The International Psoriasis Council (IPC) Think Tank brings together member experts in dermatology to deliberate on the issues that contribute to the widespread undertreatment of tens of millions of people with psoriasis worldwide.
Held virtually on December 11 due to the Coronavirus Pandemic, the 2020 IPC Think Tank convened more than 100 specialists in psoriasis and industry partners from all over the world to discuss the most pressing issues affecting psoriasis care and treatment globally. The outcome of these discussions will inform IPC initiatives in 2021 and beyond.
Below is a summary of the presentations and discussions from the 2020 Think Thank centered on four broad areas of activity: COVID-19 and Psoriasis, Projects and Partnerships, Medical Education, and Manuscripts, all critical to improving the lives of people with psoriasis.
IPC Strategic Plan Updates and Discussion
IPC Chief Medical Officer
2021 EDUCATION PROGRAMS:
- IPC will be hosting symposia during the following congresses: AAD, RADLA, IFPA, EADV, SID, and ESDR. We are planning for both live/in-person and virtual symposia.
- IPC will host four (4) global quarterly, 90-minute webinars for a global audience, focused on the most recent advances in psoriasis research and care.
- IPC will continue to host its regional Masterclasses (MC) during 2021. The first two programs will be held virtually, with 2 hours sessions, once a week for five weeks. The first program will be held for dermatologists in the Middle East and N. Africa (MENA) in Q1, followed by a program in Latin America in Q2; Additional programs may be scheduled for Q3 and Q4. IPC board member Mahira Hamdy El Sayed from Egypt and chair of the MENA MC added that there are currently 28-30 health care providers recruited for the Masterclass, which include a wide representation in the region. By the end of December, they hope to have 40 participants representing a diverse group of health care providers from the Middle East and North Africa.
- The IPC International Fellowship Program has installed a Working Group, chaired by Lars Iversen and co-chaired by Elise Kleyn. Members include Marc Bourcier, Canada; Kelly Cordoro, USA; Colin Theng, Singapore; and Fernando Valenzuela, Chile. The 2021 program is a virtual program, with onsite visits being conducted in 2022. Virtual components for the 2021 program will include: 1) a primary mentor with whom the Fellow will do their onsite observation; 2) small group mentoring, based on specific topics and led by an IPC board member or councilor; and 3) quarterly, 3-hour workshops, which will also be open to past Fellows. Many board and councilors replied to our email with valuable program contributions – thank you for sharing your time and expertise.
- In 2021, IPC will launch a new online educational initiative – the IPC Virtual Academy – some of which will be accredited by the AACME. The activities will include short videos, 90-minute symposia, case-based learning, and other formats. Q1 will focus on the Take Ten video project, and Craig is the father of this program. Many thanks to councilors for your willingness to contribute with a personalized video of 10 minutes on a specific topic about which you are passionate. Craig added that we are in the process of building software to support this initiative, and we currently have a dozen videos available after asking all board and councilors to participate. We will update the video selections every two years.
2021 KEY PROJECTS:
- Disease severity reclassification: The disease severity working group is chaired by Bruce Strober and co-chaired by Lone Skov. Members include Matthias Augustin, Germany; Cristina Echeverría, Argentina; and Marcus Schmitt-Egenolf, Sweden. The disease severity road map includes 1) validating the new classification in three populations, 2) education, and 3) engaging other stakeholders.
- Telemedicine Working Group: The telemedicine working group is chaired by Alexander Navarrini and co-chaired by Joel Gelfand. Members include April Armstrong, USA; Andrea Chiricozzi, Italy; Vahid Diamei, expert telemedicine, Switzerland; Mohamed El-Komy, Egypt; and Christoph Hsu, dermatologist, Switzerland. The initial project is to develop a consensus statement regarding telemedicine in the management of psoriasis during the first quarter of 2021.
- Global Psoriasis Atlas (GPA): Phase two of the project has been initiated in partnership with the ILDS and IFPA.
- COVID 19: The board launched a resource center on the website, which includes:
- Two statements on COVID-19 and psoriasis.
- The statement regarding vaccines and psoriasis.
- Key publications accompanied by councilors commentaries.
- Councilor videos on various aspects of COVID-19 and psoriasis; and
- A link to the PsoProtect COVID-19 registry.
- Best evidence literature review: Catherine Smith will present the 2021 review, which was a collaboration of the Biomap group and IPC. We received suggestions from the councilors for the best evidence review; many thanks for this. We are in the process of selecting the topic and group for commissioning the best evidence review 2021.
- Outreach: We are in the process of forming an editorial committee, which will be Co-chaired by Johann Gudjonsson; a co-chair and members will be appointed soon. IPC’s current communications, including the website, will be reviewed by the committee, and the committee will then propose an updated plan for communication and outreach.
Coronavirus Pandemic and Management of Psoriasis
IPC board president Jonathan Barker welcomed 34 corporate partners to the virtual Think Tank and thanked them for their continued support of IPC. He then shared with all on the call that IPC Founders Chris Griffiths and Alan Menter would be transitioning off the board into a new role as Honorary Founding Members and will continue their involvement with IPC in their new role. They were presented with recognition plaques on behalf of IPC; both Griffiths and Menter shared comments.
Barker then moderated a discussion about the Coronavirus Pandemic and the Management of Psoriasis. Below is a summary of the presentations, along with key messages.
DATA FROM PSOPROTECT AND PSOPROTECTME
To characterize the course of COVID-19 in patients with psoriasis and identify factors associated with severe outcomes, we launched the global PsoProtect registry (www.psoprotect.org) on March 27, 2020, for clinicians to report their patients with psoriasis and confirmed/suspected COVID-19. Our paper in J Allergy Clin Immunol (https://www.jacionline.org/article/S0091-6749(20)31413-5/fulltext) describes the first 374 patients reported to the registry (data cut July 1). We have subsequently updated the analysis following a more recent data cut last month. This dataset now encompasses 557 patients from 30 countries (60% male, median age 50 years) and the associations (detailed below) remain the same as in the paper.
Methods: Multiple logistic regression analysis was used to assess the association between clinical/demographic characteristics and hospitalization for COVID-19.
- 69% of patients reported to PsoProtect were receiving a biologic, 19% were receiving a non-biologic, and 11% were not receiving any systemic treatment for psoriasis.
- 94% of reported patients fully recovered from COVID-19, 18% were hospitalized, and ten patients (2%) died.
Hospitalization for COVID-19 was associated with:
- Established risk factors for severe COVID-19 in the general population:
- Older age (multivariable-adjusted odds ratio [OR] = 1.64 per 10 years; 95% CI = 1.27-2.11)
- Male sex (OR = 2.66; 95% CI = 1.45-4.88)
- Non-white ethnicity (OR = 2.61; 95% CI = 1.18-5.78)
- Comorbidities – comorbid chronic lung disease (OR = 5.51; 95% CI = 2.51-12.11).
- Established risk factors for severe COVID-19 in the general population:
- Hospitalization was more frequent in patients receiving non-biologic systemic therapy for psoriasis than in those receiving biologics (OR = 2.74; 95% CI = 1.44-5.22); however, further study is warranted on account of potential selection bias and unmeasured confounding. No significant differences were found between classes of biologics.
- The limitations of registry data were discussed (e.g., observations are not causal, and there is likely selection bias due to a predominance of patients receiving biologics)
- A separate global patient-facing registry with aligned questions called PsoProtectMe (www.psoprotectme.org) characterized risk-mitigating behaviours (which was an unmeasured confounder in the clinician reported PsoProtect registry). PsoProtectMe is completed by people with psoriasis, whether or not they have had COVID-19.
- Independent patient-reported data from PsoProtectMe (1626 participants across 48 countries) suggested lower levels of stringent social isolation (shielding/quarantine) in individuals receiving non- biologic systemic therapy compared to those receiving biologics (OR = 0.68; 95% CI = 0.50-0.94). The lower risk of hospitalisation associated with biologics use may, therefore, at least in part, be due to more stringent risk mitigating behaviour among those receiving biologics.
- Overall, these data from PsoProtect are reassuring since the majority of patients receiving drugs that affect the immune system for psoriasis fully recovered from COVID-19.
- These findings are also consistent with emerging data from other clinician-reported COVID-19 registries in other inflammatory diseases, e.g., SECURE-IBD (https://pubmed.ncbi.nlm.nih.gov/32425234/) and Global Rheumatology Alliance (https://pubmed.ncbi.nlm.nih.gov/32471903/).
- These data, along with findings from other observational studies, have helped to inform timely clinical guidance statements for the care of people with psoriasis in the pandemic, e.g., NPF COVID-19 Task Force (https://www.jaad.org/article/S0190-9622(20)32544-5/fulltext) and IPC statement (http://psoriasiscouncil.org/blog/COVID-19-Statement.htm).
- As the pandemic continues, it is important to continue to collect international data via these online registries – PsoProtect (for clinicians to report their cases of suspected/confirmed COVID-19 in psoriasis) and PsoProtectMe (for patients to self-report their experiences of the pandemic, whether or not they have COVID-19). The rapid and robust global uptake and dissemination of these registries have been facilitated by invaluable support from multiple professional and patient organisations, including the IPC (see https://psoprotect.org/partners/ and https://psoprotectme.org/who-we-are/)
COVID RISK OF BIOLOGICS FROM PUBLISHED LITERATURE
IPC Board Member
COVID-19 is usually a mild self-limited illness; however, a subset of patients have a severe life-threatening course. The case-fatality rate of COVID-19 is about 2%, resulting in over 1.7 million deaths worldwide. The primary determinants of COVID-19 outcome are advanced age and comorbidities such as hypertension, obesity, diabetes, and chronic kidney disease, all of which are more common in patients with psoriasis. As psoriasis treatments target the immune system, there is special concern that they may increase COVID-19 risk. For example, meta-analyses of pivotal trials have observed an increased risk of respiratory tract infections and symptoms from biologics that target IL17 and possibly IL23 compared to placebo. Three approaches have been taken to date: 1) Registries of spontaneous case reports, 2) Clinic-based cohorts with comparison to the general population, and 3) Automated databases of medical records. These studies have generally been reassuring regarding the safety of oral and biologic treatment for psoriasis and COVID-19, and there is some evidence that TNF inhibitors may be associated with a lower risk of severe COVID-19 compared to other treatments in the rheumatic disease population. Therefore, The National Psoriasis Foundation COVID-19 Task Force recommends that patients who are not infected with SARS-CoV-2 continue their biologic or oral therapies for psoriasis and/or psoriatic arthritis in most cases.
Gelfand et al. NPF COVID-19 TF Guidance for Management of Psoriatic Disease During the Pandemic: Version 1 JAAD 2020; 83(6):1704-1716
IPC Strategic Initiatives
PSORIASIS, ITS MANAGEMENT, AND TELEDERMATOLOGY
IPC councilor Alex Navarini served as the chair of IPC’s Teledermatology Working Group and provided an update on psoriasis, its management, and teledermatology.
The digital transformation of medicine has huge potential for dermatology because the diagnosis is usually image-based. This means that teledermatology is feasible and indeed has been practiced for decades, waiting for patients’ demand to rise. This moment seems to have arrived now, due to the generally increasing virtualization of consumers’ other habits such as teleshopping. As a second factor, the COVID-19 pandemic prompted even patients usually unwilling to use virtual consultations to try teledermatology. In the think tank lecture, Prof. Navarini introduced the audience to the current working group of the IPC for teledermatology and explained the various types of teledermatology currently practiced all over the world. Subsequently, he discussed what types of skin conditions can be diagnosed and treated with teledermatology consultations and whether psoriasis is a “teledermatosis.” Indeed, psoriasis is highly suitable for online consultations both with video as well as still images, as it has unique visual features that experienced dermatologists can diagnose with high confidence. Also, the drugs available for psoriasis are, to the greater part, highly suitable for prescription by telemedicine, especially the newer biologics and small molecules that have superior safety features. Hence, it may not surprise that the working group is aware that virtual prescriptions are performed regularly, especially the continuation of drug treatments that were started after in-person consultations. The group of Prof. April Armstrong studied virtual consultations in a cohort of psoriasis patients and found the improvement of clinical disease equal to a control group of patients treated with in-person visits. What remains to be seen is whether fully virtual, long-term patient-physician relationships are feasible and effective, and non-cutaneous aspects of the disease that dermatologists typically consider as well, such as comorbidities in psoriasis, can be addressed equally well by teledermatology.
Effectiveness of Online vs. In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial. Armstrong AW, Chambers CJ, Maverakis E, Cheng MY, Dunnick CA, Chren MM, Gelfand JM, Wong DJ, Gibbons BM, Gibbons CM, Torres J, Steel AC, Wang EA, Clark CM, Singh S, Kornmehl HA, Wilken R, Florek AG, Ford AR, Ma C, Ehsani-Chimeh N, Boddu S, Fujita M, Young PM, Rivas-Sanchez C, Cornejo BI, Serna LC, Carlson ER, Lane CJ. JAMA Netw Open. 2018 Oct 5;1(6):e183062. doi: 10.1001/jamanetworkopen.2018.3062.
DISEASE SEVERITY PROJECT
IPC Board Member
Traditionally, the severity of psoriasis has been classified as mild, moderate, or severe based on the percentage of BSA affected by the skin disease.However, this classification does not capture the impact of disease at special sites, nor does it reflect either topical treatment failure or the impact psoriasis can have on quality of life.
The limitations of the traditional definitions have contributed to a lack of alignment between patient and provider assessments of severity.Recognizing this misalignment, the International Psoriasis Council (IPC) recently undertook a Delphi exercise to recategorize psoriasis severity to better reflect real-world therapeutic choices and provide improved guidance on treatment decisions.
After multiple rounds of voting and interspersed discussion, the final consensus of the effort was that patients with psoriasis should be considered candidates for systemic therapy if they meet one of the following criteria: 1) BSA involvement > 10%; 2) disease involving special areas (face, palms, soles, genitalia, scalp, nails); 3) or failure of topical therapy. To move this effort forward, the IPC will attempt to validate the classification with supporting clinical data from multiple sources, including from clinical trials and real-world registries. The intent is to convince regulatory agencies and pharmaceutical companies to allow the inclusion of clinical trial entry requirements that closely reflect the new definition. Simultaneously, the IPC and its councilors will be encouraged to educate audiences regarding this Delphi output via various medical education platforms and presentations.
What's New in Psoriasis
Recent years have witnessed tremendous progress in the treatment of patients with Psoriatic Arthritis (PsA). Driven by the introduction into the clinic of more effective therapies that allow providers to achieve better clinical outcomes, research and assessment have further defined methods to better diagnose, stratify, and evaluate patients with PsA. There are several areas of particular relevance to dermatologists.
Most PsA patients have skin psoriasis for a number of years before arthritis develops. At present, we have very little understanding as to how to identify the 25% of psoriasis patients who will go on to develop PsA. Likely contributors include genomics, along with environmental exposures that cause epigenetic changes in proteomics and metabolomics, that in turn alter the immune and inflammatory responses resulting in the etiology and sustenance of PsA. While we cannot identify the contribution of these factors as of now, attention to psoriasis patients for the earliest signs and symptoms of PsA is crucial. Also, although it is speculative at present, better control of skin psoriasis might be expected to lessen or attenuate the development of PsA.
PsA is a heterogeneous disease, with potential involvement across a number of domains. In addition to skin and nail psoriasis, this includes inflammatory arthritis affecting peripheral joints, inflammatory arthritis affecting axial (spine) joints, enthesitis (inflammation at the insertions of tendons, ligaments, and synovial (joint) membrane into bone), and dactylitis (enthesitis plus arthritis in a single digit). Intriguingly, in the past few years, it has been demonstrated that agents with various mechanisms of action can have distinct effects on these various domains of disease. Thus, the optimal treatment of PsA requires a personalized approach to each patient, taking into account the extent and activity of disease in each domain to arrive at the optimal treatment approach.
GENETICS OF PUSTULAR PSORIASIS
- Pustular forms of psoriasis are clinically and genetically heterogeneous condition.
- Generalised pustular psoriasis (GPP) is associated with rare alleles of strong effect, most notably recessive mutations of the IL36RN gene. These damaging variants upregulate IL-36 signalling, causing cutaneous and systemic inflammation.
- In skin, IL-36 induces the expression of IL-17, which in turn promotes further IL-36 production. This is a powerful feedback loop, which sustains keratinocyte activation and leukocyte infiltration at sites of inflammation. At the systemic level, IL-36 activates neutrophil type I interferon responses.
- In keeping with these observations, neutralising antibodies against the IL-36 receptor (spesolimab, developed by Boehringer Ingelheim and imsidolimab, developed by AnaptysBio) are showing efficacy in GPP clinical trials.
- Palmoplantar pustulosis (PPP) shows distinct clinical, demographic, and genetic features. A comparison of PPP and GPP cohorts shows that the former is characterized by later disease onset, lower prevalence of concurrent plaque psoriasis, a marked sex bias towards females, and a strong association with cigarette smoking. Interestingly, smoking also correlates with disease severity, which is elevated in current vs. former and never smokers.
- IL36RN mutations are found in less than 5% of PPP cases. There is also little evidence for the involvement of other IL-36 related genes. In fact, the inheritance of PPP is likely to be driven by the interaction between multiple susceptibility alleles of small effect. Uncovering such genetic variants will require the implementation of genome-wide association scans by multi-centre consortia.
IPC Collaborative Projects
BIOMAP SYSTEMIC REVIEW OF BIOMARKERS
IPC councilor Catherine Smith provided an update on the systematic review of biomarkers being conducted.
GLOBAL PSORIASIS ATLAS (GPA) REPORT
IPC Board Member
2020 has seen further progress in the establishment of the Global Psoriasis Atlas (GPA) as a recognisable brand. Highlights over the year include the confirmation of follow-on funding from our main supporter, the Leo Foundation. The GPA has entered Phase II, which runs until March 2023. The key objectives of the second phase include epidemiology; early diagnosis, comorbid disease burden; and economic impact.
Dr. Tatjana Maul (Switzerland) was appointed as the GPA medical coordinator and is responsible for our 19 regional coordinators across the globe. The work of Dr. de la Cruz (Chile) and Professor Romiti (Brazil) and their appointment of national coordinators in South America is a paradigm for regional working. In May, the GPA published a major systematic review of the worldwide prevalence of psoriasis in the British Medical Journal; the key data are robust evidence on prevalence are available from only 1 in 5 countries, the reliable estimate of the number of people with psoriasis worldwide is at least 60 million, and prevalence varies markedly from 0.06% in Taiwan to 2% in Northern Europe. The GPA systematic review published in JAMA Dermatology in 2019 showed an increase in mortality from cancer in people with psoriasis, particularly those with severe disease, and an increased risk of oesophageal, liver, pancreatic, and bladder cancer. Further research on cancer incidence and mortality in people with psoriasis using registry data in the UK, Israel, Taiwan, and Denmark is underway.
Epidemiological studies of psoriasis necessitate accurate clinical diagnosis. Working closely with IPC councilors, the GPA ran a three-stage Delphi exercise, which determined consensus on one essential diagnostic criterion and at least four supportive criteria, including the lack of erythema in black skin. PsoProtectMe is a global patient-facing psoriasis register collecting information on how patients with psoriasis are coping during the Covid-19 pandemic. Working with IFPA, the GPA communications team promoted the PsoProtecMe register as part of World Psoriasis Day in October. Covid-19 has inevitably deferred planned filed studies of psoriasis, but two such studies in Greenland and Myanmar are planned for 2021 and 2022, respectively. We are grateful to the IPC, ILDS, and IFPA for their partnership and the pharmaceutical industry for sponsorship.
IPC Fellowship Report
IPC 2020 Fellow
My project was focused on access to treatment in Latin America. It is well known that epidemiological data and treatment registries are limited or nonexistent in most of the Latin American countries and that psoriasis patients lack access to systemic and biologic therapies.
During my time in Latin America, I implemented a pilot project to gain a better understanding of the common psoriasis characteristics in Latin American, including:
- Characteristics and frequency of comorbidities
- Available treatment options on an ethnical- and gender-based level
- Differences in quality of life
- Burden of disease
- Influence of the level of education on the treatment response
The pilot project included a questionnaire Based on the SDNTT and other European registers (such as BADBIR and PsoBest) in order to allow comparability of Latin America with Europe.
The goal of the project is to put the findings of this survey into perspective with already conducted studies and compare them across regions and countries. The study conducted was across-sectional, multi-centre study in 43 centres: 27 in Brazil, 16 in Chile; January – April 2020 (n=1431)
In this real-world multi-centre GPA study, more severe psoriasis was seen in dermatology centres in Chile compared to Brazil. We identified high needs for an improvement in access to psoriasis treatment with biologics in both countries, but with a significantly greater need in Chile. However, other treatments of severe psoriasis patients with non-biologic drugs were sufficiently available in both Latin American countries.
Our results highlight the gap between treatment recommendations in international psoriasis guidelines of care and the real-world situation. Further studies are needed globally, which will facilitate shared decisions by physicians and patients in improving access to newer psoriasis treatments.