Psoriasis: Advances in Treatment

WebMD Live Events Transcript

Has your psoriasis been tough to treat? You're not alone. Many sufferers are on the lookout for better ways to control their outbreaks. On July 28, 2004, we looked at the latest psoriasis treatments as well as what might be available in the future, with dermatologist and psoriasis expert Craig Leonardi, MD.

This event made possible through an unrestricted educational grant from Amgen Wyeth.

MODERATOR:
Welcome to WebMD Live, Dr. Leonardi.

LEONARDI:
Thank you. It's a pleasure to be with you folks today, live from New York City; and it's my pleasure to answer the questions.

MODERATOR:
You are very involved in research and in treating patients with psoriasis.

LEONARDI:
That's correct. My office is one of the large research centers in North America. I spend about half my time involved with clinical research, that is, investigating new drugs for treating skin diseases.

My strong suit is with psoriasis. I'm also a general dermatologist, so I see all kinds of skin problems. Once the patients are done with clinical research, they feel they've found a doctor who understands psoriasis. So my practice is full of psoriasis patients who are seeking aggressive and safe treatments for their skin disease.

MEMBER QUESTION:
I have a chronic, severe case of psoriasis and have had it all my life. I have done the phototherapy and ointments. What is so new about the new biological treatments and are they safe for a soon-to-be-pregnant or nursing mother?

LEONARDI:
The new biologic treatments are a series of medications that get to the heart of the cause of the disease. Technically, these drugs are targeted immunosuppressants. When we get the immune system to disengage from sites of inflammation, the psoriasis can normalize. The trick is to strike a balance between making the psoriasis better, but still leaving you safe to fight off infections and cancers. We seem to have achieved that balance with the new medicines. We've had three released in the last 16 months available for prescription, and many more are descending on our field.

With regards to the pregnancy issue, almost all of these biologic therapies are category B, which means the medicines are expected to be safe to be used during pregnancy, but formal testing has not been done. During the research trials, some of my patients did become pregnant while on a biologic therapy. All deliveries have been normal. But as part of the research protocol, we had to stop the medicine as soon as we knew about the pregnancies. I hope that answers your questions.

MODERATOR:
How effective have you found the new drugs to be in your practice?

LEONARDI:
The new drugs in my practice have been very effective and have dramatically changed the way I practice dermatology. In my office, biologic therapies are the first line of treatment once we've decided the patient needs a systemic approach to treating their psoriasis. I find that by using these new medicines our patients have better control of their disease, and fewer side effects, than with the previously available treatments.

MODERATOR:
Does it make a difference where the psoriasis strikes?

LEONARDI:
Good question. The psoriasis can affect many areas of the body. Most commonly it would be on the trunk or extremities. There are some forms of psoriasis that affect under the arms or in the groin area, or fingertips, even on hands and feet predominantly. These forms of psoriasis are sometimes very difficult to treat, even with new therapies. So psoriasis is a heterogeneous disease -- it has lots of different manifestations, or appears in many different ways. Some of the less-common ways that it appears can be difficult to treat. There may even be several types of psoriasis, genetically, biologically.

MEMBER QUESTION:
Can you give us some examples of biologic therapies? I've never heard of this term and don't exactly know what it means.

LEONARDI:
The term biologic really refers to a manufacturing process. The medicines themselves are, in fact, large proteins that are designed to bind to specific chemicals or receptors inside the body. An example of a very simple biologic would be insulin. But we're using these new drugs to cause immunosuppression, to get the immune system to disengage from the skin and from other sites of inflammation. The advantage of these new therapies is that they do a very specific job inside the body and appear to have far fewer side effects than our previously used conventional systemic therapies.

We seem to be on the verge of affording our patients chronic, convenient, and safe control of their skin, something that we have never had for our psoriasis sufferers.

MEMBER QUESTION:
My 17-year-old daughter has recurring psoriasis on her hands. She uses Protopic (although probably not as diligently as she should) but it never really goes away and sometimes is really bad, cracking and bleeding. Is there another medication that we should consider?

LEONARDI:
Protopic (the generic name is tacrolimus) is a topical immunosuppressant that was developed to treat children with bad rashes. It can be useful for some forms of psoriasis, but if there is a large area involved, you need to approach the psoriasis with a systemic approach from the inside out. For limited psoriasis, it may work just fine.

As for the cracking and bleeding with the child with hand psoriasis, it's important to moisturize, and you may need to do it hourly. So if someone's hands are cracking and bleeding, they haven't been applying moisturizers appropriately. If a medicine has been prescribed, they should be applied several times a day.

MEMBER QUESTION:
Would these biological therapies hinder the recovery of a viral infection?

LEONARDI:
Good question. During the trials, we had no evidence that the therapies made viral infections or bacterial infections worse. We did see a slight increase in the number of common colds during the trials, but they did not lead to more serious problems. In general, we feel that the new therapies are safe from an infection point of view -- with appropriate patient screening.

MEMBER QUESTION:
What are the names of these therapies and medications?

LEONARDI:
The first drug was alefacept, which is also Amevive. Our second drug that was approved by the FDA was efalizumab, also known as Raptiva. Most recently, etanercept, also known as Enbrel was approved for psoriasis as well. There are at least six other stunning drugs in development. We expect some of those will be available over the next three to four years.

MODERATOR:
Are you involved in researching these new drugs?

LEONARDI:
I'm involved in researching all of these new drugs.

MODERATOR:
It's very exciting -- it seems that there is a new era in treating psoriasis.

LEONARDI:
That would be a very fair assessment of what's going on. A huge therapeutic class of medicines has fallen out of the sky and landed in our laps. I can't think of a patient population that deserves it more.

MEMBER QUESTION:
Should any dermatologist know about these biologic treatments?

LEONARDI:
I think it's fair to say that most dermatologists are aware of these new drugs. Not every dermatologist chooses to treat these types of patients, so you may have to investigate and find out if your doctor is seeing psoriasis patients and treating those with more severe disease.

One of the resources a patient might use is the National Psoriasis Foundation web site at www.psoriasis.org. You can find a list of names of doctors who are willing to treat patients of this nature.

MEMBER QUESTION:
How much do the new biologic treatments cost if insurance is not available? Is there any financial assistance for the new biologics if no insurance is available?

LEONARDI:
These new therapies are VERY expensive. Almost certainly a patient will have to have insurance to help pay for the medication in order to make it possible. So in our office, we have to consider the patient's insurance status as part of our selection of treatment. All of the companies have financial assistance available to one extent or another. They usually ask to see tax returns to make sure the patient meets certain criteria. We have, in fact, gotten patients access to therapy who were underinsured or not insured at all. In Illinois and Missouri, some of the Medicaid plans are covering these new treatments. But this is clearly an area where we need to do a lot more work, and we need to come to grips as a society about how to deal with expensive and effective therapies.

MEMBER QUESTION:
I have liver damage after treatment with methotrexate. What can I do now, since my liver enzymes are still elevated after one year, and my dermatologist refuses any other treatments? Do these new drugs affect the liver?

LEONARDI:
Time to find a new dermatologist. The new biologic therapies have no interaction with the liver, kidneys, or any other internal organs. So if you truly have psoriasis that needs a systemic treatment, biologic therapy is ideal. You are the perfect candidate for biologic therapy.

MEMBER QUESTION:
Are these treatments feasible for infants and children or only for adults?

LEONARDI:
One of the drugs, Enbrel, has other indications, including one for juvenile rheumatoid arthritis down to age 4. So we have some guidance about the use of Enbrel in very young patients. This is not the same as saying we've tested young patients with psoriasis using Enbrel, but we do feel it is safe in the young. My pediatric colleagues are using Enbrel in children who have a serious condition with psoriasis, and by all reports, indications have been very good and encouraging.

MEMBER QUESTION:
My husband has scales on his knees that nothing will soften or get rid of. Also on other areas of his legs, bruise like scales. The dermatologist has prescribed steroid/cortisone creams in different percentages, but nothing seems to help.

LEONARDI:
This is a patient that has limited psoriasis, maybe only one or two handfuls of psoriasis on the body. We should be able to find a way of approaching this with a topical medication. One of the first things to be concerned about would be compliance. Is your husband really using the medications as prescribed every single day? I'd explore that before concluding that none of these meds work. When I have a patient with limited disease and nothing works, it's because the meds are not being used reliably.

I will say it's tough to be a patient. We prescribe meds and ask you to do things several times a day. If you get tired or discouraged and let your guard down, psoriasis comes right back. Finally, if your husband is using his meds and the psoriasis -- if it is psoriasis -- is not responding, it's possible to explore other treatments. There are laser devices that can treat small areas of skin very effectively, for example.

MEMBER QUESTION:
My 14-year-old daughter has psoriasis on her scalp. She will not go and get her hair cut/trimmed since she doesn't want anyone to see her scalp. She also covers her head with a hat or hooded jacket. What should I do to help my daughter? We have tried tree oil shampoos and medications.

LEONARDI:
Scalp psoriasis is a real problem for some people. And of course, everything that happens in the lives of our young patients is even more of a problem for them. There are a variety of topical medicines that are applied to the scalp that can be prescribed such as steroids and topical vitamin D-like medicines, and in many cases, these treatments are effective in controlling symptoms. In general, we recommend using a medicated shampoo, such as a coal tar containing shampoo. It helps, but usually doesn't help enough, so we also use a prescription approach. She should be seeing a dermatologist.

MEMBER QUESTION:
What would you recommend if you have hypothyroidism? You have to take medication to speed up the immune system. How would this all work together? Would the medications cancel each other out?

LEONARDI:
No. We know of no drug interactions with any of the new drug therapies. So I would expect that whatever meds you are taking for hypothyroidism would have no effect on the psoriasis treatment, and the psoriasis treatment would have no effect on the thyroid treatment. That's one of the benefits of the new biologic therapies.

MEMBER QUESTION:
Do these new biologic treatments contain any soy products?

LEONARDI:
No.

MEMBER QUESTION:
A good friend of mine has psoriasis but is reluctant to try any new treatments because he's had bad luck in the past. He is doubtful that some of the newer stuff is really that good. What would you say to him to get him to try anything?

LEONARDI:
It's like playing the lottery; if you don't buy a ticket you have no chance of winning. I would say that there's never been a time, ever, where there has never been more significant and new meds brought to bear on this disease. It's normal to be discouraged given the treatment options of the last 30 to 40 years. But the reason there's so much excitement is because we are changing the way we think about and treat this disease. I would encourage this patient to re-engage the health care system.

MEMBER QUESTION:
Are these treatments available in Canada?

LEONARDI:
I believe that Amevive was recently approved for use in Canada. I also believe that Enbrel and Raptiva have been submitted to the Canadian health authorities for approval. If it doesn't happen this year, it will probably happen next year.

MEMBER QUESTION:
I have eczema. Are these new drugs effective for this also?

LEONARDI:
We don't know the answer to that, although we think about it an awful lot. There are small studies underway to investigate the use of biologic therapies on different types of eczema. At this point, we don't have any data, so we don't know. Stay tuned.

MEMBER QUESTION:
Last summer I had my first case (and a severe one) of psoriasis. I was also going through a separation and divorce. My therapist blamed it all on stress. Could this be true? I'm guessing the circumstances are different for each individual.

LEONARDI:
I personally don't believe in the stress theory of psoriasis. There are certainly a lot of published reports discussing patients who had an emotional stress and linked it to the emergence of psoriasis. We know that psoriasis is a genetic inherited dysfunction of the immune system. We don't have a good explanation of how emotional stress can affect our immune system.

Personally, I try to down play that aspect in my office. When a doctor tells a patient that stress is causing a disease, they are telling the patient that they're causing their own problems, and I don't buy into that. So I concentrate on things we do know about. Over the years, I've seen many patients where an attempt was performed to reduce stress levels, such as prescribing drugs like Valium to young patients for years at a time with no success. The role of stress in causing psoriasis is not clear at this time.

MEMBER QUESTION:
I think my psoriasis and arthritis came from my mother's side. I am married and my wife and I would like to have children. What are the chances of psoriasis and psoriatic arthritis passing down to our children? Do the odds of not passing the disease down increase if the child is a boy?

LEONARDI:
The genetics of psoriasis are still not well understood. It appears to affect men and women equally, so we don't expect any difference between male and female offspring. Nearly 60% of patients will report a family history of psoriasis, but that means that 40% of the time it shows up out of the blue. I can't answer precisely, except that children do have an increased risk, but we don't know what the risk level is. The good news is that there are spectacular treatments emerging from the pharmaceutical companies for treating the disease.

MEMBER QUESTION:
I have periodic IVIG treatments for myasthenia gravis. Why does my psoriasis go away completely after receiving these treatments?

LEONARDI:
Darn good question. We don't know exactly how IVIG works for any disease, including myasthenia. I'm sure that I've read reports of IVIG success and failure in treating psoriasis. I'm happy for any treatment that works for my patients, so I'm happy for you as well.

MEMBER QUESTION:
When I was pregnant I was clear of psoriasis. What is the connection?

LEONARDI:
This is actually very interesting. During pregnancy, it's a relative state of immunosuppression for the mother. The baby is half dad and half mom. Somehow, the mother becomes tolerant of the pregnancy immunologically, and the best explanation is that the psoriasis is also improved by the same mechanism. Nearly 40% of women report that their psoriasis improves dramatically during their pregnancy. Many of them also tell us that it comes back after the delivery. There are a few, however, that get worse, so there's a lot to learn about this situation.

MEMBER QUESTION:
For other medical conditions, about four to five times in my life, I needed prednisone (steroids) and my psoriasis and eczema completely went away for that period -- just the scars were left! It was great other than the prednisone side effects.

LEONARDI:
There's no question that if prednisone had no side effects, we'd all use it to treat psoriasis. In high enough doses, it is completely effective in clearing the disease. But the problem is the terrific safety issues that long-term use brings to the table. Furthermore, when you stop prednisone therapy in psoriasis patients, some of them can have a terrific recurrence or rebound of psoriasis. We're not talking about topical steroids, but an oral steroid, such as prednisone, for treating the disease. In general, dermatologists try to avoid it because of the side effects.

MODERATOR:
Dr. Leonardi, you mentioned that you are involved in researching new drugs. What do you think we will be seeing in the future for treating psoriasis?

LEONARDI:
I think that we'll be using this approach for the next 10 years. We'll be using biologic therapies that are targeted at specific sites in the inflammatory process to achieve our control of the disease. We're going to see drugs that are given every other week, or even every other month, either by simple subcutaneous injections, under-the-skin shots, or by intravenous infusion.

We'll also raise the level of expectation in dermatology as well as in our psoriasis sufferers for achieving continuous control of the process of the disease.

Way down the road, we may start to see oral medications that will accomplish many of the things we're doing with the biologic treatments. That would mean that patients would take a pill every now and then to control their disease safely and effectively. Whether or not we can achieve that remains to be seen.

MODERATOR:
Dr. Leonardi, before we wrap things up, do you have any final words for us?

LEONARDI:
I would say that it's a fabulous time for dermatology and our psoriasis sufferers. We have a new understanding for how the disease develops and how to control it. The best news is that our friends in the pharmaceutical industry are bringing a stunning series of new medications forward to address this issue. There's no question that for our psoriasis patients, that there was an unmet medical need in our psoriasis population. We're on the verge of bringing chronic, continuous, safe, and utterly effective therapies to bear on this disease.

I'd encourage everyone to rethink their relationship with the health care system. If you haven't seen your dermatologist in a while, it may be time to get back into the office to talk about new therapies and to see if any of them are appropriate for you. It's been my pleasure to address everyone today.

MODERATOR:
We are out of time. Our thanks to Craig Leonardi, MD, for sharing his expertise with us today. For more information, please be sure to visit our message boards to talk with others and ask questions of our experts.

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