Dr. Megan Prouty discusses clinical pearls from her lecture , "Optimizing Biologic Selection and Treatment Sequencing in Psoriasis: A Case-Based Approach, " at the 2nd Annual Elevate-Derm Alliance Summer Conference at the Grand Hyatt Deer Valley in Park City, Utah.

In this video

In this conversation with dermatology NP Veronica Richardson, Dr. Prouty explains that once she's assessed disease severity, the single most important thing she wants to identify is "how does the patient feel about their disease?" She points out that body surface area alone can be misleading — patients with "quote-unquote mild disease" can be profoundly affected, while some with moderate-to-severe disease "just really aren't that bothered" — so aligning with the patient's own goals drives treatment selection. She also flags axial psoriatic arthritis as one of the more insidious presentations, walking through the questions she asks about back, neck, and hip pain, timing, and whether symptoms improve or worsen with activity, and noting these patients often present younger.

When she suspects axial disease, Dr. Prouty favors starting the TNF-alpha inhibitor conversation given the strength of data, and always refers to rheumatology — ordering labs (CBC, CMP, QuantiFERON, hepatitis panel, ESR, CRP, RF, HLA-B27) and X-rays of involved joints up front to give the rheumatologist "data to work with on day one." She makes the case for staying well-versed in traditional systemics: methotrexate as a workhorse and adjunct, and cyclosporine for rapidly clearing severe disease while a biologic is in process — both also serving as pathways through insurance step-therapy requirements.

  • After severity, ask how the patient actually feels about their disease — "if I'm not aligned with what their goals are, then we're not gonna match up."
  • Screen for axial psoriatic arthritis with targeted questions (back/neck/hip pain, timing, night waking, activity response); suspect it more in younger patients and favor a TNF-alpha inhibitor plus rheumatology referral.
  • Tee up rheumatology referrals with labs (CBC, CMP, QuantiFERON, hepatitis panel, ESR, CRP, RF, HLA-B27) and X-rays of involved joints to expedite the first appointment.
  • Methotrexate remains valuable — as a step-therapy option, a breakthrough-flare adjunct to biologics, and for psoriasis-dermatitis overlap; Dr. Prouty skips the test dose, starts ~15 mg weekly with folic acid, and builds an in-person one-month lab-and-tolerability check into the plan.
  • Cyclosporine is another route through insurance requirements and can clear severe disease quickly while a biologic is pending — she points to the two-part JAD CME article on cyclosporine in dermatology for dosing, monitoring, and weaning.