Systemic Therapy Considerations for Psoriasis in the Setting of Malignancy

JDD Podcast Recap and Author Interview

Podcast host Dr. Adam Friedman sat down with Dr. David Rosmarin, Assistant Professor of Dermatology and Residency Program Director at Tufts University School of Medicine, to dive into what he learned from performing a retrospective chart review and how his work and his experience guides his clinical decision making when managing psoriasis. Here are the highlights:

On his group’s paper that was recently published in the Journal of Drugs in Dermatology, titled: Treatment of Psoriasis With Biologics and Apremilast in Patients With a History of Malignancy: A Retrospective Chart Review”

  • Dr. Rosmarin and his colleagues came up with the idea for this study because the issue of patients with psoriasis who have a history of malignancy often comes up in clinic. The question often asked by physicians and patients is usually “is it safe to use biologics or methotrexate or apremilast in someone with psoriasis and malignancy?” Unfortunately that is a difficult question to answer due to the lack of data to help guide us as clinicians.
  • They discovered that there were several hurdles to gathering data for this study. Oftentimes they encountered data access issues, missing data or inability to obtain data from referred patients about their cancer history and management. Other limitations were the lack of available patients with psoriasis and malignancy.
  • The study included sixteen patients with psoriasis who had a history of malignancy excluding non-melanoma skin cancer. Nine patients started treatment within five years of their cancer diagnosis. Most importantly, none of the patients included in the study had worsening of their condition or recurrence of their cancer noted clinically or radiographically.
  • The data is still limited for the treatment of psoriasis in patients with a recent history of malignancy, so it is important to treat patients on an individual basis. Benefit versus risk assessment should be determined before making a decision about treatment.
  • The most ideal way to understand the risks of treating these patients is to not exclude them from clinical trials, because this limits the data available. Utilizing registries would allow both academic and private practices worldwide to add data from their patients when treating them with biologics or apremilast.

On educating, screening and treating patients with psoriasis

  • It is important to screen patients for psoriatic arthritis because it can be erosive and cause structural damage. Asking about joint pain and stiffness should be one of the first questions a clinician asked a patient with psoriasis. If a clinician is not comfortable with evaluating patients for psoriatic arthritis, they should be referred to a rheumatologist.
  • Clinicians should also gather a full history from patients, such as a family or personal history of inflammatory bowel disease (IBD), multiple sclerosis (MS), and even asking about a fear of injections. Does the patient have diabetes, hypertension or obesity? This puts them at higher risk for cardiovascular disease (CVD) and their PCP or Cardiologist should be informed that their psoriasis diagnosis adds yet another risk factor to developing CVD.
  • When it comes to which treatments to choose for particular patients, you have to look at their comorbidities. If a patient has psoriatic arthritis, anti-TNF-alpha or anti-IL-17s are typically first-line treatments.
    • IBD: slight risk for new onset or exacerbating risk, use anti-TNF-a, anti-IL-23
    • MS: anti-TNFa may exacerbate so prefer anti-IL-17 or ustekinumab
    • Fear of injection: choose an injectable with decreased frequency of injections versus those that are weekly or biweekly
    • DM2: apremilast may have ability to slightly decrease HbA1c; also an added benefit of possible weight loss which may be beneficial to those who need to lose weight

Make sure to tune in and listen to the Podcast here.

Words from the Investigator

I also had the chance to ask Dr. Rosmarin a few questions on his advice to residents and the one book he thinks everyone should read:

What are some of the key things you hope residents take away in treatment of psoriasis?

  • We don’t treat the disease, we treat the patient.
  • If a patient is bothered by even mild disease activity, it is important to be aggressive (ex: small plaque on face or psoriatic plaques and itching of scalp) vs a patient that is unbothered by plaques on the trunk
  • Always screen for comorbidities
  • Don’t get in the habit of always going for whatever is first line, but treat the patient as individual. Think about what is best for that individual patient.

What is one piece of advice for current residents and young dermatologists?

Always put yourself in the patient’s shoes and try to understand what they are experiencing.

What is one book everyone should read? 

To Kill a Mockingbird by Harper Lee. It has a hero in Atticus Finch that teaches true courage and morality.

Did you enjoy this podcast recap? You can find more here.

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