I was diagnosed with psoriasis in 1972 and psoriatic arthritis (PsA) in 1976. Prior to 1998, I was treated for scalp psoriasis with tar shampoo, and otherwise I applied various topical medications to my skin lesions. I did phototherapy using the Goeckerman treatment (tar bath followed by UVA or UVB exposure). Later, I had intralesional injections of a corticosteroid.
Over time, my psoriasis lesion coverage increased to a point where I was considered to have severe psoriasis (more than 10% body coverage), so it became appropriate to try a systemic medication (one that is not limited to individual lesions or plaques). In the early 2000s, I started taking methotrexate, a disease-modifying antirheumatic drug (DMARD) that benefits both psoriasis and PsA patients. As is often the case, doctors may prescribe methotrexate in a combination therapy with a TNF inhibitor.
The initial round of biologic drugs were all “TNF inhibitors” that block the action of a specific type of immune cell called a T cell. Besides treating skin inflammation, TNF inhibitors are also effective in controlling inflammation in the joints (PsA). I started with a self-injectable drug in 1999. For me, this first biologic worked for a while, but it became less effective over time. Fortunately, another self-injectable TNF inhibitor was approved by the FDA in 2001, so my rheumatologist switched me to the second drug. When the second drug lost its efficacy for me in 2003, I switched back to the first biologic, and then in 2004 back to the second biologic.
The earliest biologic drug approved by the FDA (1998) for use by psoriasis patients was a medication that is infused either in a doctor’s office or a hospital. I had resisted taking infusions because I was busy at work, and I figured that an infusion would take 3 to 5 hours, rather than a self-injection which took a couple of minutes. Nevertheless, I tried the infusions in 2005 for about 9 months, first in a hospital where it would take about 5 hours start to finish, and then in a rheumatologist’s office where it took no more than 2 hours. This drug did not appear to clear up the lesions or prevent the swelling of my joints. My doctor suggested an increase in dose, but I resisted since that would have cost twice as much. I know, however, that the infusion drugs have been a very effective systemic treatment for many patients.
I consider the psoriasis patient community to be quite fortunate that we have so many dedicated researchers who have enabled us to have increasing numbers of biologic treatments for our disease. As a result of genetic research, new treatments have been developed that are so-called “targeted medicines” that treat the disease by trying to control the genetic triggers that send signals to the skin cells to become inflamed and proliferate. Luckily, for me and other PsA patients, each of these drugs also blocks proteins in the immune system, such as interleukin (IL) -17A, IL-12, and IL-23, and can reduce inflammation of the synovial lining of the joints and reduce pain.
Although my personal history is anecdotal, my experience with the TNF inhibitors is not atypical. No biologic medication works for everyone, and it is not uncommon for a patient to have to try and possibly fail on one biologic drug (or ointment for that matter), until they identify the ideal treatment. This is not to suggest that some patients may use one biologic or other medication and find that it works for a long time.
Psoriasis is a heterogenous disease, meaning that there are different inflammatory networks that trigger the lesions, and research has revealed that the reaction of individual patients to medications is also variable. This may be explained by factors that influence effectiveness such as (a) differences in a person’s genetics, or (b) a patient’s vulnerability to other diseases, or (c) interactions with other medications that a patient may be taking.
I moved on to an injectable version of the infused drug, then to a self-injectable drug that blocks IL-23, and then ultimately to an IL-17 drug, which has cleared my psoriasis. My experience was that the clearing took place after the induction period, a higher dose for a few weeks, before a once-a-month regimen. Curiously, I suspended taking the IL-17 drug during the COVID-19 pandemic because the drug works by suppressing the body’s immune system, and my skin remained clear for almost 16 months (beyond my expectations). I understand that other patients on IL-17 and IL-23 drugs have had similar experiences during the pandemic when they suspended taking the drugs. However, if the psoriasis returns, it is advisable that a patient take the drug again.
As with any medication, it is important to discuss with your doctor (dermatologist or rheumatologist) the alternative medications that are available for moderate to severe psoriasis or PsA, and to learn about potential side effects and adverse interactions (contraindications) with any other medication that you may be taking.
Obviously, the nature and extent of a patient’s health insurance coverage may influence their choice of medications. My employer-based health insurer did not interfere with my doctor’s choices. If a patient is uninsured or under-insured, they can seek guidance from the National Psoriasis Foundation’s Patient Navigation Center regarding insurance options, manufacturer copay coupon programs, and other forms of financial assistance.
If you have a few concurrent conditions (comorbidities) of psoriasis and PsA, such as high blood pressure, diabetes, chronic kidney condition, etc., it is particularly important to have a thorough discussion with your doctor about all the medications you are taking. Bring a list of the medications and dosing to your appointment. I strongly recommend that you use one pharmacy so your pharmacist reviews any new medications against your current medications to make sure that there are no FDA or manufacturer warnings about contraindications among the drugs.
When I went to my first National Psoriasis Foundation conference, I recall there were about 20% of the attendees using canes, walkers, or wheelchairs. In part, this is explained because due to disease severity, PsA patients may be more likely to attend such events. At the last volunteer conference that I attended several years ago, there was only one person using an assistive device, a wheelchair. I firmly believe that the introduction of biologics to PsA patients before joint damage or destruction has occurred is the primary reason for this marked improvement in health and well-being. I know that the number of hip and knee replacements for patients with rheumatoid-like arthritis (including PsA) has declined over the past 20 years. See the American Joint Replacement Registry.
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Photo Credit: Clarissa Leahy / Image Source via Getty Images
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