Patients need to secure an effective treatment management plan.
The management plan requires cut-offs to prevent uncontrolled disease, eg. HbA1c in diabetes.
The challenge is the definition of “treatment expectations” using appropriate parameters and matching medical needs and patient perspectives, which are not always aligned with the physicians’ perspective [1].
Patients treatment goal recommend defining individualized patient-treatment goals, as every patient with PsO requires a tailor-made treatment program [2].
The most often reported patient needs are “get better skin quickly, be healed of all skin defects” [3].
Needs are higher in younger patients (<65 years) and women have higher expectations and more concern about side-effects than men [3].
PsO is not only a skin disease, but is on a spectrum, including vascular inflammation [4] (see Figure 1).
A European Consensus for treatment goals for moderate to severe PsO [5] tries to include the patients’ perspective with the Dermatology Life Quality Index (DLQI).
DLQI is not a PsO specific document, and it is always with reference to the baseline PASI values (<ΔPASI 50 à modify treatment, >ΔPASI 75 à continue treatment regimen) [6].
The cut-offs puts treatment failure (ΔPASI 50) as the real treatment goal [6].
The treatment expectation (ΔPASI 75) is low and there is discussion to raise this to PASI 90 [7] because the new generation biologic drugs have raised the expectation tremendously, as we know that 80% of the patients can achieve a PASI 90.
However, we also know that only a small proportion of patients will ever benefit from treatment (given availability and costs).
A discussion exists about the difference between absolute and relative PASI for the correct estimation of skin involvement and disease control. It has been proven that the relative and absolute PASI’s align quite well (unpublished data).
Treatment goals are necessary to prevent uncontrolled PsO disease.
Presently, PASI seems the severity score of choice (not because it’s the best but the one most utilized).
Inclusion of patient reported outcomes needs to be linked to physician assessments.
Definition of a true goal is key (eg. PASI <50) after induction therapy.
For long-term maintenance therapy an absolute PASI is superior to a relative PASI reduction (eg. PASI <3 may be a future treatment goal).
Challenges
Treatment goals should not be limited to moderate to severe PsO and should be dermatologically driven definitions of disease severity, also for topical treatments.
Treatment goals should be applicable to all measures to treat/manage PsO, even including other interventions, such as bariatric surgery in obese PsO patients.
Scores other than PASI may be helpful in the future, including the patient perspective.
van de Kerkhof PC, Reich K, Kavanaugh A, et al. Physician perspectives in the management of psoriasis and psoriatic arthritis: results from the population-based multinational assessment of psoriasis and psoriatic arthritis survey. J Eur Acad Dermatol Venereol. 2015;29:2002-10.
Kouwenhoven TA, van der Ploeg JAM, van de Kerkhof PCM. Treatment goals in psoriasis from a patient perspective: a qualitative study. J Dermatolog Treat. 2018 Nov 27:1-15.
Maul JT, Navarini AA, Sommer R, et al. Gender and age significantly determine patient needs and treatment goals in psoriasis - a lesson for practice. JEur Acad Dermatol Venereol. 2019 Apr;33(4):700-8.
Mrowietz U, Kragballe K, Reich K, et al. Definition of treatment goals for moderate to severe psoriasis: a European consensus. Arch Dermatol Res. 2011;303:1-10.
With this collection of summaries from selected presentations at SPIN 2019, and interviews with international experts, we hope to share with you some of the highlights of this year’s congress. The international network met … [ Read all ]