PASI 100 and the perfection paradox
By Warren R. Heymann, MD
June 27, 2016
I am not a psychiatrist, but over the years I have concluded that my patients’ happiness is more supratentorial than epidermal.
As we approach perfection, imperfections take on far greater importance. Some examples:
In medical school, I spent many Sunday afternoons in the stacks of the library of the Albert Einstein College of Medicine, scouring Index Medicus, finding a few relevant articles, photocopying them, and having a sense of accomplishment about the task. Now if it takes me more than 3 milliseconds to find a reference on PubMed, I can feel my blood pressure rise.
The smallest ding on a new car causes the greatest grief. A smashed bumper after 100,000 miles barely elicits a shrug.
If you stared at a Jackson Pollack painting, how would you know if he made a mistake? Alternatively, if you see a smudge on an otherwise white wall, it really stands out.
In the prebiologic era, methotrexate was the most common systemic agent that I used for my psoriatic patients. The goal was not to get them completely clear, but just enough to have a few plaques remain. That way you knew that you were not administering too much methotrexate thereby delaying future liver biopsies.
By analyzing data pooled from the nonplacebo arms of 3 phase III studies of brodalumab, Strober et al determined that PASI 100 is a clinically relevant end point, as complete skin clearance results in significant improvement in signs and symptoms of disease severity and health-related quality of life (1).
The bar is now raised — PASI 100 is psoriatic perfection. Previously, patients would be grateful for modest improvement in their disease; once the expectation (and potential reality) is complete clearance, how could anything less than PASI 100 be acceptable? Did you ever go to a movie that got stellar reviews only to feel disappointed because it wasn’t as entertaining as billed? If I spent $5000 on a ticket to see Hamilton, it damned well better be the best Broadway show ever (by the way, I bought the album for $23 and read Chernow’s book instead). Residual psoriatic plaques were formerly looked with a sense that patients have gotten so much better — now it is a source of frustration that they are still there.
PASI 100 is the new norm. Just think of the post-World War I tune: “How you gonna keep ‘em down on the farm, after they’ve seen Paree?”
1. Strober B, et al. Clinical meaningfulness of complete skin clearance in psoriasis. J Am Acad Dermatol 2016; 75: 77-82.
All content found on Dermatology World Insights and Inquiries, including: text, images, video, audio, or other formats, were created for informational purposes only. The content represents the opinions of the authors and should not be interpreted as the official AAD position on any topic addressed. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
DW Insights and Inquiries archive
Explore hundreds of Dermatology World Insights and Inquiries articles by clinical area, specific condition, or medical journal source.
All content solely developed by the American Academy of Dermatology
The American Academy of Dermatology gratefully acknowledges the support from Incyte Dermatology.