INTRODUCTION 
• Management of moderate psoriasis remains a signifi cant challenge, with some 

evidence suggesting patients with moderate disease are often undertreated 
and experience unsatisfactory clinical outcomes.1,2 However, there is a lack of 
consensus on how to defi ne moderate psoriasis, and no explicit guidelines exist 
for the treatment of this patient population. 

• Apremilast (APR), an oral phosphodiesterase 4 inhibitor, is the fi rst new oral 
systemic, nonbiologic medication approved for the treatment of psoriasis in 
the past 20 years, and is approved in the United States for treatment of adult 
patients with active psoriatic arthritis (PsA) and patients with moderate to 
severe plaque psoriasis who are candidates for phototherapy or systemic therapy.3

• Given the lack of guidance for treating patients with moderate psoriasis and the 
recent availability of APR, the objectives of the current investigation were (1) to 
determine how dermatologists in the real-world clinical setting defi ne and treat 
moderate plaque psoriasis, and (2) to describe real-world clinical characteristics 
and 6-month treatment outcomes among patients with moderate psoriasis 
treated with APR.

METHODS 
Dermatologist Survey
• The survey portion of the investigation was conducted between October 2015 

and July 2016.

• US dermatologists treating patients with psoriasis were invited to complete an 
online survey which asked:

 – How they typically assess psoriasis severity
 – What cutoff criteria they use to defi ne moderate psoriasis
 – Which treatments they commonly prescribe to patients with moderate 

plaque psoriasis

• Eligible survey participants were US dermatologists who:
 – Treat ≥20 adult patients with plaque psoriasis per month, ≥1% of whom 

must be considered to have moderate psoriasis
 – Spend ≥40% of practice time in medical dermatology or ≥70% in medical 

and surgical dermatology
 – Have been in practice for 2 to 30 years
 – Spend >75% of practice time in direct patient care

Prospective 6-Month Patient Chart Review
• Surveyed dermatologists were also asked to provide data from charts of 

4 patients with a diagnosis of moderate plaque psoriasis whom they had seen 
in the last month, including ≥1 patient treated with APR; 6 months later they 
were invited to provide follow-up patient chart information.

• The patients were required to meet the following criteria:

 – Adult patient (≥18 years of age), diagnosed with plaque psoriasis and 
currently living

 – Moderate disease severity (as determined by the surveyed, treating 
dermatologist)

 – Seen by the dermatologist within the month before the dermatologist took 
the survey

 – Using prescription topical or systemic medication for the treatment of 
moderate plaque psoriasis at the time of the survey

METHODS (cont’d)
• Chart information included:

 – Patient demographic characteristics

 – Clinical disease characteristics

 – Treatment patterns, including treatment shifts and discontinuations

 – Effectiveness of treatment

 – Safety and tolerability

RESULTS 
Dermatologist Survey
Respondent Dermatologists
• A total of 150 dermatologists responded to the survey.

• Dermatologists had an average of 13.5 years in practice; most currently worked 
in a single-physician or multiphysician dermatology specialty practice (83%). 
They saw an average of 72 patients with psoriasis per month.

Scales Used to Assess Psoriasis Severity 
• The large majority of dermatologists (95%) reported they assessed disease 

severity based on the percentage of psoriasis-affected body surface area (BSA) 
(Figure 1). 

 – 59% of dermatologists responded that they also considered location of the 
affected area in their assessment of severity.

Figure 1. Criteria Used to Assess Psoriasis Severity

Dermatology Life
Quality Index

0 20 40 60 80 100

Physician Global
Assessment

Psoriasis Area and
Severity Index

Patient assessment
of their disease

Location of
affected areas

BSA 95%

17%

20%

25%

41%

59% Location Mentioned

Palms 88%
Genital Area 85%
Feet 81%
Face 78%
Scalp 75%
Nails 50%
Legs 43%

Arms 42%

Dermatologist (n=150) response to questions: Which of the following metrics do you use to determine if a patient has moderate 
plaque psoriasis? What locations do you use to determine if a patient has moderate plaque psoriasis?

Defi ning Moderate Plaque Psoriasis
• Dermatologist-reported BSA cutoffs to defi ne moderate psoriasis varied widely, 

revealing a lack of consensus among dermatologists (median: 5% to 10%) 
(Figure 2).

RESULTS (cont’d)

Figure 2. Dermatologist-Reported BSA Cutoffs for Moderate Psoriasis

0

Overall Range

Mean Range

D
er

m
at

ol
og

is
t-

Re
po

rt
ed

 B
SA

 
Su

m
m

ar
y 

St
at

is
tic

s 
(n

=
14

2)

Psoriasis-Affected BSA (%)

Median Range

20 40 60 80 100

5–10

8–18

1–70

BSA low and high cutoff values reported by dermatologists who use BSA to assess disease severity (n=142) in response to the 
question: For the following metrics [including BSA], what are your typical cutoffs for moderate/severe psoriasis patients? Please 
enter numbers for each.

Treatment of Moderate Plaque Psoriasis
• When asked to estimate what proportions of their patients with moderate 

plaque psoriasis receive various types of medications as their primary 
treatment, dermatologists reported that 47% were receiving biologic agents, 
28% prescription topicals, 18% oral systemics, 5% phototherapy, and 2% 
over-the-counter (OTC) topical agents (Figure 3).

Figure 3. Primary Treatments for Moderate Plaque Psoriasis

Proportion of PatientsPrimary Treatment

Phototherapy 5%

OTC Topical 2%

Prescription Topical 28%

Oral Systemics

APR
Methotrexate 
Acitretin 
Cyclosporine

18%

7%
7%

3%
1%

Infliximab 0%

Biologics

Adalimumab
Ustekinumab
Etanercept
Secukinumab

47%

19%
13%

11%
4%

Dermatologist (n=150) response to the question: What percentage of your moderate plaque psoriasis patients are currently on 
the following types of treatment as their primary therapy? Must add to 100%.

6-Month Prospective Chart Review of Patients With Moderate Psoriasis 
Treated With APR

Patient Disposition and Demographic/Clinical Features
• The participating dermatologists identifi ed 270 patients with moderate psoriasis 

who had ≥1 follow-up visit within the 6-month follow-up period. Among these, 
70 patients who had ≥1 follow-up visit (mean visits=2) within the 6-month 
follow-up period were initially receiving APR.

RESULTS (cont’d)
• At the 6-month chart review, among patients treated with APR at baseline, 

91% (64/70) remained on APR; 3 patients were new to APR (Figure 4).

• 65 patients (24%) were receiving APR as their primary therapy.

• APR discontinuation occurred in 6 patients; reasons for discontinuation included 
loss of effi cacy (n=2), poor tolerability (n=3), and noncompliance (n=2); 
1 patient discontinued due to both poor tolerability and noncompliance.

Figure 4. 6-Month Disposition of APR-Treated Patients 

270 patients with moderate 
psoriasis with ≥1 visit within 
the 6-month follow-up period

200 patients were taking
other therapies

70 patients were
taking APR  

6 discontinued APR 64 continuing APR 3 new to APR

67 patients currently
taking APR

• 1 patient switched from
biologic + topical steroid

• 2 patients added APR
to topical

• Demographic and clinical characteristics of the patients receiving primary 
treatment with APR included in the current prospective chart review are 
summarized in Table 1.

• Patients given APR had been treated by the responding dermatologists for 
a mean of 24.8 months, with offi ce visits occurring at a mean of every 
2.8 months.

Table 1. Demographic and Clinical Characteristics Among Patients 
With Moderate Psoriasis Receiving APR as Primary Treatment

Characteristic

Patients With Moderate Psoriasis Receiving APR 
as Primary Treatment* 

n=65

Age, mean (range), years 47.3 (20–75)

Male, % 45

Weight, mean (range), lb. 163.7 (130–245)

Race, %

White 92

Hispanic 3

African American 3

Asian 2

Employed full-time, % 62

Any comorbidity, % 57

Comorbidities in >5% of patients, %

Hypertension 23

Obesity 9

Dyslipidemia 19

Diabetes§ 8

PsA 9

Depression 6

*Primary therapy as defi ned by the surveyed dermatologist. §Includes type 2 diabetes mellitus.

RESULTS (cont’d)
Clinical Effectiveness of APR Treatment for Moderate Psoriasis
• In patients receiving APR as their primary therapy, mean BSA changed from 

9.9% at initial chart review to 4.9% at the 6-month chart review (Figure 5).

Figure 5. Change in BSA at 6 Months With APR Treatment

12

10

8

Ps
or

ia
si

s-
Af

fe
ct

ed
 B

SA
 (%

)

6

4

2

0
Initial Chart Review 6-Month Chart Review

9.9

4.9

• Of patients receiving APR as their primary therapy, 54% were rated as having 
mild psoriasis at the 6-month chart review, marking a shift for these patients 
from moderate psoriasis at baseline (Figure 6).

Figure 6. Disease Severity at 6 Months, Among Patients With Moderate 
Psoriasis Treated With APR

Mild

NOTE: 100% of patients
were considered to have
moderate disease severity
at baseline

Moderate
Severe

5%

54%
42%

Data shown refl ect dermatologist (n=150) response to question: What would you consider to be this patient’s current disease 
severity level?
Note: Percentages shown may not add to 100 because of rounding.

• At the 6-month chart review, 65% of patients receiving APR as primary therapy 
were rated by dermatologists as having shown at least some improvement; 
17% were rated as having shown signifi cant improvement (Figure 7).

• When asked about their clinical experience with APR, 68% of dermatologists 
stated that APR exceeded or met their expectations.

RESULTS (cont’d)

Figure 7. Dermatologist Assessment of Condition Change at 6 Months 
in Patients Treated With APR 

Seen significant improvement

Seen moderate improvement

Seen some improvement

Been stable

Deteriorated

17%
34%

31%

17%

2%

Data shown refl ect dermatologist (n=150) response to the question: How has this patient’s condition changed over the past 6 months?
Note: Percentages shown may not add to 100 because of rounding.

Side Effects With APR Reported During the 6-Month Chart Review Period
• Among patients with available safety information, 8/66 (12%) reported 

side effects during treatment; these included diarrhea (n=5), nausea (n=3), 
abdominal pain (n=3), and headache (n=1).

 – All side effects were considered mild, except 1 case of diarrhea that was 
considered moderate; 2 patients took loperamide to manage diarrhea.

• On average, side effects resolved within 2 weeks, with the exception of 
abdominal pain, which persisted for an average of 7 weeks. 

• 1 patient temporarily discontinued APR because of diarrhea but was re-initiated 
and continued on treatment. 

CONCLUSIONS 
• In the real-world clinical setting, widely varying BSA cutoff values to identify 

moderate psoriasis reveal a lack of consensus surrounding the defi nition of 
moderate psoriasis among US dermatologists.

• Based on patient chart review, APR is well tolerated and effective for treatment 
of moderate psoriasis. 

REFERENCES
1. Armstrong AW, et al. JAMA Dermatol. 2013;149:1180-1185.
2. Lebwohl MG, et al. J Am Acad Dermatol. 2014;70:871-881.

3. Otezla [package insert]. Summit, NJ: Celgene Corporation; 
June 2017.

ACKNOWLEDGMENT
The authors acknowledge fi nancial support for this study from Celgene Corporation. The authors received editorial support in the 
preparation of this report from Amy Shaberman, PhD, of Peloton Advantage, LLC, Parsippany, NJ, USA, funded by Celgene Corporation, 
Summit, NJ, USA. The authors, however, directed and are fully responsible for all content and editorial decisions for this poster.

CORRESPONDENCE
Melissa L. F. Knuckles – mlfk@aol.com

DISCLOSURES
MLFK: AbbVie, Allergan, Amgen, Celgene Corporation, Eli Lilly, Galderma, Novartis, and Sun Pharma – advisory board member, 
consultant, and/or speaker. AbbVie, Amgen, Bayer, Biogen, Crown Labs, Eli Lilly, Johnson and Johnson, LEO Pharma, and 
Medimetriks – investigator. EL: Celgene Corporation – employment. JS: AbbVie, Allergan, Amgen, Celgene Corporation, Eli Lilly, 
Genentech, Genzum, Janssen, Kadmon, Merz, Pfi zer, and Regeneron – advisory board member, investigator, and/or speaker. 

Presented at: the 2017 Fall Clinical Dermatology Conference; October 12–15, 2017; Las Vegas, NV.

Defi ning and Treating Moderate Plaque Psoriasis in a Real-World Clinical Setting: A Dermatologist Survey and Prospective 
6-Month Chart Review of Patients Treated With Apremilast
Melissa L. F. Knuckles, MD, PSC1; Eugenia Levi, PharmD2; Jennifer Soung, MD3
1Melissa L. F. Knuckles, M.D., P.S.C. Dermatology, Richmond, KY; 2Celgene Corporation, Summit, NJ; 3Southern California Dermatology, Santa Ana, CA


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