Pharmacy Times interviewed Stephanie Pilat, PharmD, clinical pharmacy specialist, dermatology, University of Rochester Specialty Pharmacy, and Monica Dougherty, PharmD, BCACP, clinical pharmacy specialist, dermatology and asthma, University of Rochester, on plaque psoriasis and atopic dermatitis. In this discussion, Pilat—who specializes in plaque psoriasis—and Dougherty—who specializes in atopic dermatitis—discuss the key differences between the 2 conditions and how they affect patients’ everyday lives. Pilat also describes how pharmacists are involved with dermatologists, physicians, and insurance providers in order to assure that patients are receiving the best care possible.
Key Takeaways:
- Differences in Impact and Management: Atopic dermatitis and plaque psoriasis share similarities in the significant impact they have on patients' quality of life. Both conditions—characterized by symptoms like itchiness, rash, and skin thickening—can lead to sleep disturbances, psychological distress, and limitations in daily activities. Patients often struggle with self-management routines and the psychosocial implications of their conditions.
- Psychosocial and Physical Impact: The psychosocial impact of atopic dermatitis and plaque psoriasis affects patients’ confidence, social interactions, and daily activities, with patients reporting avoidance behaviors due to embarrassment or discomfort. The physical toll can also include sleep disturbances, joint pain (for patients with psoriasis), and the burden of staying consistent and adhering topical treatments.
- Pharmacist Role in Comprehensive Care: Pharmacists play a crucial role in the comprehensive care of patients with atopic dermatitis and plaque psoriasis. Pilat describes that pharmacists serve as “liaisons” between dermatologists, patients, and insurance providers and assist in medication selection, prior authorizations, financial assistance, and ongoing monitoring of treatment efficacy and adverse effects.
Pharmacy Times: In terms of their underlying causes or typical presentation, what are the differences between atopic dermatitis and plaque psoriasis?
Stephanie Pilat: Plaque psoriasis is really the most common subtype of psoriasis; it accounts for roughly 75% of psoriasis cases. So, it typically presents as thick, coarse, scaly patches, which can appear silvery to white on the skin and it can be itchy. Common areas of involvement are typically the scalp, elbows, and the knees, but it can also impact the palms of the hands, soles of the feet, and the nails, whereas atopic dermatitis is associated with the development of pruritis with dry patches that may be red and irritated or hyperpigmented, often involving areas near the skin folds. [It] also typically presents much earlier in life than psoriasis does, so it's much more common in children.
As far as the underlying causes, psoriasis is thought to be hyperproliferative in nature. It is immune-mediated involving various cytokines, so these create a target for several of our medications that treat psoriasis—particularly Interleukin (IL)-23, IL-17 and tumor necrosis factor (TNF). Risk factors generally include genetic predisposition, smoking, obesity, and psoriasis can be exacerbated by a number of factors as well, so, stress, weather, and illness are all causes of potential exacerbation and flaring and psoriasis symptoms. Diagnosis is typically made by a physical exam. For those uncertain cases, sometimes skin punch biopsies are used or when patients are refractory to treatments that are typically very successful in treating psoriasis. A skin punch biopsy might help to kind of clear up whatever diagnosis actually exists there.
Monica Dougherty: Atopic dermatitis is also caused by inflammation, but also caused by skin barrier dysfunction that kind of contributes a lot to exacerbations. I think maybe a little bit more [common] with atopic dermatitis is the itchiness. Pretty much all patients will experience the itch, and then [it is] also characterized by dry skin, the patches of rash, oozing, crusting, and then eventually lichenification can occur—which is the thickening of the skin, the patches of the skin will kind of look a bit rubbery—and that kind of happens over time because of the constant damage to the skin.
Another difference, a lot of patients report that when they itch so much, they're often bleeding, their skins cracking, they're bleeding, which I think happens a little bit more with atopic dermatitis versus plaque psoriasis.
Pharmacy Times: How might these conditions affect patients on a day-to-day basis?
Dougherty: The itch really contributes to that, and so patients with more severe atopic dermatitis are actually at an increased risk for anxiety and depression, and that's typically due to the itch. And I see this in the patients we care for, usually they're at their wit's end when they're starting an advanced treatment. Then also the itch can cause sleep disturbance, so patients can't sleep at night because of [it]—so you can imagine how awful you'd feel the next day if you're not sleeping—a lot of patients wake up and they've been itching all night, and their sheets are covered in blood—which is just awful for your quality of life—and it just really affects their confidence as well. A lot of patients avoid wearing certain clothes like shorts or short sleeves in the summer, and that seems to be with both atopic dermatitis and plaque psoriasis.
And then I work with a lot of pediatric patients, a lot of their parents report bullying at school, [they’re] not able to partake in certain activities like swimming or [other] athletic activities. And then they also can sleep through the night which, of course is going to affect their development and quality of life, and then apart from the disease itself, but management of the disease I think can really affect a person's quality of life. So, the application of topicals is just such a huge commitment…every day, morning and night having to take that time to apply a cream-based moisturizer, but then also typically prescription creams and ointments, just keeping up with that regimen can take a toll. And then the act of like putting on an ointment in the morning and then putting your clothes on, a lot of patients are just not comfortable, and they don't feel great during the day because of that as well. So, it can really, really take a toll on a patient's life.
Pilat: I would emphasize the psychosocial impact, often after we initiate treatment options for patients, they'll tell us, “I haven't been able to wear shorts in 20 to 30 years,” and that's consistent for both conditions. Or [they’ll tell us] “I can finally wear a black shirt to work again without having to worry about flaking and being embarrassed over that,” and while these things may seem minor to an average individual, they can certainly impact patients over time, very significantly from the psychosocial impact.
And then the only other thing that I would add as far as psoriasis goes, psoriatic arthritis is very common in patients with psoriasis—I think it's an outdated statistic at this point—I believe the most updated 1 we have is about 30% of patients will go on to eventually develop psoriatic arthritis after the cutaneous involvement of plaque psoriasis. Oftentimes, these patients will experience extreme joint pain and stiffness in the morning, which of course significantly impacts patients on a daily basis as well.
Pharmacy Times: How might the pharmacist collaborate with dermatologists, primary care physicians, etc. to treat these conditions in patients?
Pilat: So, we fall into a unique area being in the specialty pharmacy. We’re kind of acting as the liaisons between the dermatologist the insurance companies and actually getting the medication to the patient in the end. So, we're involved from the very beginning, we can assist with the appropriate selection of a biologic considering patient-specific factors, we're checking on prior authorization statuses for these medications, so thankfully, we do have a centralized PA department where we are so we're not as involved with the submission process. But we definitely assist with handling the outcome of the prior authorization, so whether it's approved, oftentimes, financial assistance comes into play here and we'll seek this from manufacturer copay cards or supplemental government programs, sometimes patient assistance programs through manufacturers as well. If the medication is denied, we're communicating that a dermatologist what options might we have to appeal the denial for the original biologic that was submitted, or maybe switching to a preferred medication on the formulary, whatever it might be, we're kind of talking through those different options with a dermatologist. And then once a patient starts the biologic, we’re contacting them to review the medication beforehand, which includes a thorough review of the dosing schedules, potential [adverse effects (AEs)] that we might encounter, storage parameters, and then other pearls about the medications themselves. After the patient is starting the biologic, we're frequently checking in with them for any [AEs] or if a medication is just simply not working well [enough] to control the patient's symptoms. We're communicating both [AEs] and efficacy over to the dermatologist to potentially expedite a sooner follow-up visit in the office for reevaluation and consideration of other options that we have.
As far as some other things that might be helpful for [pharmacists] to be aware of, I would probably [say] lab monitoring…especially with the psoriasis medications. I can say that we do that here with our own internal pharmacy, and I'm working very closely with the dermatology office. If it's going to an outside pharmacy that doesn't necessarily have access to our health system records and those lab results, that creates kind of a difficult situation there, so we're lucky to fall within the same health system as the dermatology office that we primarily work with.
I would say that those are mainly the areas in which we collaborate with the dermatologists. As far as primary care physicians, they might assist in the referral to a dermatologist. Once they get to a systemic option, or especially biologics, it's typically coming from the dermatologist and maybe not the pediatrician office or the primary care physician. I would say that that's primarily how we're collaborating with those individuals.
