In this video blog, Michael Hewitt, MD, discusses highlights from his lecture, Treating Psoriasis in Special Populations, on July 27, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.

In this video

In this interview with dermatology PA Butch Anita, Dr. Hewitt outlines his screening approach before starting biologics and small molecules. For hepatitis B he follows the WHO "triple threat" — surface antibody, core antibody, and surface antigen — so he can discern whether a patient is unvaccinated, vaccinated, or carrying an occult, acute, or chronic infection before choosing a mechanism of action. For TB he has moved away from the "good old PPD arm test," which he calls unreliable in psoriatic disease and non-specific, favoring the QuantiFERON-Gold/IGRA and reserving the TB-spot test for indeterminate results and immunocompromised patients.

Throughout, his refrain is that it's fine to have "multiple cooks in the kitchen as long as we're making the same darn thing" — looping in ID, hepatology, or heme-onc so patients with prior hepatitis B, latent malignancy, or breast/prostate cancer history aren't neglected from effective therapy. He notes IL-17 and IL-23 inhibitors have not shown malignancy reactivation out to five to six years of safety data, urges providers to document and share how they handle these cases, and covers vaccination strategy: age-appropriate vaccines, avoiding live vaccines on therapy, and recommending the inactivated zoster vaccine with JAK, TYK2, and some TNF inhibitors.

  • Screen hepatitis B with all three tests — surface antibody, core antibody, and surface antigen — to distinguish vaccinated, occult, acute, and chronic patients before starting a biologic.
  • With a positive hep B result, involve ID or hepatology, choose a mechanism of action least likely to reactivate disease, and use antiviral prophylaxis if a higher-risk agent is unavoidable.
  • Skip the PPD; use QuantiFERON-Gold/IGRA as first-line TB screening and reserve the TB-spot test for indeterminate results and immunocompromised patients.
  • Treat prior malignancy case-by-case with heme-onc onboard — IL-17 and IL-23 agents have shown no reactivation out to five to six years, and providers should document and share their approach.
  • Give age-appropriate vaccines, avoid live vaccines on therapy, and recommend the inactivated zoster vaccine with JAK, TYK2, and some TNF inhibitors.