Alexa Hetzel, MS, PA-C: Let’s move on to our next case. This is a 23-year-old female who presents with several thick, scaly, well-defined erythematous plaques that are silver in color. [It’s] very textbook for us to [make] this diagnosis. It’s very prominent, especially on her elbows, thighs, and her scalp, and it’s covering 15% of her body surface area. She mentions having rashes in the past but nothing severe. She was initially started on apremilast but is [experiencing] nausea and diarrhea.
Laura Bush, DMSc, PA-C: And she wants to wear shorts and put her hair in a ponytail.
Alexa Hetzel, MS, PA-C: I had this patient today…I was doing a full body check and she had her hair up. It looked really fancy, [so] I didn’t want to mess it up. I was combing through without being too crazy. I [asked her to take her] hair down, [and] her scalp was covered. I really wouldn’t have noticed; [she did a] good job of hiding and covering. But she said to me, “That’s why I wear my hair like this, because nobody can see the scales. And I keep my hair light because it blends in with the scales.” And that really hit me. I [said], “Why didn’t you tell me sooner? We can get this better.” But that was what her coping mechanism was. I think people come up with so many different things, and so many people really wouldn’t know. They’re so good at hiding it, but it really is affecting how she’s getting ready every day. That’s her style.
Laura Bush, DMSc, PA-C: Hair is important to young women.
Alexa Hetzel, MS, PA-C: Hair is important to everybody. Jennifer, what is your initial impression on this case?
Jennifer Conner, MPAS, PA-C: Apremilast is out. She’s already tried it [and] didn’t tolerate it well. I think she would be a great candidate for deucravacitinib if she wants to try another oral agent. She started with apremilast, so it sounds like she [may be] someone who likes an oral agent for an option. I would probably start there, then offer her biologics as well. We don’t know the rest of the story. Is she needle phobic? What does that look like? Deucravacitinib would be the next step for me with this patient, knowing the [adverse] effect profile is going to be much more tolerable for her.
Alexa Hetzel, MS, PA-C: Right. Terry, discuss with us the factors that influence your treatment options for her.
Terry Faleye, MPAS, PA-C: Just like Jennifer said, I would consider deucravacitinib for her. Just in itself, knowing the data—especially with scalp data deucravacitinib has and just seeing the level of improvement that patients see with it—I would consider it for her. She’s tried apremilast and didn’t have great success with that, and she didn’t want any of the [adverse] effects associated with it.
I would honestly even [ask about] how she [lives], too. Because even in the midst of it, I can sit back and say an oral agent would be awesome for her, but she may be someone [who doesn’t] want to take a pill every day. What if she [says she wants] wants it out of sight, out of mind? Maybe she is perfect for an injectable that she’s injecting once every 3 months or whatnot. I think it will truly be tailored to what fits her lifestyle, because I want her to be happy at the end of the day.
Alexa Hetzel, MS, PA-C: Yeah, somebody’s lifestyle [is a huge component]. If it’s going to be a daily pill, can they do that? I feel like a lot of people are on oral therapy for other things, like Lakshi mentioned, whether it’s high blood pressure or diabetes. We already assume most Americans are taking pills now, but are people good at being consistent? Is it easier to inject a biologic sometimes? I think that varies based on what you ask. That’s why it’s important to have a conversation.
Terry Faleye, MPAS, PA-C: And some patients don’t. Amazingly, even this time frame, there’s some people who [are] not on anything.
Alexa Hetzel, MS, PA-C: Or they can’t.
Terry Faleye, MPAS, PA-C: Yeah, and to go from the paradigm of never taking anything and all of a sudden—for the patient who doesn’t potentially have any high blood pressure or diabetes and this is the first time something major is going on with them, apart from having some type of infection—to now saying you have a chronic immune-mediated disease we need to get under control. To come to grips with the fact that we may have to pivot here could be a big shift to a daily usage. So for her, deucravacitinib, just like you said, would probably be a great option, especially transitioning already from an oral. But you never know, she may shock you.
Alexa Hetzel, MS, PA-C: Sometimes they do. Laura, is there any hesitation that you would have using an oral therapy as first line instead of just either [using] topical or biologic therapy?
Laura Bush, DMSc, PA-C: No, I wouldn’t hesitate to use deucravacitinib for her. I would hesitate to use methotrexate for her. I would not—that would be a definite no. Apremilast [already failed], so I would not hesitate at all, as long as she can swallow a pill—and she could swallow the apremilast, so she could swallow a pill. Believe it or not, there are people out there who can’t swallow a pill. So I would have no reservation. She’s young and able to do it, and I think [with her] lifestyle, a lot of us can manage 1 time a day. If it were twice a day, I would say probably not.
Alexa Hetzel, MS, PA-C: Right. Or, if she’s in graduate school and she’s living somewhere else and she can’t come into the office or can’t get a biologic shipped to her, sometimes that’s a little tricky. You want to keep those cold, so it’s much easier to sometimes give something that is room temperature stable.
Laura Bush, DMSc, PA-C: Yeah, good point. I also have a lot of patients [who] travel, so sometimes I’ll switch them to an oral agent because they’re traveling. A lot of young people are traveling these days…so it’s a good option to carry with you. You’re right.
Alexa Hetzel, MS, PA-C: Absolutely.
Transcript edited for clarity.