Multidisciplinary Treatment Approach to Psoriasis

Joel M. Gelfand, MD, MSCE, professor of dermatology and epidemiology, University of Pennsylvania Perelman School of Medicine, has researched and published extensively on the epidemiology of psoriasis and psoriatic arthritis, the impact of psoriasis on health-related quality of life, and the risk of various comorbidities such as obesity, diabetes, hyperlipidemia, lymphoma, renal disease, dementia, major cardiovascular events, and mortality associated with psoriasis. Dr. Gelfand is also the co-chair of the annual Interdisciplinary Autoimmune Summit (IAS), which runs from March 24 to 26, 2017 at the Marriott Marquis in New York, NY.

In an interview with The Dermatologist, Dr. Gelfand discusses developments in psoriasis research, psoriasis as a predictor of other comorbidities, and considerations of a multidisciplinary approach to treating patients who present with inflammatory conditions in multiple organ systems.



Q. What are some highlights of your recent psoriasis related research?
a. About a decade ago we initially established that psoriasis—particularly severe psoriasis—is associated with an increased risk of cardiovascular events such as heart attack, stroke, and mortality independent of traditional risk factors. Indeed, in patients with moderate to severe psoriasis, the extra risk of major cardiovascular events and premature mortality is quite similar to the risk conferred by rheumatoid arthritis.1-6

Our more recent research shows that the body surface area that is affected by psoriasis is an important driver and that the effects start becoming important in patients who have 3% to 10% of body surface area affected by psoriasis, but it is probably most clinically important in those who have 10% or more of their body surface affected.7 We have also been doing a variety of translational studies using PET [positron emission tomography] scan imaging, which has shown that there is metabolic activity in the aorta of psoriasis patients.8,9

We think the metabolic activity is a sign of inflammation in the aorta, and that this is prognostic for future cardiovascular events. We and others have shown that patients with psoriasis have an increased amount of inflammation in their aorta compared to controls, and we have recently shown that this correlates with how bad their skin disease is.8,9


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Q. What are the greatest challenges on the psoriasis research and treatment front?
a. The greatest challenge is that it is very hard to maintain remission for all psoriasis patients. Many patients, despite achieving a great response early on—particularly with biologic therapies, tend to lose response after a year or 2 or 3. I have patients who are close to the end of the line—they have tried and failed TNF [tumor necrosis factor] inhibitors, used ustekinumab (Stelara) and IL-17 inhibitors, and are still looking for the next mechanism of action to come out because they respond, they do well, and then they lose response. For most patients, we can improve the disease substantially and safely, but it remains an open question of how well we can control the disease for a long time—and long-term control is what patients and dermatologists need.

Q. What does the landscape of the future look like in psoriasis?
a. It looks very bright. There are many more drugs under investigation that continue to raise the bar of how well psoriasis can be cleared without compromising safety. Also, we understand the disease much better, at a basic level. Recent studies have identified potential antigens that seem to drive the inflammation, and understanding how the body responds immunologically holds hope for moving the work forward toward a cure because once you understand what the body is reacting to there may be ways of altering that response. Another key thing that we are starting to see is randomized studies (that we and others are conducting) that elucidate psoriasis treatments’ impact on cardiovascular disease. Ultimately that is where we would like to see the field go—toward not only clearing the skin disease but also lowering the risk of future comorbidities such as heart attacks and strokes.  

Q. What are some of the benefits for dermatologists attending the IAS?
a. IAS is a unique meeting that brings together rheumatologists, dermatologists, gastroenterologists, as well as internal medicine doctors, and people from a variety of different fields and disciplines. Oftentimes our most challenging and difficult cases are patients who are exhibiting inflammatory conditions in multiple organ systems. For instance, they have inflammatory bowel disease and psoriasis or they have bad joint disease and psoriasis, so this meeting is a unique opportunity to get a multidisciplinary, cutting-edge education from a lot of different perspectives about the most challenging diseases we treat. For more information on the IAS meeting, visit www.joinIAS.com.

Q. Is there anything about an immune inflammatory disease that you would like to share with readers of The Dermatologist?
a. I would say that all the progress that we are making gives opportunities for physicians to really make a difference in people’s lives by being an expert in diagnosing and treating these diseases.

References
1. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;11;296(14):1735-1741.
2. Mehta NN, Azfar RS, Shin DB, Neimann AL, Troxel AB, Gelfand JM. Patients with severe psoriasis are at increased risk of cardiovascular mortality: cohort study using the General Practice Research Database. Eur Heart J. 2010;31(8):1000-1006.
3. Ogdie A, Yu Y, Haynes K, et al. Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study. Ann Rheum Dis. 2015;74(2):326-332.
4. Gelfand JM, Dommasch ED, Shin DB, et al. The risk of stroke in patients with psoriasis. Invest Dermatol. 2009;129(10):2411-2418.
5. Gelfand JM, Troxel AB, Lewis JD, et al. The risk of mortality in patients with psoriasis: results from a population-based study. Arch Dermatol. 2007;143(12):1493-1499.
6. Ogdie A, Haynes K, Troxel AB, et al. Risk of mortality in patients with psoriatic arthritis, rheumatoid arthritis and psoriasis: a longitudinal cohort study. Ann Rheum Dis. 2014;73(1):149-153.
7. Yeung H, Takeshita J, Mehta NN, et al. Psoriasis severity and the prevalence of major medical comorbidity: a population-based study. JAMA Dermatol. 2013;149(10):1173-1179.
8. Naik HB, Natarajan B, Stansky E, et al. Severity of psoriasis associates with aortic vascular inflammation detected by FDG PET/CT and neutrophil activation in a prospective observational study. Arterioscler Thromb Vasc Biol. 2015;35(12):2667-2776.
9. Mehta NN, Yu Y, Saboury B, et al. Systemic and vascular inflammation in patients with moderate to severe psoriasis as measured by [18F]-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT): a pilot study. Arch Dermatol. 2011;147(9):1031-1039.