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Professor David Jay Cohen, M.D., is Chief of Dermatology – Mercer University School of Medicine, Assistant Clinical Professor- Department of Medicine, and owns and operates Skin Care Physicians of Georgia in Macon, GA.

Welcome back, Medscape Readers! This month in Dermatology, we speak with Dr. David Cohen about several topics within the area of psoriasis treatment.

We discuss the data on IL-17 or an IL-23 blocker being utilized first for psoriasis versus TNF blockers, future impactful products in the pipeline, and the challenge of keeping up with treatment options and the literature supporting them.

Last month we spoke with faculty on practice pearls to be shared at the 2023 Skin of Color Update. Click here to if you missed it! 

Save the Date and Register Now!

2023 Skin of Color Update  

October 6–8, 2023 | New York Hilton Midtown | New York, NY

  • Educate dermatology clinicians and trainees to best ​diagnose and treat dermatologic disorders in populations with skin of color, including those that disproportionately affect higher skin phototypes. 
  • Educate clinicians and trainees to best treat the aesthetic needs of patients with skin of color.
  • Provide the latest updates on diagnostic, therapeutic, and cosmetic treatment best practices for dermatologic conditions in populations with skin of color.
  • Equip practitioners to deliver safe, effective, and culturally competent care to a diverse patient population.
  • Click here to register!

46th Annual Hawaii Derm 2024 

  • Presidents’ Week February 19, 2024 
  • In-person event!
  • World-class faculty bring the latest dermatological advancements with presentations that go beyond the podium.
  • New developments in aesthetic medicine to the latest breakthroughs in the treatment of skin diseases.
  • Acne to atopic dermatitis, psoriasis to skin cancers, surgical pearls to nonsurgical facial rejuvenation, and more.

Thank you to Dr. Cohen for his time and expertise this month. Enjoy the rest of the summer and happy reading! —Colleen Hutchinson

Panelists in past issues have stated that current data provide strong evidence that an IL-17 or an IL-23 blocker should be utilized first for psoriasis, and not TNF blockers, which are less efficacious and less safe. Would you say TNF inhibitors are obsolete for psoriasis?

Dr. Cohen: As we have developed a better understanding of the immunology of psoriasis, it is evident that activation of the Th17 pathway plays an important role in the propagation of the disease. Two important cytokines that are targeted with high efficacy in this pathway are IL17 and Il23. Both are efficacious, with good durability and acceptable safety.

The older therapies that target TNF are still valuable in some cases, especially when other comorbidities exist, such as psoriasis with IBD or hidradenitis suppurativa (HS). In summary, it’s good to have all the agents available for selected patients. However, I do see a decline in the use of TNF agents in dermatology as compared to years ago.

What are some products in the pipeline that you believe could have an important impact on psoriasis treatment paradigms?

Dr. Cohen: Recently we have seen approval of two new nonsteroidal topicals for psoriasis and two new systemic agents, one being an oral TYK2 inhibitor, while the other is approved for severe pustular psoriasis, which fortunately is rare. The topicals offer advantages being steroid-free and can be used anywhere on the body with the ability in some cases of some long-term remissions. I think with the excellent biologicals we have that are safe and durable, the need for a somewhat less effective oral agent with unknown long-term side effects is not as appealing. For patients who absolutely want a pill, oral options can be considered. However, I find most patients that are so-called needle-shy can overcome that easily, especially with the need for infrequent injections. My first choice would still be a biologic for moderate to severe disease. The newer drug for severe pustular psoriasis will rarely be used due to the infrequency of the disease in clinical practice and the fact that we have other meds to quiet the disease down that we can obtain quickly.

There is less research going on in psoriasis than there was a few years ago. I believe we have great drugs to quiet the disease in most patients. There is a drug called bimekizumab (Bimzelx®) from UCB that has been trying to get FDA approval for several years now. It is an IL-17AF blocker and shows promising high efficacy for skin and joints. My wishes would be to have a psoriatic arthritis drug with as high an efficacy in the joints as we see in the skin.

Dermatology research needs to now focus on the other many diseases for which we have no approved therapies or limited approved therapies, such as lichen planus, hidradenitis, atopic dermatitis, and many other serious skin diseases.

In a recent Cutis review article, the authors state: “The landscape of psoriasis treatments has undergone rapid change within the last decade and the dizzying speed of drug development has not slowed, with four notable entries into the psoriasis treatment armamentarium within the last year: tapinarof, roflumilast, deucravacitinib, and spesolimab. Several others are in late-stage development, and these therapies represent new mechanisms, pathways, and delivery systems, meaningfully broadening the spectrum of treatment choices for our patients. However, it can be quite difficult to keep track of all the medication options.” How do you advise fellow dermatologists to keep track of, or how do you keep track of, all of the options?

Dr. Cohen: For those of us that treat psoriasis and have a passion, we read the literature and keep on top of the science even before the drugs come out. No worries if you miss something as the pharmaceutical companies will gladly teach you about their drug after it gets released.
I personally love the science and immunology that we have learned about this autoimmune disease and hope to expand that to all the immune mediated diseases that we encounter.

Dermatology Resource Section: 

Cutis Original Research: Cancer Screening for Dermatomyositis: A Survey of Indirect Costs, Burden, and Patient Willingness to Pay

NEJM Editorial: DOCK11 and Immune Disease

Dermatology News: On the trail of a new vaccine for Lyme disease

JAMA Dermatology Editorial: High-risk Prognostic Tumor Features of Squamous Cell Carcinomas in Organ Transplant Recipients Compared With the General Population

Dermatology News Article: Analysis reveals recent acne prescribing trends