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A new report from the National Psoriasis Foundation (NPF) has been developed with input from many leading researchers and clinicians in the field of psoriasis and psoriatic arthritis (PsA).

The is a data-rich document designed to help the psoriasis community plot a course for the future of psoriasis care, including by addressing care disparities, enhancing health equity, and improving access to care -- including in relevant specialties like rheumatology -- for individuals with psoriasis.

Among the report's key data points:

• People with psoriasis face a 46% higher risk of cardiovascular disease mortality than the general population, a 17% higher risk of myocardial infarction, a 19% increased risk of stroke, and a 20% increase in diabetes risk for every 10% increase in body surface area.
• Screenings for high blood pressure, diabetes, high cholesterol, and obesity do not occur at most outpatient visits for psoriasis.
• Depression and suicidal ideation among patients with psoriasis range as high as 28% and 10%, respectively. Meanwhile, only 27% of dermatologists reported asking psoriasis patients about their mood, and only 7% used a depression screening tool.

The report also identified opportunities for improvements in psoriasis care, including:

• Addressing health disparities and enhancing health equity
• Learning more about relationships between psoriasis and comorbid conditions
• Improving coordination to improve management of comorbidities
• Exploring impact of psoriasis treatments on preventing PsA in particular and managing and reducing comorbidity risk in general
• Addressing mental health impacts of psoriasis, including enhancing understanding of the relationship between mental health conditions and psoriasis.

Mark Lebwohl, MD, is dean for clinical therapeutics at Icahn School of Medicine at Mount Sinai in New York City and chairman emeritus of the medical board of the National Psoriasis Foundation. Lebwohl recently discussed the new report and trends in psoriasis care and management with the Reading Room. The discussion has been edited for length and clarity.

Are there any broad themes or trend lines you'd like to point out from this report or related to psoriasis in general?

Lebwohl: First, what we know about psoriasis is that it doesn't just affect the skin or joints. Joints are certainly the well-known comorbidity, but for decades investigators have found dramatic increases in cardiac events, specifically heart attacks, in patients with psoriasis. Among 60- and 70-year-olds with psoriasis, there's a substantial increase in heart attacks compared with the general public.

It was very clear from our oldest biologic drugs -- the TNF blockers -- that treating psoriasis prevents this major comorbidity.

There are other studies showing that psoriasis also affects the liver, kidneys, and many other organs. So, it's not just the skin we're treating. What I tell patients is, "I'm not just thinking about your skin, I'm thinking about your heart and your joints and other organs, because if we continue on the treatments enough to suppress your psoriasis, we're actually preventing a lot of other disease." That, I think, is the most important thing.

This new document also reports on the mental and social components of psoriasis. For example, we highlight a study showing that people who don't have psoriasis would feel uncomfortable eating with someone who has psoriasis, or sitting in a car or making friends with a patient who has psoriasis.

So there are many non-skin issues that occur when a patient has bad psoriasis.

How can clinicians and practices better manage or think about these issues in the short-term?

Lebwohl: I'm often asked: "What's the best drug?" It's a very complicated answer. As just one example, if a patient has Crohn's disease, they're not going to get an IL-17 blocker, even though those drugs are very safe, because they've been shown to make Crohn's disease a bit worse. There is a long list of factors and questions just like this one.

The point is, every patient has to be treated individually. There are a whole host of conditions that impact the decision as to what drug is best.

What can be done to address disparities in psoriasis care, which the document points out as a key area for improvement?

Lebwohl: Many of the drugs that we know about are very effective for psoriasis and PsA -- and probably reverse many of the comorbidities like heart disease. They are available, but they're only available if you have the means to get them. They're incredibly expensive.

Commercially insured patients often are able to get them, and I will say the pharma industry deserves a lot of credit for that. They're blamed all the time for the cost of the drugs, and certainly they're making enough money on the drugs, but most of the money goes to the insurance companies. And I think that the word on that is not clear enough.

Regardless, unfortunately, these drugs are often not covered for Medicare and Medicaid patients. It becomes a problem. Even Medicare patients who previously spent their whole life with commercial insurance suddenly reach 65 and find there are only a few biologics, very few, that are completely covered by Medicare. This can mean thousands of dollars in out-of-pocket costs.

There is a real disparity there, and I don't see anything in the near future that's going to dramatically reverse it. I think the Inflation Reduction Act will do it for one year, but at the end of 2025 it's done, and who knows whether it will be renewed? My suspicion is that it's going to be hard to see how the country, both in terms of drug development and in terms of the cost to the taxpayer, will be able to afford that. So those disparities, I think, are with us for the future and until we come up with a better solution.

What are you most excited or intrigued by when you look into the foreseeable future?

Lebwohl: In the short run, we've now figured out a way to create oral medications that target the same molecules as the injectable medications. So we will soon be able to take oral medications that are very targeted, safe, and effective. Those are in the research pipeline now.

We also have JAK inhibitors, which have been dramatically effective for PsA. They are available in oral form as well. So that's the short-term future.

In the long-term, we still need much better treatments for PsA. We need better treatments for nail psoriasis, and we need better treatments for palm and sole psoriasis. All of those are being worked on, but they're a bit further off.