Considerations for Treatment Decision-Making

This session explores evidence-based approaches to treatment selection for genital and intertriginous psoriasis, emphasizing the role of nonsteroidal and systemic therapies. Learn how shared decision-making and patient-centered goal setting can support long-term disease control, improve adherence, and optimize genital wellness outcomes.

Watch the full series: Genital and Intertriginous Psoriasis Expert Panel Video Series

John Zampella, MD, FAAD: All right, we're having an amazing conversation today about genital psoriasis. We're going to move into maybe the most important part for patients because it's one thing to make a diagnosis, but the patient really wants to know, “What are you going to do to fix me?” We're going to get into some treatment. We spent the last little bit talking about corticosteroids and some of their side effects and how we use them. I kind of want to get a little better feeling of how do you use corticosteroids, what do we feel about corticosteroid stewardship, and when do we transition from that to another treatment modality? 

Michael Payette, MD, MBA, FAAD: Yeah. as I kind of alluded to, I think that when I first started practicing, steroids were a mainstay of therapy. I mean, that was what we had. Then calcineurin inhibitors came out and they didn't really… they were designed to address this steroid stewardship issue and reduce topical steroid application. At least for me, I fundamentally never was impressed by them. I mean, there are some instances where I feel like they're a success, but for the most part, after you get over the lymphoma risk, which of course is really irrelevant, they don't really work. Then you're giving people these regimens where—I remember we used to do this all the time—when times are good, you're going to use your tacrolimus or you're going to use your pimecrolimus and then reduce the amount of topical steroids. When times are bad, now you're going to reduce your calcineurin inhibitor, you're going to increase your steroid use.  

And oh, by the way, your class 6 low-potency steroids for your face and your armpits or your groin, your mid-potency steroids for your trunk, and your high-potency steroids for your hands and feet. You good with that plan? We see this now still because they'll come in with their grocery bag of 18 different tubes and they're like, "What am I supposed to be using out of this?” Half the stuff is expired. Half the stuff is duplicates. 

Zampella: The adherence thing is actually really important, especially if you talk about tachyphylaxis to topical steroids. There was a little study on this showing that the average dermatology patient leaves with 4 prescriptions. I can barely imagine having to remember 4 different things. Imagine your 80-year-old…  

Payette: Right, and then different ones for different body areas. I used to have to take a Sharpie and write "flare" on the tube so they wouldn't have to remember which one, because they have tacrolimus and triamcinolone—you're like, it's too similar.  

Zampella: They sound the same. 

Payette: Yeah. So, I would write "flare" or "maintenance." Most steroids have to be applied twice a day. Most people can't adhere to a twice-a-day regimen for more than a week. As we've gotten newer modalities, especially advanced topical therapies that allow us to do once-daily application that don't carry these risks of tachyphylaxis and atrophy and acne and whatnot, I think it's easier now to introduce these as first-line options. I really try to do that, especially within the topical space. 

Melodie Young, MSN A/GNP-c: There's a lot less chance for error. Because the other thing is the prescriptions come in a box and the label's on the box, the box gets tossed. When they come in, and they'll say it's the red tube, well, most of the corticosteroids now are generic. There are multiple manufacturers. You don't even really know what all the other ingredients are, the inactives, because sometimes they didn't used to sting, now they sting. So, it's a challenge. I kind of a few years ago started saying, “It's time for us to get rid of all those things that I've given you through the years. Bring them in next time I see you.”  

Zampella: Or half of them are expired. 

Young: Or just throw it out. Let's freshen up. It's like your mayonnaise—you get rid of it after a while, and then you get a new jar. It's time. We have new technology. We have new medications. We have things that are safer, more effective, easier to use.  

Payette: How fun is it to say, “This is safe for any body part. You've got one prescription. Head to toe. Once a day, it's safe for any body part you want, whether you're putting it on your face, your feet, your hands, your groin, it doesn't matter.” 

Young: As long as you need to. 

Payette: Yeah. 

Young: As long as you need to. We used to do the rotational therapy where you would use the steroid on the weekends and the non-steroid option, which was calcipotriene for a long time, and then the calcineurin inhibitors—they would do that. It was just crazy, something you would include, something you wouldn't include. It was really cumbersome. I couldn't keep up. 

Payette: The other thing is, where did you guys even learn to do that? Because there's not really data on this. We don't have good guidelines on what to do. 

Zampella: It's actually interesting. Part of this was trying to elicit the variability in algorithms that we have. I always like to say, we're physicians and practitioners, and I don't follow an algorithm except that I have infinite algorithms in my brain that I'm doing, whether the patient is old or young or whatever. We don't have guidelines for how to treat genital psoriasis. In that space, what do we do? How do you work through each of those things? There are layers to this, too, because some of the newer agents that we might want to get, maybe they're not covered by someone's insurance, or their patient has Medicare and the newer agents are covered but there's a thousand-dollar copay with it. So, how do you kind of work all of those things into your treatment approach? 

Shehla Admani, MD: I usually start with some topical steroid. There are some guidelines that say that you should use a low-potency product, and I personally find that it just takes a lot longer to get under control with that. If I do something like a more medium or high potency for a short period of time, that helps me kickstart things, but I do like to write for a non-steroid at the same time. It gives me a chance to work through insurance issues. If the one that I wanted initially wasn't covered, I can move on to another one, but it buys us a little bit of time. Steroid for limited time periods only, and then you have to make a transition. I am very comfortable with my patients using steroid therapy intermittently for flares, but it’s in a way that's supervised and that we're all comfortable with. It can't be 10 products. It gets too complicated, but if there is one for bad flares and then one that you can just use all the time, it makes it very easy. 

Payette: If you think about the clinical trial space in psoriasis, we have some of the best clinical trials, right? Randomized, placebo-controlled. We've been doing this for years, but we don't really have trials that are looking at genital psoriasis, probably because, as we talked about at the beginning, there isn't an ICD-10 code. Most of these things are being done by sub-analyses. I can only think of one dedicated trial that specifically looked at genital psoriasis as an outcome versus looking at it as an ad hoc or post-hoc analysis or whatnot. That's a real deficiency in our space, and I think it hinders our clinicians from getting the information to know how to actually approach this therapeutic area. 

Young: It's not being done in other specialties. No one's doing it. It's not being done in gyno or urology. It's derm. We have to claim the genitalia.  

Zampella: Talk to me a little bit about how patient demographics might influence your choice of therapy. We mentioned older patients, children, patients who don't have insurance, and how that kind of influences things. 

Young: You want to try to make all things available to all patients because the goal again is clear, no matter where you have it, how much you have it, all things being clear. Unfortunately, the bulk of patients are going to qualify for something that has a very good chance of getting them clear. Then it's kind of the tweaking piece. It's 20% of your patients take up 80% of your time, or maybe even 5% of your patients take up 95% of your time, because they're the ones that you have to go to bat for to try to get things approved. There are some companies that have programs for the uninsured or underinsured. I'm a geriatric-certified nurse practitioner as well, and I have a particular passion for the elderly, of which now I'm a part. 

Payette: I don't believe that. 

Young: There are different needs, and they're very similar to peds, very similar to children with issues. Because of the new Medicare plan, the new Part D, most of the time, once they meet their deductible, now I just say, "Are you on a GLP-1? Are you on something that's an expensive drug where you have to spend a couple hundred dollars a month on your meds?" If you do, then you'd be able to get it approved. I also think about that when it gets towards the end of the year, that's a good chance for them to buy their product that they're going to need. In the Medicare population and Medicaid, more and more of the states are approving these better therapies. I think we have to advocate to get these non-steroid advanced topical therapeutics and more biologics and systemics approved based on even site-specific conditions. I think it's our job. 

Payette: To your question though, John, I think we've already kind of alluded to the fact that genital skin is different. 

Zampella: Yes. 

Payette: But genital skin also gets more different with time, right? 

Young: Perfect. Yeah. 

Payette: Your 40-year-old doesn't have the same skin as your 75-year-old, and we have to be even more cognizant in those populations, more cautious that we don't do something. Let's say somebody who has a lot of pubic hair—you're not going to give them an ointment. Where's it going to go? Those are unique considerations that we probably work through in milliseconds in our head when we're evaluating that.  

Zampella: Part of your infinite algorithms. 

Payette: Infinite algorithms. We also think about polypharmacy. What other medicines are they utilizing? Is there a risk there? You can't just look at genital skin as a subset of psoriasis. It's a subset of psoriasis that is at a subset of your entire lifespan. 

Young: Do you think about some of the topical products in terms of it can also contribute to candida? Contributing to increased HPV, those sorts of things. Do we ever talk about that, mention that, worry about it? Because the newer advanced topicals I don't think are as much of a concern, that you're going to cause some sort of secondary infection or contribute to it. 

Zampella: Certainly, there are systemic therapies that increase your risk of infections, and certainly that would come into play, especially in older patients, and that I consider. I mentioned that I like phototherapy, and I use phototherapy in older patients for genital psoriasis sometimes. But yeah, I think the point is well taken and we have a lot of very safe topical medications now that don't carry that risk. 

Young: Older people wear diapers. 

Zampella: Yep, totally. 

Payette: We also shouldn't assume that some particular ethnicity, age, or whatnot is going to—we automatically know what that patient wants. I think it's really important that every time we're offering therapeutic interventions, we should say, "Hey, there are topical therapies, there are oral therapies, there are injectable therapies. Which of those do you feel might be the most appropriate choice for you?" They may not understand that question, we have to expand on it, but allowing them to participate in that conversation and allowing them to have some weight in terms of what they think would best fit their lifestyle—as long as they're not doing something that's going to be harmful or unsafe—I think it's actually okay to do that therapy that they've selected. 

Admani: Yeah. 

Zampella: I want to double-click on that in a second, but I did want to just go back to something Melodie said about getting involved in advocacy, as a plug for people listening. If you're not involved in your state or local society, a lot of Medicaid decisions happen at the state level, not the national level. If you are not at the table advocating for your patients, your patients are on the menu. 

We need to be able to get the best care for all of our patients regardless. Little plug there for that. But actually, Mike brings up this idea of talking with your patients about the therapies that are available, this idea of shared decision-making. Maybe we all come from a time where actually that wasn't the case, right? You walk in, this is what you're doing.  

Payette: See you in 2 months. 

Zampella: But now medicine is catching up, right? Our system is catching up to a patient-centered kind of form of care. How do you navigate that? You're mentioning all the options. How do you navigate when patients come in asking for something specifically? How do you navigate that shared decision-making process? 

Young: I think the other part, because he was talking about the skin changing and the genitalia, or the body, the skin of a child all the way up to a geriatric or a nursing home patient, their psoriasis can carry through all that. The hope is that you're going to be that provider for that patient for a very large portion of their life, and you're going to have to make those changes. When you're saying that you’re giving them all of those options… For this point in life, this is good, but at some point, we may need to do something else. If you're happy now, but the disease is going to change. Your life, your goals are going to change. The therapies are going to change. What we offered 20 years ago, 10 years ago, 5 years ago versus what we have now.  

It's just the encouragement. Come on, clinicians. Dermatology has some kick-ass drugs. It's awesome that we get to use so many therapies and impact people. 

Payette: How frustrating is it to a patient when you finally feel like you get to an expert and they offer you the same stupid therapy that your previous provider… I hear that not infrequently from people around town, not even my patients. Like, "I can't believe I saw this guy. He did the same thing the other guy was doing, and it wasn't working then, and it's not working now." We are the experts. When you come to us, we should be offering you the top of the line, most advanced, cutting-edge science. That's why we have our jobs. I couldn't agree more. 

Payette: That gets to your advocacy point too, right? If we're not advocating for it, then we're just receiving it, taking it. 

Zampella: That's where you're getting it. Yes, for sure. 

Admani: I think sometimes in my pediatric clinic specifically, families can come in with an agenda. They're like, "Oh, my neighbor used this, his cousin used this, and this is the medication that I want." Having an open and honest conversation like, "Hey, this may have worked for these reasons, but we also have X, Y, and Z that we can use." We are so lucky, even in peds, that we have more FDA-approved medications now. We have many different options, and not one thing is going to be perfect for everyone, even in the same age group. I have some parents who, even though I may feel comfortable with the steroid, have absolute steroid phobia. They cannot dream of putting a steroid on their child. If they don't want to, we don't have to, because we have other choices. Other families worry about the black box warning, even though we are not worried about specific black box warnings, but you tell that to a parent…  

Zampella: They go home and look it up afterwards. 

Admani: Or the pharmacist, "I can't believe your dermatologist did this." 

Payette: Oh, don't get me started. That one really aggravates me, when we come up with a plan and the pharmacist changes it.  

Admani: You don't want to do this. I think just having these trials, getting these drugs approved, it improves access for all of our ages, and then we have to work on the cost piece. It has to be affordable. 

Young: Something we haven't even mentioned is just something being aesthetically pleasing. You ask about someone if they're worried about it getting in their partner's mouth, but the stinging and burning—that has been a huge thing in pediatrics. For the calcineurin inhibitors that we used in psoriasis, even though they're off-label, we would always say they're spicy. They feel like you've got a paper cut and you're going to put lemon juice on it, but go ahead and put that on your genitalia. To have advancements that the patients don't mind using… 

Zampella: Go ahead, please. 

Admani: I was just going to say, we often reserve our systemic agents for patients who are not responding to topical therapies. I think sometimes that may be doing them a disservice. Maybe you will clear with topicals, but you have to put something on 2 times per day. It's greasy, it gets on your underwear, it causes all these problems. Realistically, it's just not a good, feasible option for them long-term. We should tell them about other things. We should tell them about oral options, injectable options, and have them participate in that decision-making because we have so many drugs that are very safe. 

Payette: That's why I really love the IPC and NPF's change in what qualifies for systemic therapy. 

Admani: Yes. 

Payette: It's failure of 2 topicals over 4 weeks. That really argues so much to your point that we should be offering these patients these therapies. This is beyond the scope of the conversation today, but we all recognize that this is still a systemic inflammatory disease. There are systemic complications of not treating a patient systemically. 

Young: Sometimes, you treat them systemically and everything clears but 1 spot. They're 95% better on a biologic. We don't have a lot of studies showing about adding add-ons, tandem therapies. I think we have to, again, go back to what we talked about at the very beginning: can we make you happier? Is everything clear? Are there things we can do to add to quality of life, newer things? 

Zampella: I think you both hit on the idea of the chronicity of psoriasis. Part of that is, this is probably going to be something you're going to have forever, and having something that you can potentially do forever is paramount to making people happy.