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What’s on the outside can often distract us from what’s happening on the inside. For people with plaque psoriasis, that can mean treating their outer symptoms, but sometimes their treatments aren’t addressing the deeper problem within.

On this year’s World Psoriasis Day (October 29), it’s time to gain a better understanding of psoriasis: an autoimmune condition that causes an overactive immune response. It’s this immune response that causes the rapid growth of skin cells, leading to red, raised, itchy and scaly patches. By understanding this, people with psoriasis can better understand all of their possible treatment options.

To learn more about plaque psoriasis and available treatment categories, visit

Never judge a book by its cover: for TV host and fashion journalist Louise Roe and the millions of people living with psoriasis in the United States, it is more important than ever to understand this chronic condition.

Roe has teamed up with Celgene to launch INSIDE PERSPECTIVE, a campaign that aims to raise awareness about plaque psoriasis – an autoimmune condition that appears on the surface of the skin but starts inside the body.

While working at a fashion magazine in London at the age of 25, Roe was diagnosed with plaque psoriasis. Initially, she struggled with the diagnosis and managing the condition – planning her wardrobe and work events around hiding plaques on her skin.

“It was quite tough for me at first given the fashion industry is very focused on outward appearances,” said Roe. “At times, when the symptoms were too severe to hide, I canceled plans and social events – it definitely affected my confidence and my life in general.”

After working with her dermatologist, she was able to better understand plaque psoriasis and found ways to help manage the symptoms, all while building a successful fashion career as a journalist, author and blogger. Because of her personal experiences with her condition, Louise is speaking out to further educate the psoriasis community to treat the condition from within.

Through INSIDE PERSPECTIVE, Roe also had the opportunity to swap worlds for a day with Alycia, one of her fans who lives with moderate to severe plaque psoriasis. Their experiences are chronicled in an inspiring video where they share heartfelt insights about living with the condition, as well as the importance of looking beneath the surface and embracing who they are both inside and out. The full story and video can be viewed at

“What I’ve learned through this experience is that there’s always more to the story,” said Roe. “By opening up about my experience, I hope the campaign will help inspire and empower others.”

Louise is one of the estimated 7.5 million people in the United States living with plaque psoriasis—an autoimmune disease that appears on the skin as red, itchy patches that starts inside the body. Though often seen as a skin condition, plaque psoriasis can have both a physical and an emotional impact on those living with it.

To learn more about the INSIDE PERSPECTIVE campaign and Louise’s personal story, visit

The current benchmark for efficacy in clinical trials of new plaque psoriasis treatments is a 75 percent reduction in the Psoriasis Area and Severity Index (PASI), which is a measure of the area of skin affected along with the skin’s appearance. But the most bothersome symptom, according to a survey of patients with plaque psoriasis, was not skin appearance, but itching.

As thousands of dermatologists gather at the 27th European Academy of Dermatology and Venereology Congress in Paris to discuss the latest data from ongoing clinical trials in psoriasis, Dr. Colby Evans, M.D., a dermatologist in Austin, TX, and also the immediate past chair of the Board of Directors of the National Psoriasis Foundation, discusses how researchers measure the effectiveness of treatments in clinical trials and how those measurements could be more comprehensive.

How do researchers measure the effectiveness of new plaque psoriasis treatments in clinical trials?

“Efficacy of plaque psoriasis treatments has immensely improved over the last 20 years, making more ambitious endpoints realistic. While a 75 percent reduction in PASI score has been the Food and Drug Administration’s benchmark, we see a growing interest in PASI 90 or 100 in more current trials. We want to get patients as close as we can to PASI 100. That being said, achieving a PASI 50 along with an improvement to quality of life is still clinically beneficial.”



Does PASI comprehensively capture all the clinical benefits of psoriasis treatments?

“PASI measures the size, as well as the level of scale, redness and thickness of psoriasis plaques. It does not capture other debilitating symptoms associated with psoriasis, such as psoriatic arthritis, itching or social stigma.”

How impactful are those symptoms on the lives of patients with plaque psoriasis?

“Itching can be debilitating and miserable, and can interfere with daily functioning. Survey data showed that people with psoriasis reported having a higher level of sleep-related problems compared to the general population.

Psoriatic arthritis is also of high concern among patients with psoriasis. Approximately 30 percent of plaque psoriasis patients develop psoriatic arthritis. It’s painful, can distort the joints and can be permanently disabling if untreated.”

What are the potential consequences of not capturing improvements in these symptoms?

“It’s important to take full measure of the patient and their life before you decide on treatment. PASI is a reasonable place to start, but it is more complicated than just the extent and thickness of their plaques. If you’re ignoring specific symptoms, patients can get left behind, and treatment decisions may be made without factoring in critical information.”

The more safe and effective treatment options we have, the better for patients with plaque psoriasis.

Do you measure PASI to make treatment decisions for patients who are not in clinical trials?

“In the real world, outside of trials, we don’t use a strict algorithmic treatment of psoriasis. In the regular clinical setting, I am more interested in knowing if the patient can live their life socially, occupationally and recreationally, and without feeling limited by their psoriasis. If they are, I know we’re on the path to success.”

How can clinical trials evolve to more comprehensively measure meaningful improvements for patients with plaque psoriasis?

“It’s becoming fairly common to have secondary endpoints that include itching and quality of life, which is progress. We’re seeing better management of psoriasis sub-types, such as patients with severe hand and foot psoriasis or patients who have severe arthritis without a lot of skin disease. Since the condition is quite diverse, there’s no one treatment for every patient. So the more safe and effective treatment options we have, the better for patients with plaque psoriasis.

With that in mind, many people who have had plaque psoriasis for decades aren’t aware of some of the new treatments. So a tremendous amount of patient education needs to be done.”

To learn more about treatment challenges that patients with psoriasis continue to face, read “Moderate Psoriasis Patient Needs Should Not Be Overlooked.”

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Patients with plaque psoriasis who see their doctor frequently can increase their odds of finding an effective and appropriate treatment for them, especially as there are more ways to treat psoriasis than ever before. According to an analysis of the MarketScan Medicaid database, the average time between a psoriasis patient’s initial visit to the doctor’s office and a follow-up appointment is 153 days.

To raise awareness about why it’s important for patients to work with their doctors to help manage psoriasis during this year’s Psoriasis Awareness Month (August), Mark Jackson, M.D., Clinical Professor of Medicine (Dermatology) at the University of Louisville and Forefront Dermatology, explains how often patients with psoriasis should see their doctors, how psoriasis treatments have evolved and why it’s important for patients to feel empowered to help take control of their disease.



How often do you recommend your patients with psoriasis see you?

“Plaque psoriasis requires active management. It’s essential that doctors make sure that their patient’s condition is improving within four to six weeks of starting a new treatment for them. Even if their current treatment is effectively controlling their symptoms, they should still see their doctors every three to six months. Seeing their physician frequently is imperative for patients with psoriasis.

That being said, if a patient is experiencing new symptoms or treatment side effects, they should call their doctor immediately.”

Why is it important that people with psoriasis see their doctors frequently?

“Psoriasis is not just a rash; it’s an inflammatory disease. Patients with psoriasis are more likely to have other health conditions, including metabolic syndrome, diabetes, heart disease and obesity. Up to 30 percent of psoriasis patients eventually develop psoriatic arthritis as well.

During office visits, doctors check the signs and symptoms of psoriasis and its comorbidities. Dermatologists are not just skin experts; we’re physicians. We can optimize our patients’ overall health and if we can assist in controlling the inflammation from psoriasis, we might possibly be able to help reduce the risk of these other conditions as well.”

What are some symptoms that you tell your patients to look out for?

“For most patients, psoriasis symptoms can fluctuate on a seasonal basis or with life changes. Cold, dry weather and stress can both trigger a psoriasis flare, and certain medications can make some symptoms worse.

Because of the increased risk of developing psoriatic arthritis, I make sure my patients are on the lookout for any joint pain and swelling. Patients should also know and watch out for the signs and symptoms of other comorbid conditions.”

The more that people with psoriasis take charge of their overall health and treatment, the better their outcomes can be.

How can doctors encourage their patients to see them more frequently?

“Doctors should foster a partnership with their patients through regular communication. The best outcomes occur if patients and doctors are both engaged and involved in their care. The more informed a patient is, the better decisions they make and the more compliant they can be with treatment.

Some patients may get scared when they learn about the risks that come with some systemic psoriasis treatments. It’s our job as physicians to thoroughly explain to our patients the risks and benefits of all their options and address their concerns, so we can make the most appropriate choice together.”

How have psoriasis treatments evolved over the past decade?

“We’ve seen a dramatic increase in the number of available psoriasis therapies as well as the efficacy and tolerability of those treatments. Newer treatments have become much more targeted compared with many of the older systemic medications, which cast a wider net on the immune system.”

Why is it important that patients feel empowered to manage their psoriasis?

“We can’t make patients take their medicines or schedule appointments, but we need to work to make them engaged participants. We can only provide the best information and try to build their confidence with the hope of helping improve their treatment compliance.

I encourage my patients to get involved with the National Psoriasis Foundation and learn more about their disease. My patients don’t always love hearing about diet and exercise, but I try to explain to them that their therapy may be more effective if they maintain a healthy body weight. The more that people with psoriasis take charge of their overall health and treatment, the better their outcomes can be.”

To learn more about how comorbidities can affect the health and care of people with psoriasis, read “Painting a Clearer Picture of Psoriasis Comorbidities.”

The public often only sees the outside symptoms of plaque psoriasis: raised, red patches of skin covered with silvery scales. But the “Psoriasis Inside Out” theme of this year’s World Psoriasis Day (October 29) implores us to look at the “less visible” aspects of the disease.

New research is shining a light on one of those hidden characteristics of psoriasis: the increased risk of developing other diseases. Comorbidities associated with psoriasis include psoriatic arthritis, depression, diabetes, cardiovascular disease and metabolic disease.

Dr. Steven Feldman, a dermatologist practicing at Wake Forest University, explains that the presence of psoriasis comorbidities can affect a patient's health and their care.

Dr. Steven Feldman, a dermatologist practicing at Wake Forest University, explains that the presence of psoriasis comorbidities can affect a patient’s health and their care.

The presence of these comorbidities can not only impact a patient’s health but also affect their care. “For example, if a patient has a comorbidity of diabetes or liver disease, certain medicines may not be the most appropriate choice of treatment because they could increase the risk of liver damage,” explained Dr. Steven Feldman, a dermatologist practicing at Wake Forest University.

Although physicians who treat patients with psoriasis may be aware of comorbidities, dermatologists often focus on the skin, and other specialists may not pay attention to psoriasis as they focus on the particular disease or condition that they have expertise in. As a result, the medical community has struggled to understand the full extent of comorbidities in psoriasis patients.

To paint a clearer picture, Dr. Feldman and his colleagues analyzed insurance claims data from over 460,000 Americans diagnosed with psoriasis from 2008 to 2014. They found that 46 percent of those psoriasis patients were also diagnosed with high cholesterol, 42 percent with high blood pressure and 18 percent with depression. Other common comorbidities in this psoriasis population included diabetes, obesity and heart disease.

“While this approach is good, it’s not perfect,” Dr. Feldman explained. “For instance, if people don’t go to the doctor, then their psoriasis or their comorbidities would not be detected in studies.”

People with psoriasis should have regular health exams and screening tests to monitor their weight, blood pressure and cholesterol.

While the study provides a clearer picture of the burden of comorbidities, the relationship between psoriasis and these coexisting diseases remains less clear. So far, researchers have identified some potential contributing factors including common inflammatory pathways, cellular mediators and genetic susceptibility.

“Also, people living with psoriasis can make lifestyle choices that could reduce their risk of comorbidities,” Dr. Feldman said. “For instance, exercise and a healthy diet may help to prevent cardiovascular disease for people with psoriasis.”

The Most Prevalent Comorbidities in Psoriasis Patients


While dermatologists commonly screen for comorbidities such as psoriatic arthritis and depression, screening for other comorbidities such as cardiovascular disease is often done by the patients’ primary care providers.  Even though we do not understand the underlying factors that link these diseases, the fact remains that it’s important for patients and physicians to be aware of these comorbidities. Increasing awareness can help these psoriatic disease comorbidities and their risk factors from being overlooked and could potentially lead to earlier diagnosis and management.

“We don’t have enough research to know fully how comorbidities should affect our treatment,” Dr. Feldman said. “But given the increased risk of cardiovascular disease, people with psoriasis should have regular health exams and screening tests to track their weight, blood pressure and cholesterol.”

To learn why it’s important for psoriasis patients to obtain access to their recommended medications immediately, read “Psoriasis Patients Deserve Their Prescribed Therapy Without Delay.”

Recently, several insurers updated their formularies to offer patients with plaque psoriasis and psoriatic arthritis access to more treatment options without requiring them to follow step therapy protocols. This protocol required prior authorization process makes patients go through a series of steps, trying other medications and failing on them before the insurance company will pay for another available medication that may have been originally prescribed by their doctor.



Dr. Jerry Bagel, a certified dermatologist at Windsor Dermatology and an expert in the treatment of psoriasis, explains the importance of patients obtaining access to their recommended medications immediately and why it’s critical that dermatologists continue to encourage insurers to cover prescribed treatments from the outset.

Why is it important that patients have access to psoriasis therapies?

“We know that not every psoriasis treatment is right for everyone. Doctors have recommendations for the most appropriate therapies, patient responses to treatments vary, and each patient has their own preferences as well.

“That’s why when a patient with psoriasis recently told me that she was worried about the increased risks that come with certain injectable drugs, we decided on a medication that could be taken orally and with an acceptable risk-benefit profile at that time in her treatment regimen. It was an appropriate option for her.

“But her insurer declined our reimbursement request because they required she first step through a preferred formulary agent. As a result, she is considering foregoing treatment altogether.”

How common are situations like this in the treatment of psoriasis?

“Unfortunately, this story is not unusual. Nontreatment and undertreatment of psoriasis remains a significant problem in the U.S., according to the National Psoriasis Foundation (NPF). The main reason isn’t surprising; patients can’t get their insurance to cover their medication.”

“For example, another patient of mine with moderate to severe psoriasis was so self-conscious about his appearance that he rarely left home. I prescribed a treatment to help manage his disease, and he was eager to try it. But his insurer said we first had to try a Tier 1 treatment.”

“When the Tier 1 treatment did not work, the insurer agreed to the treatment that I initially prescribed. Within months, his condition improved. Today, he is feeling sufficiently self-assured to go bowling with his friends and start dating again. However, he may have reached that point months earlier if there had been no treatment delay or mandated step.”

In a perfect world, every psoriasis patient would get access to the chosen therapy for his or her specific situation.


How has access to psoriasis treatments changed over the course of your career?

“When I started practicing dermatology 35 years ago, insurers showed little interest in psoriasis treatments. It was not until biologics were introduced in the first decade of the 21st century that they began to take notice.

“Biologics and other targeted therapies provide additional therapeutic options for psoriasis. However, drug utilization review of preferred therapies with high market demand and high volume often prevents the use of new treatment options. Pharmacy benefit managers (PBMs) and insurers implement step therapy policies that favor the current preferred brands until the demand for the newer treatment is impactful enough to add it to their formularies as an additional option.”

How do step therapies affect doctors?

“These policies mean we doctors and our office staff spend too much time on the phone and filling out paperwork — time that could be better spent caring for our patients. As a doctor who has dedicated his life to helping patients, this is downright frustrating.”

What needs to happen to improve treatment access for psoriasis patients?

“In a perfect world, every psoriasis patient would get access to the chosen therapy for his or her specific situation. We must keep patients and doctors at the center of medical decisions. I hope that the recent progress we’ve seen from certain insurers in offering additional options is a sign of what’s to come, and this type of advocacy for appropriate treatments continues. If we help patients and physicians immediately access the prescribed psoriasis therapies, we could potentially improve thousands of lives.”

PsA-Day-2016-logoMore than 1 million people in the U.S. live with psoriatic arthritis, or PsA. To educate the community about this chronic autoimmune disease, Celgene has partnered with the National Psoriasis Foundation (NPF) to launch the first-ever Psoriatic Arthritis Awareness Day on Wednesday, September 28th, 2016.

PsA-Day-2016boxPsA Awareness Day is a day dedicated to raising awareness around the importance of recognition, diagnosis, and treatment. People are encouraged to join the movement at to learn factors associated with PsA, to help spread the word via their social channels, and to stand up and be counted for those living with this disease.

Psoriatic arthritis is a chronic inflammatory disease characterized by swelling, pain, and tenderness of the joints. It is also associated with the skin condition, psoriasis. In fact, in 85 percent of PsA patients, psoriasis occurs before joint disease.

It can be challenging living with this disease and can impact a person’s common day-to-day activities, such as walking up the stairs, driving a car, and doing laundry. While there is no cure, PsA can be managed. Early recognition, diagnosis, and treatment are critical to relieve the pain and inflammation of PsA. That is why it is important to know about some of the factors associated with PsA:

PsA-Day-2016factorsThose who are experiencing any of the common symptoms of PsA should contact their healthcare team.

To learn more about PsA and help spread the word about awareness day efforts, visit

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Dara Torres

Fresh off her poolside reporting assignment in Rio, 12-time Olympic medalist, best-selling author, and mom Dara Torres is diving into a very important conversation about psoriasis. This summer, Torres is teaming up with Celgene to share her personal story with psoriasis and raise awareness about the disease through the SHOW MORE OF YOU campaign.

ShowMoreMeScreenShotThe campaign aims to inspire people living with psoriasis to raise awareness about their condition and celebrate their accomplishments. People with psoriasis and those who support them can join Torres and others at by sharing inspirational photos and messages of how they are showing more of their true selves.

Psoriasis is a chronic, systemic autoimmune disease, which causes increased skin cell growth that may appear on the skin as raised, sometimes red patches, covered with a silvery buildup of dead skin cells. People living with psoriasis often report that the disease has emotional and physical challenges. In fact, a survey reported nearly 9 out of 10 people living with psoriasis experienced self-consciousness or embarrassment about their condition.

As one of 7.5 million people in the U.S. living with the disease, Torres knows what it means to overcome her fears and achieve her goals both in and out of the pool. In fact, she is the first and only female swimmer to represent the U.S. in five Olympic Games, and, at age 41, she was the oldest swimmer ever to earn a place on the U.S. team. Despite having lived with plaque psoriasis for nearly two decades, Torres has never let fear or embarrassment keep her out of a bathing suit, out of the pool, or stop her from realizing her dreams. She didn’t let the impact of the disease force her to adapt her life at the expense of her dreams – and she wants to encourage others to do the same.

To learn more about the SHOW MORE OF YOU campaign, psoriasis, Torres’ personal story, and to upload inspiring photos or messages, visit

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For a long time, Élodie Laurent loved nothing more than baking for the people who visited her French café. But that joy was taken away by something out of her control—psoriasis.

She has the obvious physical symptoms of the disease, including the red, scaly patches on her face and arms. But a closer look into her day-to-day life reveals the emotional and psychological toll that this immune-inflammatory disease has taken on her: she is self-conscious about her appearance, imagines her disease to be much worse than it is and actively avoids family and friends. Having been forced to give up her job as a pastry chef, she lives a solitary and isolated existence in London.

Although Élodie is a fictional character—the protagonist of the new short film Millefeuille (A Thousand Leaves)—her story is inspired by psoriasis and psoriatic arthritis patients around the world. The movie was produced following extensive research in this space to raise awareness of the sometimes hidden burden of psoriasis.

In Millefeuille (A Thousand Leaves), Elodie (left) initially resists the warmth of Holly’s friendship because of the emotional effects of her psoriasis.


Typically, when filmmakers set out to educate on a topic close to their hearts, they lean toward a documentary style. But here, they instead set out to make a short drama, aiming to attract a wider audience and a patient community who may have given up hope that life with psoriasis could be different.

“It’s been a really fascinating process doing this,” the film’s director Alistair Clayton said. “It’s not something I’ve seen done before.”

To learn more about Elodie’s condition, read “The Reality Behind Millefeuille.”

To learn more about Elodie’s condition, read “The Reality Behind Millefeuille.”

Over 100 million people worldwide—including some 14 million Europeans—have psoriasis. Beyond skin effects, up to 30 percent of people living with psoriasis are likely to develop psoriatic arthritis, which can lead to painful swollen joints and a loss of physical functioning. The toll of the disease is often hidden from the public; patients like Élodie wear sleeves and hats to strategically cover their skin lesions and hide from friends and family when their psoriasis flares. Hard-to-manage symptoms like itching can often become hugely burdensome for some patients as we see in the film.

Millefeuille is an accurate portrayal of the experiences that commonly affect those living with psoriasis,” said Nikhil Yawalkar, a dermatologist at the University Hospital Bern in Switzerland who served as a consultant on the film. “Many people with psoriasis isolate themselves because of such a deep sense of shame, embarrassment and low self-esteem, and Élodie’s experience is reflective of this.”

Indeed, 88 percent of psoriasis patients said their condition affected their emotional well-being according to surveys conducted by the National Psoriasis Foundation between 2003 and 2011. Most psoriasis patients said they experienced anger, frustration and helplessness due to their disease.

Through Holly’s understanding and acceptance of her disease, Elodie rekindles her passion for baking and life.


But the film also portrays the hope that remains for people living with psoriasis. When Élodie befriends Holly, an outgoing young neighbor, she finds understanding and acceptance and discovers that Holly is a ‘millefeuille’ herself—deep, sweet, with many layers. Holly helps Élodie rediscover her passion for baking and place in the world.

“We’re delighted to see a story that shows us the value of looking beyond the disease and seeing the person.”

“It’s fabulous to see psoriasis getting this type of creative exposure,” Christine Janus, CEO of the International Alliance of Dermatology Patient Organisations, said. “Most people love cinema and a good story, and we’re delighted to see a story that shows us the value of looking beyond the disease and seeing the person.”

The film, produced through a collaboration between Celgene, Bedrock Multimedia and Turtle Canyon Films, launches today.

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A Call for Improved Access to Psoriasis Treatments

View the complete “A Call for Improved Access to Psoriasis Treatments” infographic.

In the recent Global Report on Psoriasis, the World Health Organization (WHO) has called for governments and policymakers around the world to work toward improving access to care for patients with psoriasis.

“Too many people in the world suffer needlessly from psoriasis due to incorrect or delayed diagnosis, inadequate treatment options and insufficient access to care,” WHO authors wrote in the report.

Psoriasis, at the most basic level, is a skin disorder, characterized by skin cells that multiply faster than usual, causing raised, red plaques. But the disease is far more than just a rash. As the WHO called attention to in a 2014 resolution, psoriasis can shorten patients’ lifespans and is associated with multiple comorbidities. People with psoriasis are at higher risk of developing cardiovascular diseases, metabolic syndrome and mental health disorders. Those who develop psoriatic arthritis are particularly burdened, facing high levels of disability and unemployment.

“Like many diseases, there is ample need to continue to educate and raise awareness about psoriasis as a chronic, systemic disease,” said Lindsay Bohlander, the associate director of patient advocacy at Celgene.

That need is only growing in importance as psoriasis is becoming more common around the world. From 2004 to 2010, the percentage of the U.S. population with psoriasis nearly doubled, and similar upward trends have been seen in other countries as well.

Implementation of the WHO’s recommendations is imperative for psoriasis patients.

Caring for patients with moderate or severe psoriasis, the WHO report points out, is more complex than treating skin symptoms. Not only do clinicians need to prescribe effective therapies, but they also need to screen for complications and comorbidities, recognize an individual’s triggers for psoriasis flares and avoid any medication interactions when simultaneously treating multiple aspects of the disease.

According to WHO statistics, access to health care—including the care required for psoriasis—is still limited in many countries. And even when basic care can be accessed, primary care physicians may not know enough about psoriasis, and burdensome insurance requirements can delay appropriate care.

Diagnosing and treating psoriasis and its comorbidities as early as possible is key to improving clinical outcomes. One study, for instance, found that when it comes to psoriatic arthritis, delaying diagnosis by a year reduces a patient’s chance of achieving a positive outcome.

To help patients receive early diagnoses and adequate treatment, the WHO report emphasizes a few areas for policymakers to focus on, including universal access to health services and medications, patient-relevant benefits and a people-centered model of care to treat chronic complex conditions like psoriasis.

“Implementation of the WHO’s recommendations is imperative for psoriasis patients,” Bohlander said. “To truly make an impact for psoriasis patients to gain the access to care and treatment they need, it will take all stakeholders to become vested in their health and care.”

For an overview of the key points and issues raised by the WHO report, download our summary.

According to a National Psoriasis Foundation survey, 25 percent of people living with moderate psoriasis are not receiving treatment, and 30 percent are being undertreated with only topical medications. These patients face an uphill battle in getting a proper diagnosis and accessing treatment options that could improve their lives.



Psoriasis is an inflammatory disease that causes red, scaly patches on the skin, most commonly on the elbows, knees or scalp. Dermatologists classify a patient’s disease as mild, moderate or severe based on how much of the body is affected. If less than 3 percent of a patient’s body is covered with psoriasis, it is considered mild, and if more than 10 percent is affected, it is considered severe. Those cases that fall in between are called moderate.

“Unfortunately, it’s an imperfect diagnostic tool that fails us often,” said Dr. Abby Van Voorhees, the chair of dermatology at the Eastern Virginia Medical School and chair of the National Psoriasis Foundation medical board. “It doesn’t take into account the impact of the location or the severity of inflammation on a patient’s life.”

For instance, a patient with psoriasis on the palm of his or her hands would technically have a mild case based on the small area affected, but the location could be debilitating. That impact on the patient’s life might justify classifying this case as more severe, according to Van Voorhees.

Traditionally, dermatologists have prescribed topical medications for mild psoriasis and systemic therapies for those with severe psoriasis. But for the 40 percent of psoriasis patients who identify their disease as moderate, few treatments really addressed their unique needs. As a result, doctors had little choice but to prescribe topical treatments for most moderate psoriasis patients.

To improve the lives of patients stuck in between mild and severe psoriasis, we need to educate doctors and insurers about the impact of moderate psoriasis on patients’ lives and about the potential of these new treatments.

However, new treatment options for moderate psoriasis have recently become available and are continuing to be explored. “New data is continuing to come out that shows these new therapies can improve patients’ lives and lower their risk for other diseases with minimal risk,” Van Voorhees said. “Dermatologists need to stay informed and encourage patients to explore these treatment options for moderate psoriasis.”

Even if a dermatologist prescribes a new therapy, insurance companies could still deny coverage. Insurers often only cover systemic therapies if 10 percent or more of a patient’s body is affected by psoriasis, meaning only severe psoriasis patients would have access to these therapies. According to a 2014 study, insurance problems were one of the top reasons psoriasis patients stopped taking their treatment.

“It’s very distressing but not surprising,” Van Voorhees said. “To improve the lives of patients stuck in between mild and severe psoriasis, we need to educate doctors and insurers about the impact of moderate psoriasis on patients’ lives and about the potential of these new treatments.”

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Some insurers are forcing patients with diseases such as psoriasis and psoriatic arthritis to try, and fail, one or more treatments before approving the medicine originally recommended by their doctors.

This practice, known as step therapy or “fail first,” is delaying appropriate treatment for patients with these diseases. One recent survey found that 67 percent of patients whose specialty prescriptions were rejected under step therapy policies did not receive an alternative within 30 days.

Delays can be detrimental to patient health. For patients with psoriatic arthritis, for instance, they can lead to worsened bone and joint deterioration and a lower likelihood of success with appropriate therapies.

“It’s all about costs,” Dr. Philippe Saxe, managing partner at Arthritis Associates of South Florida in Delray Beach and immediate past president of the Florida Society of Rheumatology, said. “It has nothing to do with the specific patient’s condition or medical history.”

Step Therapy Delays Treatment

Some insurance plans, for instance, unreasonably require patients with moderate to severe psoriasis first try topical treatments — creams or ointments — even if they need to treat a large body area.

Meanwhile, other insurers force patients with psoriasis or psoriatic arthritis to try the newest innovative therapies in a specific order, known as sequencing, without regard for physician’s discretion.

It’s all about costs. It has nothing to do with the specific patient’s condition or medical history.

Policies such as these often do not take into account therapies the patient has previously tried and found unsuccessful in years past. It may also ignore patient-specific contraindications, side-effects, or logistical challenges.

Because insurers provide little transparency to their step-therapy policies, patients and doctors often don’t learn about the specifics until the patients’ attempts to fill their prescription at their local pharmacy are rejected.

That’s when the paperwork and administrative burdens begin. Doctors and their staff are required to fill out documents and call the insurer to help their patient get the more appropriate treatment. “It’s an extremely time-consuming and frustrating process for both physicians and patients,” Saxe said.



Beyond eliciting frustration and wasted time, these policies also increase health care costs and the economic burden of psoriasis, which reached an estimated $112 billion in 2013 in the U.S., including direct costs and lost productivity.

Changing therapies requires patients to pay additional copays for doctor visits and prescriptions and to spend more time away from work and family. And as we have seen in other diseases, restricting access to effective therapies can also lead to more frequent hospitalizations that increase overall costs.

“The vast majority of doctors will prescribe the least expensive medicine if it is appropriate, but there are occasions where the least expensive is not the most effective option,” Saxe said. “Physicians need the ability to override step-therapy policies.”

The efforts of Saxe and other physicians in the Florida Society of Rheumatology have been instrumental in efforts to pass legislation in Florida, bill SB 784, that allows bypasses in certain situations, such as a history of side effects with the least expensive option. It will also prohibit insurers from creating step-therapy protocols that are not supported by sufficient clinical evidence.

Step Therapy State Legislative Action

Other states, including New York, California, Missouri, Illinois, Maine, Massachusetts and Rhode Island, are considering similar legislation to protect patients from step therapy policies.

There is precedent for success with such bills; last year, Connecticut passed a bill that prevents insurers from forcing patients to take a less expensive treatment option for more than 60 days. And advocates are calling for national action as well.

“This is important legislation that will allow the patients to get access to necessary treatments,” Saxe said.


The World Health Organization (WHO) recently recognized psoriasis as a serious non-communicable disease that requires better global awareness and care. For the 125 million people worldwide with psoriasis, this recognition provides hope that governments will improve education about this disease and access to effective treatments.

“It’s an extremely important step to be recognized,” said Dr. Mahira El Sayed, professor of dermatology, venereology and andrology at Ainshams University in Cairo. “Governments around the world need to recognize the importance of psoriasis as a disease and its association with comorbidities.”

Although some think of psoriasis as simply a cosmetic condition, severe psoriasis can shorten lifespans by 3.5 years on average for men and 4.4 years for women.

“Psoriasis is an inflammatory disease that not only affects the skin,” El Sayed said. “It also involves the blood vessels, for example, and has been found to be very closely related to diabetes.”



Other comorbidities include heart attacks, ulcers and mild liver disease. And up to 30 percent of psoriasis patients also suffer from psoriatic arthritis, according to the National Psoriasis Foundation.

The odds of comorbidities increase with a patient’s age and disease severity, according to recent studies. For those 65 and over, nearly half have at least three comorbidities.


Increased Risk of Comorbidities Associated with Severe Psoriasis


With the development of new and effective therapies for the disease, researchers are now investigating whether early treatment could help reduce the impact of comorbidities on patients and the health care system.



Comorbidities increase overall health care spending. Treating patients who have multiple chronic diseases costs up to seven times as much as treating those with just one, according to the Agency for Healthcare Research and Quality. And people living with psoriasis are almost twice as likely to be hospitalized for an infectious disease compared with the general population.

“Psoriasis is directly linked to higher costs in health care services and has a direct impact to productivity, limiting the ability of people to work,” said Mario Ottiglio, director of public affairs and global health policy at International Federation of Pharmaceutical Manufacturers and Associations. “So the economic impact is relevant.”

The WHO resolution recognizes the comorbidities that plague psoriasis patients and encourages governments to reduce social stigma and discrimination through advocacy. Now that governments have been provided with a direction, it’s time to act and help ease the burden on patients.

To learn more about recent advances in psoriasis treatment, read our Developments in Psoriasis Management report.