Psoriasis: One Treatment Failure May Overshadow a Subsequent Successful One

—South Korean researchers found that adult patients who have failed a prior biologic therapy for their psoriasis perceive their quality of life to be significantly lower than those who had not.

By Gloria Arminio Berlinski, MS
Reviewed by Christopher Sayed, MD, Professor, Department of Dermatology, University of North Carolina School of Medicine

Previous research indicates that about 1 in 5 patients with psoriasis who have clear skin, and about half of those who have nearly clear skin, still report that their disease negatively impacts their quality of life. Additional research also suggests that patient perceptions about the effects of psoriasis differ from clinicians’ observations.¹

To explore this inconsistency, investigators from Seoul, South Korea, sought to assess the factors that influence quality-of-life outcomes as reported by patients who have had successful responses to biologic agents. The researchers commented that, in the current era of biologic treatment, successful therapy for psoriasis depends on both positive clinician- and patient-reported outcomes. Their findings, published in a recent issue of The Journal of Dermatology, revealed that minimal residual skin lesions and the experience of having previously failed biologic therapy were associated with worse patient-reported outcomes as determined by Dermatology Life Quality Index (DLQI) scores.¹

An analysis of retrospective data

The researchers conducted a retrospective observational study at an academic hospital in Seoul among 96 adult patients (mean age 43.7 years, 76% men) with a confirmed diagnosis of chronic plaque psoriasis, who were responding to at least 6 months of current and continuous biologic therapy.¹ No concomitant systemic treatment was administered.

Achievement of at least a 75% improvement in the Psoriasis Area and Severity Index (PASI) score from baseline indicated a therapeutic response.¹ A DLQI score of 0 or 1 signified no impact of psoriasis on the patient’s quality of life, whereas a score of ≥2 to 30 signified a negative impact (ranging from a small or moderate effect to a very large or extremely large effect).² Medical records were used to obtain data on demographic and clinical variables, such as age, sex, body mass index (BMI), biologic treatment, and comorbidities.¹

PASI and DLQI scores mirror patients’ experiences

“A robust clinical response to biologic treatment” was achieved among the study cohort, the authors noted in their report, as reflected by a median PASI score of 0.4. However, roughly half (52.1%) of patients indicated a negative impact of psoriasis on their quality of life, demonstrating a “notable discordance between clinician-assessed outcomes and patient experiences,” the authors wrote.¹

Complete skin clearance (PASI 100) was achieved in 37.5% of patients. Overall, 28.1% of the study group had a history of biologic treatment failure.¹

According to a multivariable logistic regression analysis, PASI 100 was significantly associated with patient reports of psoriasis having no impact on quality of life (adjusted odds ratio [aOR] 3.88, 95% confidence interval [CI] 1.49 to 10.91; P=.007). On the other hand, a prior biologic treatment failure was associated with a decreased number of patient reports of psoriasis having no impact on quality of life (aOR 0.13, 95% CI 0.02 to 0.65; P=.023).

“In other words, patients with residual skin lesions and a history of previous biologic treatment failure were more likely to report a negative impact of psoriasis on their quality of life,” the authors commented.¹

For some patients, negative impacts persist

Similarly, a separate multivariable analysis that specifically included “residual lesion in the exposed area” and excluded “clear skin” revealed that the former variable was linked to patient reports of psoriasis having a negative impact on their quality of life (aOR 0.33, 95% CI 0.12 to 0.85; P=.024).¹

Median PASI score did not vary by prior biologic treatment failure (P=.304). In contrast, median DLQI score was significantly higher among patients who had a history of biologic treatment failure (P<.001), even among those with clear skin (P=.033).¹

“This suggests that, regardless of an excellent response to the current biologic agent, prior failure of biologic treatment leaves a substantial effect on patients’ quality of life,” the authors commented.¹

No significant associations were apparent between DLQI scores and age, sex, BMI, or comorbidities (P=.399, P=.225, P=.433, and P=.604, respectively), which did not align with some prior research, perhaps due to variations in treatment approaches and study populations, the researchers speculated.

Getting to goal: PASI 100

The authors noted that most of the cases of biologic treatment failure (85.2%) were grouped as “secondary failures,” meaning that there was a decrease below <75% PASI improvement after the patient had initially experienced a ≥75% PASI improvement.

“This suggests that prior experiences of biologic failure, signaling a decline in drug efficacy, might have prompted patients to question the persistency of the excellent efficacy of the currently used biologic agent,” the authors remarked.¹

Limitations of the study include its retrospective nature and relatively small sample size, which make it difficult to generalize the findings to wider populations. The authors also acknowledged that they didn’t have data on individual psychological conditions and socioeconomic status, although they noted that all of the study participants had health insurance.

Finally, the authors remarked that genuine success with biologic treatment that aligns with patient perspectives hinges on targeting PASI 100, as well as on selecting an agent with the highest predicted efficacy. “This approach,” the researchers concluded, “is preferable over a ‘step-up’ strategy, which carries a higher risk of treatment failure.”¹

Published: June 20, 2024

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