GRAPPA Point-Counterpoint: Should Biologics Be Used for Mild Psoriasis?

Psoriasis (PsO) is commonly classified as mild, moderate, or severe, usually based on body surface area (BSA) or other validated measures. Although most dermatologists agree that mild PsO should be treated with topical therapies, there are circumstances where mild or limited PsO should be treated with biologics, even as first line. A debate about use of topical vs biologic therapy was presented at the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 annual meeting. Arguments in favor of using biologics when patients have mild disease on limited BSA included presence of psoriatic arthritis (PsA) and symptoms on special sites (ie, scalp, face, body folds, genitals, nails, palms, soles). New data suggest that treating limited or early PsO may decrease the risk of developing PsA. Arguments against using biologics for mild PsO focused on the definition of mild PsO, citing that limited BSA with PsA and significant quality of life impact should not be defined as mild. Truly mild PsO should be treated with topical agents, given their safety and relative low cost. The availability of newer agents like roflumilast and tapinarof have expanded therapeutic choice and have data supporting their use for treatment of special sites.

Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis, Palmoplantar Pustulosis, and Neutrophilic Dermatoses: A GRAPPA 2023 Annual Meeting Update.

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome and chronic nonbacterial osteomyelitis (CNO) are rare autoinflammatory/autoimmune conditions seen in adults and children. Although osteoarticular manifestations are the primary distinguishing features of SAPHO, over half of patients also have palmoplantar pustulosis (PPP). These and other associated disorders such as acne, inflammatory bowel disease, and hidradenitis suppurativa are characterized, at least in the early stages, by neutrophilic infiltration. The bone and skin manifestations exhibit both innate and adaptive immune responses and therefore share similar pathogenic molecules and overlapping treatment targets. At the Group for Research and Assessment for Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 annual meeting, a 3-part presentation provided an overview of current efforts at establishing consensus on diagnosis/classification, treatment, and core outcome sets for SAPHO/CNO; an overview of PPP in SAPHO and as a standalone condition; and finally, an overview of the role of the neutrophil in these disorders.

GRAPPA Debate: Targeted Small Molecules Versus Biologics as First-Line Systemic Therapy After Conventional Therapy for Moderate-to-Severe Psoriasis.

In this debate at the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 annual meeting, arguments were made contrasting the first-line use of oral targeted small-molecule drugs vs biologic therapy for the treatment of moderate-to-severe psoriasis (PsO) after failure of conventional therapy. Arguments in favor of small-molecule drugs included good efficacy and safety, patient preference, cost savings, global health equity, and environmental stewardship. Arguments in favor of biologics included superior efficacy, excellent safety, availability of long-term data, pediatric regulatory approvals, and potential benefit for comorbidities. By the end of the debate, there was recognition of significant pros and cons of each approach. Both small-molecule drugs and biologic therapy are valuable options for PsO treatment, and their use can be tailored toward specific individuals or healthcare systems.

Measuring Psoriasis Severity at Home.

Psoriasis plaque severity metrics, such as induration (thickness), erythema (redness), and desquamation (scaliness), are associated with the subsequent development of psoriatic arthritis (PsA) among cutaneous-only psoriasis patients (patients with skin or nail psoriasis but no psoriatic arthritis). These metrics can be used for PsA screening. However, a key challenge in PsA screening is to optimize accessibility and minimize costs for patients, while also reducing the burden on healthcare systems. Therefore, an ideal screening tool consists of questions that patients can answer without a physician's assistance. Although reference images can be used to help a patient self-assess erythema and desquamation severity, a patient would need a tactile induration reference card to self-assess induration severity. This protocol describes how to create an induration reference card, the Psoriasis Thickness Reference Card, as well as how to use it to assess lesion induration severity. Administration of reference images for erythema and desquamation and a Psoriasis Thickness Reference Card for induration to 27 psoriasis patients showed that patients were moderately successful at self-assessing the severity of these three metrics. These findings support the feasibility of a future PsA screening test that patients can complete without the need for physician assistance.

Impact of psoriasis disease severity and special area involvement on patient-reported outcomes in the real world: an analysis from the CorEvitas psoriasis registry.

BACKGROUND: The impact of psoriasis in special areas (i.e., scalp, nails, palms, soles, genitals) on patient physical functioning, health-related quality of life (HRQoL), and work abilities has not been fully characterized. We assessed associations between disease severity and special area involvement in psoriasis symptoms, HRQoL, and work/activity impairment. METHODS: Patients with psoriasis from the CorEvitas Psoriasis Registry who initiated systemic treatment between 04/2015-06/2020 were included. Outcomes were change from baseline in psoriasis symptoms, Dermatology Life Quality Index (DLQI), and work/activity impairment at 6 months stratified by baseline disease severity and special area involvement. RESULTS: Among 2620 patients, increasing disease severity was associated with worsening patient-reported outcomes. Patients with (46.0%; N = 1205) versus without (54.0%; N = 1415) psoriasis in special areas reported greater HRQoL and work/activity impairment. Over 6 months, patients with unchanged or worsening disease severity had reduced HRQoL and increased symptom severity; incremental increases in patient HRQoL and decreases in symptom severity were associated with improved disease severity. CONCLUSIONS: Higher disease severity and special area involvement was associated with worse outcomes and impaired work abilities. These data highlight the significant impact that adequate treatment of severe psoriasis and/or special area involvement may have on patient HRQoL and function.

Advances and Controversies in Our Understanding of Guttate and Plaque Psoriasis.

Acute guttate psoriasis (AGP) is considered an uncommon variant of psoriasis (PsO), characterized as a widespread eruption of erythematous, psoriasiform papules, and plaques on the trunk, extremities, and scalp. Predisposing factors include a family history of PsO, variation in the main PsO susceptibility gene HLA-Cw*0602, and previous infection with viruses or acute ß-hemolytic Streptococcus A program focused on controversies and recent advances in understanding AGP was presented at the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2022 annual meeting. Topics included an overview of clinical presentation and natural history, predisposing genetic and environmental factors, and the recent molecular profiling that supports classification of AGP as a form of PsO. Early molecular profiling studies using proteomic signatures have suggested similarities between AGP and contact dermatitis, but recent studies using gene expression profiling and gene set enrichment scores demonstrate that AGP is more similar to chronic PsO. The expression of regulatory immune pathways seen with AGP suggests potential for early and sustained remission if the disease is suppressed by targeted treatments. Published case reports documenting clinical improvement of AGP with biologics that antagonize interleukin (IL)-12/23, IL-23, and IL-17 support the role of the IL-23/IL-17 axis in AGP, similar to that in PsO. Data supporting the use of antibiotics and other therapeutic agents for AGP are lacking, and randomized controlled trials are needed. Trial design for AGP is challenged by the low incidence, tendency for spontaneous remission, lack of validated end points, and the need for long-term follow up.

Proceedings of the GRAPPA 2022 Executive Retreat.

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) leadership congregated for a strategic planning meeting before the 2022 GRAPPA annual meeting in New York, USA. Meeting aims were to review GRAPPA's performance in relation to its 2016 goals and identify successes and areas for further improvement, identify key GRAPPA priorities and activities for the next 5 years, and explore committee structures to best support these aims.

Achieving consensus on patient-reported outcome measures in clinical practice for inflammatory skin disorders.

BACKGROUND: International Dermatology Outcome Measures and the American Academy of Dermatology recently agreed on a physician-reported global severity measure to demonstrate quality of care in inflammatory dermatoses. OBJECTIVE: Because patient-reported outcome measures are also important, we aimed to achieve consensus on 1 of these measures for clinical practice. METHODS: Patients and providers participated in a consensus-building study involving a modified-Delphi technique. Voting was focused on identifying a minimal set of assessments for clinical practice, patient global assessments (PtGAs), Skindex instruments, and final instrument selection for quality improvement. RESULTS: Among 53 stakeholders, >70% agreed that identification of patient goals, assessment of treatment harm, and assessment of the adequacy of treatment response were the minimal assessments needed for clinical practice. The most preferred PtGA was a 5-point PtGA (scale 0-4; 0 = clear, 4 = severe) having an optional check-box for worst ever. A new metric to assess change since treatment initiation, which we called a trajectory measure, was proposed. Stakeholders preferred Skindex instruments over PtGAs and a trajectory measure for clinical practice. LIMITATIONS: A small number of patients and caregivers were involved and a consensus was not reached on all items. CONCLUSION: PtGAs as standalone measures do not adequately capture the patient's assessment of disease severity or the effect of care. The combination of a PtGA with a Skindex instrument or another measure of health-related quality of life might provide a more comprehensive evaluation of patients in clinical practice.

Treatment of Psoriasis in Patients With Psoriatic Arthritis: An Updated Literature Review Informing the 2021 GRAPPA Treatment Recommendations.

OBJECTIVE: Our aim was to summarize and evaluate the current quality of evidence regarding the efficacy of therapies for cutaneous psoriasis (PsO) in patients with psoriatic arthritis (PsA). METHODS: A literature search of MEDLINE, Embase, Cochrane Library databases, and conference abstracts was conducted to identify interventional randomized controlled trials in patients with PsA between February 2013 and December 2021. Studies were included if PsO outcomes included achieving at least 75% improvement in the Psoriasis Area and Severity Index and the blinded comparison period was ≥ 10 weeks. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology was employed to assess quality of the evidence to inform and update the 2021 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) treatment recommendations. RESULTS: A total of 116 studies and 36 abstracts identified in the initial search were screened. A total of 37 studies (40 treatment arms) met the criteria for final inclusion. Phosphodiesterase 4 inhibitors, Janus kinase inhibitors, and tyrosine kinase 2 inhibitors, interleukin 17 inhibitors (IL-17i), IL-12/23i, IL-23i, and tumor necrosis factor inhibitors (TNFi) had high-quality data broadly supporting the efficacy of each class for plaque PsO over placebo. Head-to-head studies with high-quality data supported both IL-17i and IL-23i over TNFi. CONCLUSION: Several pharmacologic therapeutic classes have high-quality evidence demonstrating efficacy for cutaneous PsO in the PsA population. The findings will be integrated into the 2021 GRAPPA treatment recommendations, intended to guide selection of a therapeutic class where efficacy in 1 or more cutaneous or musculoskeletal domains is required.

2021 GRAPPA Meet the Experts Session: A Summary of Presentations.

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis hosted a Meet the Experts session at its 2021 virtual meeting. Dermatology and rheumatology experts held 5 sessions that broadly centered on psoriasis and psoriatic arthritis.

Challenges in the Diagnosis and Assessment of Psoriatic Arthritis.

Each year, the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) holds a trainee symposium adjacent to the GRAPPA annual meeting. The target audience for this meeting includes trainees in rheumatology, dermatology, and related fields. The 2021 GRAPPA Trainee Symposium focused on challenges in the diagnosis and assessment of psoriatic arthritis (PsA). During the meeting, speakers focused on identification of psoriasis (PsO), the differential diagnosis for both PsO and PsA, diagnostic errors and pitfalls, physical examination in PsA, patient-reported outcomes and composite measures in the assessment of PsA, and the patient perspective on diagnosis and assessment, followed by a panel discussion. This paper summarizes the content discussed at the meeting.

Promoting Diversity, Equity, and Inclusion for Psoriatic Diseases.

There is increasing evidence of racial and ethnic disparities in the evaluation and treatment of people with psoriasis (PsO) and psoriatic arthritis, and inadequate racial/ethnic diversity in psoriatic disease (PsD) research. At the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2021 annual meeting, a program focusing on diversity, equity, and inclusion (DEI) was presented to highlight known health and healthcare disparities in PsD. There is limited understanding of the prevalence and severity of PsD and how it affects quality of life among racial/ethnic minorities with PsD. Educational gaps and lack of diversity in our dermatology workforce may be contributing to challenges in appropriately diagnosing and treating PsO in darker skin types. Racial/ethnic minorities are also inadequately represented in clinical research, including trial recruitment and participation, for PsD. A panel of patient research partners, researchers, and clinicians ended the session with a broad discussion on how GRAPPA can better ensure racial/ethnic DEI in their educational, research, and clinical missions.

Prologue: 2021 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) held its annual meeting in 2021 in an online format due to travel restrictions during the ongoing COVID-19 (coronavirus disease 2019) pandemic. The virtual meeting was attended by rheumatologists, dermatologists, representatives of biopharmaceutical companies, and patient research partners. Similar to previous years, GRAPPA's annual meeting focused on the 3 overlapping missions of education, research, and clinical care of psoriatic disease (PsD). The virtual meeting allowed a variety of different types of sessions to be held, including the trainee symposium, keynote lectures, interactive sessions (5 Meet the Experts sessions, a debate on first-line therapy, and 5 guided poster sessions), 4 workshops (trainee workshop focusing on the diagnosis of PsD, ultrasound, magnetic resonance imaging, and the International Dermatology Outcome Measures group), updates on a variety of research topics (research findings from the 2020 GRAPPA research grant awardees, 3 basic science talks, Outcome Measures in Rheumatology [OMERACT] Working Group efforts, and Collaborative Research Network progress), current "hot topics" (use of Janus kinase inhibitors, promoting diversity and inclusion in PsD, progress on the updated GRAPPA treatment recommendations, and the introduction of the Young GRAPPA member group), and the presentation of four 2021 GRAPPA grant awardees and election results. In this prologue, we introduce the papers that summarize this meeting.

Clinicians' perspectives on the integration of electronic patient-reported outcomes into dermatology clinics: a qualitative study.

BACKGROUND: Skin conditions can have profound negative symptomatic and psychological effects. Failure to address these effects can lead to poor treatment adherence and/or patient dissatisfaction. Despite patient-reported outcome (PRO) use being highly recommended, real-world adoption has been slow. OBJECTIVES: To assess clinicians' perceived facilitators and barriers to using PROs in daily practice. METHODS: We conducted in-person semi-structured interviews with 19 clinicians and thematic analysis of transcripts. RESULTS: Three main themes emerged: (1) clinicians' attitudes about the value of Skindex-16 in daily practice, (2) patient attitudes influencing clinicians' use of Skindex-16, and (3) clinicians' perceptions of their ability to use PROs successfully for clinical care. Clinicians recognized benefits to using Skindex-16, such as revealing patients' hidden concerns and highlighting discrepancies with the clinician's severity assessments. Conversely, clinicians also identified limitations, such as time constraints and lack of relevance for some skin conditions. Patient complaints about PRO relevance have influenced clinicians' use of Skindex-16 negatively. Finally, some clinicians recognized the need for more training in score interpretation and implementation strategies for optimal clinical flow. CONCLUSIONS: While most clinicians believed PROs like Skindex-16 can be useful for patient care, barriers need to be addressed to make PROs more practical for routine clinical care.

Prologue: 2020 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) held its annual meeting in 2020 in an online format due to travel restrictions during the coronavirus disease 2019 (COVID-19; caused by SARS-CoV-2) pandemic. The virtual meeting was attended by 351 rheumatologists, dermatologists, representatives of biopharmaceutical companies, and patient research partners. Similar to previous years, GRAPPA's annual meeting focused on the 3 overlapping missions of education, research, and clinical care of psoriatic disease. Trainee sessions this year included the annual trainee symposium and a grant-writing workshop. Plenary sessions included updates on COVID-19 and psoriatic disease from multispecialty and patient perspectives, and updates on pustular psoriasis and associated musculoskeletal manifestations. Progress on research and updates were presented for the following groups: Collaborative Research Network, Outcome Measures in Rheumatology (OMERACT) Psoriatic Arthritis Working Group, International Dermatology Outcome Measures, Composite Measures, Education Committee, and Treatment Guidelines. New this year were 3 concurrent workshops on ultrasound assessment of joints and entheses, magnetic resonance imaging of psoriatic arthritis, and pustular psoriasis efficacy endpoints; 6 "Meet the Expert" sessions; and facilitated "poster tours." In our prologue, we introduce the papers that summarize this meeting.

Psoriasis and Psoriatic Arthritis in the Context of the COVID-19 Pandemic: A Plenary Session From the GRAPPA 2020 Annual Meeting.

The coronavirus disease 2019 (COVID-19; caused by SARS-CoV-2) pandemic has affected the healthcare system on a global scale, and we utilized the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2020 annual meeting to examine how COVID-19 might affect patients with psoriatic disease (PsD) and the clinicians who care for them. Pressing issues and concerns identified included whether having psoriasis increased the risk of acquiring COVID-19, vaccine safety, and the acceptability of telehealth. The general message from rheumatologists, dermatologists, infectious disease specialists, and patient research partners was that data did not suggest that having PsD or its treatment significantly increased risk of infection or more severe disease course, and that the telehealth experience was a success overall.

Pustular Psoriasis and Associated Musculoskeletal Disorders.

Pustular psoriasis (PsO) is an uncommon variant of PsO that may present in a generalized or localized fashion with or without musculoskeletal or systemic inflammatory involvement.Generalized pustular PsO (GPP) presents as a widespread acute or subacute pustular eruption that may be familial and is often associated with severe flares and systemic inflammation. The palmoplantar pustulosis variant is localized to palms and soles, whereas acrodermatitis continua of Hallopeau is localized to the nail apparatus. Patients with pustular PsO may have overlapping plaque PsO and may develop psoriatic arthritis (PsA). Pustulosis is also a feature of both synovitis, acne, pustulosis, hyperostosis, osteomyelitis (SAPHO) syndrome and chronic non-bacterial osteomyelitis. At the 2020 Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) annual meeting, members were given an overview of the cutaneous features of pustular PsO, SAPHO, and recent insights into the genetics of GPP, leading to new targeted drug therapies and the development of validated endpoints.