Dermatology Express Report

Based on data presented at a CME-certified Satellite Symposium held during the Dermatology Nurses’ Association 25th Annual Convention, February 2, 2007, Arlington, Virginia

Publication date: 2007-05-10

Treating Psoriasis with TNF Inhibitors: The Nursing Perspective

This report was reviewed for medical and scientific accuracy by Mark A. Gendreau, MD, MS, Associate Vice Chairman, Senior Staff Physician, Lahey Clinic, Burlington, Massachusetts.

Expert Commentary

Craig L. Leonardi, MD, Associate Clinical Professor of Dermatology, St. Louis University School of Medicine, St. Louis, Missouri

Psoriasis is a chronic, immune-mediated disease characterized by recurring and remitting inflammatory disease, ranging from mild to severe and affecting the skin, the scalp, and sometimes the joints. Although rarely life-threatening, psoriasis is associated with significant morbidity and is considered by many to be an emotionally crippling disease. ¹ The impact of psoriasis on physical and emotional functioning is comparable with that of other serious medical conditions such as rheumatoid arthritis, heart disease, cancer, depression, and Crohn's disease. ^2,3 Indeed, the effect of psoriasis on quality of life can be devastating. Moreover, approximately 20% to 25% of patients with psoriasis have extensive disease requiring aggressive therapy. ^1,4

Treatment goals include rapidly controlling the disease process, achieving and maintaining remission, minimizing adverse events associated with therapies, and improving quality of life. Patients with mild-to-moderate psoriasis can generally be managed with topical therapies, including emollients, keratolytics, anthralin, coal tar, corticosteroids, vitamin D analogs (eg, calcipotriene), and topical retinoids (eg, tazarotene). For patients with moderate-to-severe psoriasis or for those with significant psoriatic arthritis, systemic therapies are dramatically changing outcomes. These treatments include phototherapy, traditional systemic medications (eg, acitretin, methotrexate, and cyclosporine), disease modifying anti-rheumatic drugs (DMARDs) for patients with psoriatic arthritis, and a relatively new class of immunomodulatory biologic agents. The biologic agents work to control the inflammatory response that underlies psoriasis. For example, the tumor necrosis factor (TNF) inhibitors (adalimumab, etanercept, and infliximab) control inflammation by binding to TNF-α, a proinflammatory cytokine, that is overexpressed in psoriatic skin and joints. These agents represent a significant advance in treating psoriasis and psoriatic arthritis.

For those patients whose psoriasis cannot be controlled with traditional treatment options, the TNF inhibitors can safely and effectively treat their psoriasis and enhance their quality of life as well. Unfortunately, treatment with biologic agents is not reaching many of these patients. According to a recent survey of patients with psoriasis, ⁵ the majority of patients with moderate-to-severe psoriasis were not receiving systemic or biologic agents for their psoriasis. Indeed, more than 39% of surveyed patients were not currently receiving any treatment for their psoriasis. Another survey demonstrated that 78% of patients with psoriasis were frustrated with their currently prescribed therapies. ⁶ Clearly, much work needs to be done for patients with psoriasis.

My hope is that as dermatologists and nurses become more knowledge-able about biologic agents-their efficacy, safety, and tolerability profiles, and their proper administration-these agents will be offered to more patients who could greatly benefit from their use. Moreover, we should not wait until patients fail other treatment options, particularly if they are young, have comorbid disease, or find applying topical therapies to large areas of skin impractical. In the emerging treatment paradigm for psoriasis, choice of therapy is no longer approached in a stepwise manner, but is dictated by individual patient characteristics.

This Dermatology Express Report^TM reviews data on biologic agents used to treat psoriasis that was presented at a CME-certified satellite symposium held during the Dermatology Nurses' Association 25^th Annual Convention, Feb