By Alan Menter, MD
There has been significant progress in psoriasis research in the past 20 years, but there is still much we can learn about this complex disease. That’s the focus of the research behind the January 2014 JAAD article, “Research gaps in psoriasis: Opportunities for future studies,” of which I was senior author, along with 11 of my esteemed psoriasis colleagues.
This paper is a very comprehensive review of the most important gaps in research, and it makes suggestions for basic science and clinical research studies to be performed to address these deficits. I wanted to give you some highlights of this paper because now that we have identified and suggested studies to fill these gaps, we can work cooperatively to expedite research in the psoriasis field for the benefit of dermatology and psoriasis patients.
Pediatric psoriasis patients
There are multiple studies that look at plaque psoriasis, but there is little research on the pediatric population for this disease. Even if a patient develops psoriasis at a young age, the International Psoriasis Group has shown that these patients are heavier, which sets them on the path to developing multiple comorbidities. There is tremendous potential to examine ways to reduce their weight and prevent a host of issues, including hypertension, fatty liver disease, metabolic syndrome, and other complications.
We also need to take a closer look at psoriatic joint disease and diagnose it early to prevent chronic and irreversible disease. Most patients have this cutaneous condition for five to 10 years before they develop their joint disease. This is another tremendous area for research. Are there any markers or screening tests that could help us diagnose this condition earlier? Right now we don’t have any. For common manifestations, we don’t have very good screening tools. We also need to optimize the role of the dermatologist in early screening and diagnosis.
Another important research gap is around the study of psoriasis and its comorbidities, and how to reduce inflammation in the treatment of psoriasis. There is a $5 million National Institutes of Health (NIH) research study currently being conducted to look at this. So many psoriasis patients are morbidly obese, with a body mass index (BMI) of 40 or higher. We know that for some patients who undergo gastric bypass and lose a lot of weight, their psoriasis improves. But having five or 10 anecdotal cases is not enough. If a patient has a gastric bypass and loses 125 pounds, what effect does it have on the patient’s treatment schedule as well as on all their comorbidities?
The hidden disease
And, a topic that many patients are reluctant to discuss is psoriasis in the genital area. Psoriasis by nature is a hidden disease, but what effect does genital psoriasis, present in more than 50 percent of patients, have on their relationships? We need to be able to ask questions in the course of our research that patients will be comfortable with. How can we help patients better care for this condition? There is a need for further research, and we need to have better recognition, as well as treatment, for this condition.
Psoriasis drugs and efficacy
We’re all familiar with the three TNF-alpha drugs and the IL12/23 drug used to treat psoriasis — etanercept, adalimumab, infliximab, and ustekinumab — but we need develop better registries that will help us study these drugs and find out more about what kind of effects they have. Most dermatologists can agree that we need a better way of looking at data on real-world patients, and better patient registries will help us get there.
In addition, we need to take a closer look at methotrexate; why does it only work in 45 percent of patients? Does injectable methotrexate offer better efficacy? We also know that methotrexate reduces the level of folic acid in patients who use it. There isn’t any evidence-based data to tell us what the correct dose of methotrexate, or even folic acid, should be to treat certain types of psoriasis.
We also need long-term safety data for the drugs we are prescribing to treat psoriasis. Dermatologists are great at mixing and matching topicals, systemics, and biologics, but what are the correct combinations? When should the various combinations be initiated? If a patient is clear for a year or two and all of a sudden he or she flares, why does he or she flare? What are the trigger factors? Can we take a patient off of treatment? Are there any markers that can detect flares early? About 90 percent of the time we don’t have a good understanding of why psoriasis suddenly flares.
Finding the answers to these and many other complex questions about the treatment and comorbidities of psoriasis offers a promising future for patients. We know that the ultimate “cure” of psoriasis is likely many years away, but the key research priorities that we have unearthed in the process of researching this paper have set us on the right path to finding the answers we seek.
Dr. Menter is chief of the division of dermatology at Baylor University Medical Center in Dallas; clinical professor of dermatology at the University of Texas, Southwestern Medical School; director of the fellowship program at the Baylor Psoriasis Center in Dallas; director of the dermatology residency program at Baylor University Medical Center; and chair of the AAD’s Psoriasis Guidelines Committee.
“Research Gaps in Psoriasis: Opportunities for Future Studies and Development of New Outcome Measures for Clinical Trials” and “Translating Evidence into Practice: Psoriasis Guidelines” will be offered at the 72nd Annual Meeting in Denver, Colo.
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