Implementing treatment goals for successful long-term management of psoriasis

Treatment goals are commonly used throughout medicine to ensure efficacious therapy of diseases and to prevent complications related to uncontrolled disease activity, such as the management of hypertension and diabetes. Psoriasis is a systemic immune-mediated inflammatory disease comprising characteristic skin manifestations. A range of co-morbidities has been associated with it, including diabetes and cardiovascular diseases such as myocardial infarction (MI) and stroke. There is good evidence that the severity of skin symptoms is related to mortality associated with MI. Therefore, long-term efficacious control of skin inflammation is the treatment paradigm of choice, particularly in patients with severe skin involvement. Surveys in a number of countries have revealed a substantial under-treatment of patients with moderate-to-severe psoriasis, leaving a considerable proportion without adequate disease control. In addition, a high number of patients were not satisfied with their treatment, including the time they needed to allocate for skin therapy and the number of visits to physicians. Therefore, the use of effective therapies is necessary to achieve appropriate control of inflammation and to improve patient satisfaction. The definition of treatment goals is an appropriate instrument for raising the quality of care and sets therapeutic standards in addition to evidence-based guidelines. Consensus treatment goals for moderate-to-severe psoriasis were recently defined, and a treatment goal algorithm was developed through a Delphi process by a group of experts from 19 European countries. These have since been adopted into the update of the German S3 guidelines for treatment of psoriasis. Furthermore, a novel analysis was carried out on published Phase 3 clinical trial data from three studies of adalimumab therapy in psoriasis, which used the consented definition of moderate-to-severe disease and the proposed treatment goal algorithm. The data showed that the 'treatment goal' was achieved in 68.2-79.3% of the patients treated with adalimumab by week 16, with >93% achieving 'treatment success' (a ≥75 reduction in psoriasis area and severity index compared with baseline). These results were similar to those achieved using the protocol-specified definitions of disease severity. Regular assessment of treatment goals during maintenance phase at intervals recommended by the published guidelines, such as 16 weeks for adalimumab, will ensure efficacious therapy over time. This may, consequently, represent progress towards establishing a standard of care for psoriasis.