for sharing that important message. Continuing treatment is so important for long-term success and overall health. For our listeners, if you find yourself in need of more information about treatment options contact our Patient Navigation Center by email at education@psoriasis.org or calling (800) 723-9166, option 1 today. And finally thank you to our sponsors who provided support on behalf of this Psound Bytes™ episode through unrestricted educational grants from Bristol Myers Squibb, Janssen and UCB.

Transitions and Changes That Impact Psoriatic Disease

Psound Bytes™ Transcript: Episode 185

Release date: January 17, 2023

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