The World Congress of Dermatology (WCD) convenes every four years, and in 2023, Singapore had the honor of hosting this event from July 3–8. This report covers the latest and most intriguing updates on psoriasis, sourced directly from the International Psoriasis Council’s (IPC) Symposium: Psoriasis Management and Treatment – An International Perspective, and WCD’s four psoriasis-focused sessions, Psoriasis I, II, III, and IV, for a total of 21 summaries. Download the full comprehensive report or read on for highlights.
IPC SYMPOSIUM: PSORIASIS MANAGEMENT AND TREATMENT - AN INTERNATIONAL PERSPECTIVE
The IPC symposium presented an international review of the global challenges met with psoriasis regarding epidemiology, genetic diversity, clinical presentations, diagnosis, and management, shedding light on patients’ perspectives and value-based healthcare.
- Dr. Claudia de la Cruz presented “A Patient-Inclusive Approach in the Treatment of Psoriasis: A Principal Without Borders.” She highlighted the patient perspective as an independent dimension in the management of psoriasis and how it is crucial to consider the patient’s perspective about the disease (e.g., quality of life, inaccessibility to treatment, and impact on education, career, and social life), which can differ from the healthcare provider’s perspective.
- Prof. Jo Lambert presented “An International Perspective on Value-Based Healthcare,” discussing the application of value-based healthcare in psoriasis. As treatments for psoriasis are quite expensive, an adequate healthcare cycle for psoriasis patients can put the patients on effective medications rapidly with better results and, thus, less frequent follow-up visits. This can achieve an overall more cost-effective healthcare service for the patients.
- Dr. Johann Gudjonsson presented “Genetic Differences Across the Globe,” reviewing the diversity of the biological processes involved in psoriasis. As different genetic predispositions across the globe may explain this diversity, the types and frequency of risk genes for these predispositions differ between ethnic groups. This likely contributes to the heterogeneity of molecular pathways, clinical presentations, and treatment responses between races and skin colors.
- Prof. Mohammad Huq presented “Pitfalls in Diagnosis and Phenotypic Differences Related to Skin of Color,” where he illustrated the diagnostic challenges with psoriasis to consider in different skin colors. Challenges include underdiagnosis, atypical morphology, and diversity in severity, distributions, and frequency of subtypes. Post-inflammatory hyperpigmentation in skin of color complicates the evaluation of the disease activity. This is in addition to diagnostic confusion with other dermatological conditions. People of color are four times more likely to require a skin biopsy or dermoscopy to diagnose psoriasis and wait three times longer for a definitive diagnosis. Further, cultural factors affect the patient’s willingness to seek medical attention and delay diagnosis.
- Prof. Mahira El Sayed presented “Therapeutic Challenges Related to Skin of Color.” She discussed the difference between race and ethnicity and reviewed definitions in the literature for “skin of color.” In terms of skin color, psoriasis is different regarding genetic basis, clinical presentation, and treatment availability and effectiveness. In low-income countries, treatment choice is primarily based on economic availability. She highlighted that there are unmet needs for clinical guidelines on managing patients with plaque psoriasis in Africa and the Middle East. There are also unmet needs for educating dermatologists, access to biologics, and more biosimilars.
- Prof. Chris Griffiths presented “Availability of Therapies Across the World: Data from the GPA,” explaining unmet needs for psoriasis epidemiology. The Global Psoriasis Atlas (GPA) addresses vital questions about psoriasis epidemiology. To map epidemiology, accurate diagnosis is essential. GPA studies showed limited accessibility to therapies in some regions, e.g., Chile.
- Dr. Hoseah Waweru presented “Every Patient in the World Has the Right to Optimal Treatment.” He emphasized that psoriasis patients worldwide deserve optimal care. We must address treatment access barriers, be patient-centered, and use better outcome measurements to achieve this.
PSORIASIS – PSORIASIS I
- Prof. Darren Ashcroft presented “Epidemiology and the Global Psoriasis Atlas,” he explained that the GPA research highlighted marked variations in the reported prevalence and incidence of psoriasis within and between countries. Most of the studies on disease prevalence were published in Western Europe and the USA, with few studies from Asia, Africa, Eastern Europe, and South America. Further, very few studies focused on the incidence of psoriasis and trends over time.
- Qing Sheng Mi presented “New Developments in Biomarkers and Psoriasis,” where he illustrated that genetic studies revealed the complex genetic variation and ethnic heterogeneity of psoriasis. This is mirrored by various pathways involved in the pathogenesis of psoriasis, e.g., the skin barrier, antigen presentation, NF-KB, and Th1/Th17 pathways.
PSORIASIS – PSORIASIS II
- Prof. Ricardo Romiti presented “Racial/Ethnic Disparities in the Prevalence of Psoriasis.” He explained that Asians and Hispanics/Latinos have higher odds of having pustular psoriasis than Caucasians. Asians also have a higher frequency of erythrodermic psoriasis but a lower frequency of inverse psoriasis than Caucasians. Even though African Americans have less psoriasis than whites, they tend to have more severe skin involvement, more significant psychological impact, and a significantly lower likelihood of receiving biologic medications. He also highlighted the Amazon study, which investigated the prevalence of psoriasis in the Yanomami Indians in villages in the Amazon rainforest on the border between Venezuela and Brazil.
- Dr. Siew Eng Choon presented “Current and Emerging Treatments for Generalized Pustular Psoriasis,” discussing the clinical presentation, pathogenesis, and treatment options of Generalized pustular psoriasis (GPP). She highlighted the high cutaneous and systemic burden of GPP. She reviewed the IL-36 as a key driver of GPP pathology. Notably, IL-36 is upregulated in GPP regardless of IL36RN mutation status. Regarding GPP therapy, IL-36 can be targeted by IL36R antagonists (spesolimab, Imsidolimab, and HB0034). Spesolimab is the first GPP-specific treatment with evidence of its efficacy in aborting GPP flares. The recent Effisayil 2 study showed successful prevention of GPP flares using subcutaneous doses of spesolimab.
- Dr. Claudia de la Cruz presented “The Importance of Early Detection and Management of Psoriatic Arthritis,” highlighting that diagnosing and treating psoriatic arthritis are suboptimal. Similarities to other arthritic diseases complicate the diagnosis of the condition. Early detection and treatment are critical for improving long-term patient outcomes for psoriatic arthritis. Dermatologists are uniquely positioned to early screen for psoriatic arthritis. The best practice indicators for psoriatic arthritis involve shortening the time to diagnosis, improved multidisciplinary collaboration, optimized disease management, and improved disease monitoring.
- Dr. Hazel Oon presented “Challenges in Managing Psoriasis in Tropical Areas,” where Dr. Oon reviewed some differences regarding psoriasis in tropical areas.
PSORIASIS – PSORIASIS III
- Dr. Andrew Blauvelt presented “Cardiovascular Disease and Psoriasis: Can We Make a Difference With Our Treatment?.” He discussed a high relative risk of cardiovascular disease (CVD) even in young psoriasis patients. Regarding psoriasis therapies, there is a decreased incidence of myocardial infarction in psoriasis patients treated with TNF-blockers or methotrexate. The therapeutic improvement in psoriasis correlates with less aortic inflammation. A randomized, placebo-controlled trial with adalimumab, ustekinumab, and secukinumab utilizing FDG-PET/CT scanning showed that aortic inflammation didn’t progress over one year. Studies showed that low-dose aspirin and Atorvastatin reduce vascular endothelial inflammation in psoriasis.
- Dr. Mark Berneberg presented “Phototherapy for Psoriasis: Still a Viable Option?” He illustrated that phototherapy has good efficacy and safety in psoriasis. Phototherapy can be favorably combined with topical therapy, systemic therapy (classical immunomodulator), and biologics. However, combining phototherapy with cyclosporine is unfavorable because of the increased risk of squamous cell carcinoma.
- Dr. April Armstrong presented “Oral Therapies for Psoriasis: Methotrexate, Apremilast or Deucravacitinib.” In the talk, Dr. Armstrong thoroughly reviews each oral drug for psoriasis (including methotrexate, cyclosporine, acitretin, apremilast, and deucravacitinib). She illustrated their current indications, appropriate dosing, suitable baseline and ongoing monitoring, and the precautions with vaccine intake.
- Dr. Joel Gelfand presented “New Findings of Clinical Trials of Phototherapy for Psoriasis.” He emphasized that phototherapy is recognized as an effective and safe therapy for psoriasis. Patients frequently prefer it because it is a “natural” treatment. Phototherapy can be safely used even in patients with multiple comorbidities. Regarding vascular inflammation, phototherapy can decrease the level of CRP and IL-17 and improve lipid metabolism. Yet, phototherapy has several barriers, e.g., inconvenience and insurance coverage. Additional research to investigate the effect of phototherapy on cardiovascular risk is needed.
PSORIASIS – PSORIASIS IV
- Prof. Lars Iversen presented “TNF Antagonists With and Without Methotrexate: Indications, Risks, and Limitations.” The benefit of the concomitant use of methotrexate with TNF inhibitors includes less antibody formation, better efficacy, and longer drug survival. The risk of the combination includes increased immune suppression, infection, and increased risk of cancer. This combination can be considered in individual patients. If methotrexate is added, it should be started before or at the initiation of treatment with the TNF inhibitors.
- Dr. Kenneth Gordon presented “IL-17 and IL-23 Antagonists”, reviewing the IL-17 and IL-23 antagonists regarding the current evidence on the mechanisms, efficacy, long-term maintenance, and effect on special areas. Both IL-17 blockers and IL-23 blockers usually can maintain PASI 90 responses through two years with persistent efficacy. Whether these classes of biologics will be able to inhibit the development of psoriatic arthritis is still a topic of research.
- Dr. Melinda Gooderham presented “JAK Inhibitors.” She explains that Tofacitinib (an oral Janus kinase inhibitor) failed to gain US regulatory approval for psoriasis, and clinical development of JAK1-3 inhibitors for psoriasis has largely been abandoned. Targeted TYK-2 inhibitors have good efficacy, and allosteric inhibitors have favorable safety profiles in managing psoriasis. Further development of JAK inhibitors and allostatic TYK-2 inhibitors can be promising.
- Dr. Bruce Strober presented “New Drugs in the Pipeline,” where he showed some updates about psoriasis treatment, for example, studying apremilast in pediatric patients with moderate to severe psoriasis and for adults with moderate to severe genital psoriasis. He also shed light on the in-the-pipeline “oral” biologics, e.g., an oral IL 17A inhibitor and an oral therapeutic peptide that selectively targets the IL-23 receptor.
The summary above is a glimpse into the thought-provoking psoriasis sessions from the 25th World Congress of Dermatology in Singapore. For those seeking a deeper dive, we encourage you to download the full report for a more comprehensive understanding of the sessions and their valuable takeaways.