“There are a lot of treatments out there and they are quite effective, but often they stop being effective,” says Mark Lebwohl, MD, chair of the department of dermatology at Mount Sinai Medical Center in New York City. “There isn’t one treatment over a lifetime, necessarily.”
Taming the beast
“I describe psoriasis to my patients as a wild animal in a roomand the room is their life,” says dermatologist Andrew Blauvelt, MD, who sees a variety of complex cases as the research director of the Center of Excellence for Psoriasis and Psoriatic Arthritis at Oregon Health & Science University in Portland. “The goal of therapy is to build a good cage for the animal. The animal’s always going to be there, but an effective treatment will allow the patient to move around the room and live his life.”
For physicians, a series of factors are weighed to determine how aggressively and with what tools they treat a particular case of psoriasis, including:
- How widespread the disease is on the body
- Whether lesions appear in sensitive areas, such as the face, palms, soles, or genitals
- The patient’s experience with previous treatments
- The cost of medications and what insurance will cover
- The patient’s other medical conditions (especially psoriatic arthritis)
- The patient’s preference for one type of treatment over another
The group of drugs known as biologics have in recent years expanded the number of people who can be treated, says Dr. Lebwohl. They have also pulled some patients away from older systemic (as opposed to topical) drugs often used for moderate-to-severe cases, such as methotrexate and cyclosporine, which patients sometimes need to take in rotation to minimize the risk of cumulative damage to their organs.
“Biologics are costly and have potential side effects, some of which are serious. But psoriasis is a bad disease, too,” says Steven Feldman, MD, PhD, professor of dermatology at the Wake Forest University School of Medicine in Winston-Salem, NC. “The potential benefits of biologics outweigh the risks for many patients.”
According to some doctors, the newer drugs appear safer for use over the long-termso long as they continue working. Instead of acting like “shotgun blasts,” as the older systemic drugs do, the biologics are “much more like a rifle shot, where there’s a whole lot less collateral damage and fewer side effects,” says David M. Pariser, MD, president-elect of the American Academy of Dermatology.