This panel discussion featured experts in dermatology from various countries—including Canada, Brazil, Malaysia, and Romania—focusing on the management of psoriasis, particularly the switch from topical to systemic treatments, the availability of biologics and biosimilars, and challenges faced in clinical practice. The panelists agreed that the decision to transition from topical to systemic therapy depends heavily on patient satisfaction, disease severity, and clinical judgment rather than strict scoring systems like PASI or DLQI. The importance of early and effective treatment, especially in younger patients, was highlighted across regions.
Regarding biologics and biosimilars, there was a marked disparity in availability and cost across countries. Canada was portrayed as having wide access to multiple biologics, supported by public and private insurance, while Brazil has more limited options, with regulatory hurdles and pricing issues, especially around biosimilars. Malaysia has access to most biologics but faces budget constraints and specific treatment protocols due to tuberculosis prevalence. Romania, despite being a poorer European country, surprisingly has broad access to biologics but sees limited biosimilar usage. The panel discussed how biosimilars can reduce treatment costs but noted inconsistent pricing and adoption worldwide.
Challenges in psoriasis treatment varied by region; difficulties included managing complex cases, such as those with coexisting eczema, limitations in available mid-range systemic drugs, public health policy constraints, and the cost and availability of advanced treatments. The discussion underscored the global diversity in psoriasis care while identifying shared concerns such as treatment accessibility, cost management, and optimizing patient outcomes.
Highlights
💊 Treatment switch decisions prioritize patient satisfaction and clinical judgment over rigid scoring systems.
🌍 Availability and access to biologics and biosimilars vary significantly between countries and healthcare systems.
💰 Cost and pricing strategies for biosimilars show vast global variability, impacting patient access.
👶 Early aggressive treatment is emphasized for younger patients to prevent long-term life impairment.
🔄 In some countries, mandatory switching to biosimilars has been implemented for cost savings.
🏥 Public healthcare policies and endemic diseases (e.g., tuberculosis) influence biologic treatment protocols.
⚠️ Supply shortages of mid-level systemic therapies pose treatment challenges in some regions.
Key Insights
💡 Patient-Centered Decision-Making is Crucial
Across different regions, the decision to move from topical to systemic therapies is not solely based on objective clinical scores but involves significant patient input. This reflects a more personalized approach to managing psoriasis, acknowledging patient satisfaction as a core metric, emphasizing the importance of shared decision-making in chronic disease management.
🌐 Diverse Healthcare Systems Affect Biologic Availability
Countries exhibit varied levels of access to biologics and biosimilars shaped by healthcare infrastructure, policies, and economic factors. For instance, Canada offers extensive biologic availability supported by both public and private insurance, whereas Brazil’s public sector mandates starting with anti-TNF agents and faces financial and regulatory constraints. This highlights the influence of systemic healthcare structures on therapeutic options.
💵 Cost and Pricing Are Major Barriers, with Biosimilar Variability
Pricing strategies for biosimilars differ substantially worldwide. While some European countries achieve up to 90% price reduction compared to originators, other countries like Brazil and Egypt see minimal biosimilar cost advantages. The panel suggests that price transparency and international benchmarking could pressure healthcare systems to negotiate better biosimilar prices, potentially increasing patient access.
👧 “Hit Hard and Early” Strategy Particularly Important for Young Patients
The emphasis on aggressive early intervention in young patients aligns with current dermatologic thinking aimed at reducing cumulative life impairment caused by chronic psoriasis. Early systemic therapy initiation may limit disease progression and its psychosocial and physical impact, especially in children and teenagers, underscoring the long-term benefits of timely effective treatment.
🔄 Mandatory Biosimilar Switching Can Optimize Healthcare Budgets
Canada, as shared by the panel, has implemented mandatory switching from originator biologics to biosimilars, resulting in widespread biosimilar use. This strategy, while economically beneficial, requires careful management of patient and physician expectations and monitoring for efficacy and safety to ensure clinical outcomes remain stable during the transition.
🌍 Endemic Infectious Disease Influences Biologic Selection
In regions with high tuberculosis prevalence like Malaysia and Brazil, treatment protocols favor skipping anti-TNFs due to infection risks, tailoring therapeutic choices to local epidemiological realities. This illustrates the need to adapt global clinical guidelines to local infectious disease burdens and healthcare practices.
⚠️ Mid-Range Systemic Therapies Facing Supply Issues
Several panelists highlighted shortages in essential systemic psoriasis treatments like acitretin and methotrexate tablets, complicating treatment algorithms by limiting options between topical and biologic therapies. This “missing middle” forces dependency on either less effective topicals or high-cost biologics, posing a challenge for practitioners and patients alike.
The panel discussion thus paints a comprehensive picture of the multifaceted nature of psoriasis management worldwide—from clinical decision-making nuances, through economic and regulatory challenges in biologic use, to the real-world difficulties faced by dermatologists trying to deliver optimal patient care in diverse settings.
Shifting from Topical to Systemic Treatment
Question: What are the most important reasons you would switch a patient from a topical to a systemic treatment?
Mark Lebwohl (Canada): It’s a pleasure to be here. Canada is a very large country with diverse opinions, and we don’t have a national consensus or specific guidelines on when and how to switch a patient from topical to systemic treatment. What’s certain is that it’s not solely based on scores like PASI, DLQI, or BSA. It’s a collaborative decision between the physician and the patient. If the patient is satisfied, then I’m satisfied. However, if there’s still, say, 4% or 5% body surface area involvement, I’ll let the patient know that other options could improve their condition. But ultimately, if they’re happy, we can continue as is. I’ll always keep the door open for potential improvement, even if the patient is currently satisfied.
André Vicente Esteves de Carvalho (Brazil): Brazil is also vast and opinions vary from place to place. However, we do have national guidelines and a consensus published in 2020, with many authors here in the audience. We follow the IPC severity classification, which helps us determine when to move from topical to systemic therapy. I completely agree with Mark; the DLQI and what the patient expresses are the most crucial factors in that decision.
Ee Shye Tunn (Malaysia): Hi everyone, I’m from Malaysia, and we also have psoriasis management guidelines in our country. When asked about switching patients from topical to systemic therapy, it obviously depends on whether the patient is happy with the topical treatment. I’m very ready to switch if they’re not happy. I also tend to switch a bit faster if my patient is young. As we’ve heard several times, it’s important to “hit hard and hit early,” particularly for young patients, because it significantly impacts their quality of life, leading to a huge cumulative life impairment for children and teenagers.
Georgi Tchernev (Romania): Thank you. I’m Georgi Tchernev from Romania, a European country. What I can tell you is that we don’t have national guidelines, but we follow the EADV guidelines. Regarding the question, I think that, of course, we’ll switch when the patient isn’t happy and when we’re not happy. However, I don’t typically “switch” but rather “add” something else. I keep the topical treatment and don’t remove it completely because it can still be beneficial for the patient, even if they’re not entirely satisfied with topicals alone. I believe adding some low-class dermatocorticosteroids or keeping emollients is very beneficial for them.
Availability of Biologics and Biosimilars
Question: Can you tell us a little bit about whether you feel the availability of biologics and biosimilars is sufficient in your country to provide optimal care to patients?
Mark Lebwohl (Canada): I’d be very happy to start. Professor Iversen showed that 12 biological agents are currently approved by the FDA, and we are very lucky in Canada. Our patients are very fortunate that 12 drugs are approved here, and these are covered by either private or public insurance. While it’s not always easy, and sometimes we have to advocate a bit to get the patient on the drug, currently, no Canadian patient will be left untreated with a specific biological agent if we feel it’s indicated. Yes, we have to deal with biosimilars, especially for drugs like adalimumab. However, for drugs like ustekinumab or other newer agents, we can still use the originator medication because there aren’t yet biosimilars for those. I should also mention that infliximab, a very popular drug, was first approved in Canada in December 2008, before the US. We were very proud of that. So, we’re pretty lucky so far in Canada; our patients are very lucky.
Audience Member: Mark, can there be a situation where you might be incentivized to prescribe relatively more anti-TNFs, for example, over an IL-17 or IL-23 inhibitor? I’m just challenging a little bit.
Mark Lebwohl (Canada): Presently, no such thing is happening in Canada. I know it occurs in some other countries, but it’s certainly not happening here at this stage. We do have some private insurers who sometimes suggest offering a particular drug first, but we are not obligated to follow that.
Audience Member: Canada sounds like a dream for me and a lot of Dutch people! It’s minus 30 in the winter months, but I’m happy when I can get that.
André Vicente Esteves de Carvalho (Brazil): From the 12 biologics available globally, we have nine in Brazil. However, until 2018, we had none available for prescription, not even in the private sector. Nowadays, in the public sector, we have to choose an anti-TNF first. We do have some criteria to bypass anti-TNFs, but we generally have to use them if those criteria aren’t met. Regarding biosimilars, rheumatology uses far more biosimilars than dermatology. The problem is that biosimilars are supposed to be at least 30% cheaper than originator drugs, but they aren’t in Brazil. This is an issue. The other thing that happened is when biosimilars became available and started dropping prices, the originator pharmaceutical companies also began lowering their prices. This was beneficial for our patients, and now we are paying less for biologics, thankfully not enough less, but less.
Audience Member: To give the international perspective, there’s extreme variability in the price reduction for biosimilars. Lars and I live in countries where there’s a 90% reduction, and perhaps Italy as well.
André Vicente Esteves de Carvalho (Brazil): Yes, we have some reduction, a consistent and very important reduction, mainly in anti-TNFs. I couldn’t say the exact percentage now, but it’s perhaps $200 per injection of adalimumab, which was much, much more expensive for us previously. For example, in Egypt, the price reduction for biosimilars is only marginal.
Ee Shye Tunn (Malaysia): The IPC has published a few papers about the use of biosimilars throughout the world, and we’ve definitely seen impressive price decreases. However, this is highly variable; in some countries, it’s a 10% decrease, and in others, it’s 90%. What I’m about to say might mean I won’t be invited to speak at conferences, but I have to say it anyway: I think this global variation should be highlighted. I’m quite sure that if healthcare managers or decision-makers saw such high variability, and if, for instance, the President of Brazil saw a 90% price reduction in some European countries, he would say, “We can do it in Brazil as well!” I believe it’s the IPC’s role to showcase this variation, which will eventually lead to a decrease in biosimilar prices. That’s my belief. Thank you very much.
Ee Shye Tunn (Malaysia): In Malaysia, we have all biologics available except for bimekizumab. We don’t have to go through a step-therapy approach; we don’t have to use anti-TNFs first because TB is a significant problem in Malaysia, so it makes sense to skip anti-TNFs if we can. We have two biosimilars in Malaysia, one for infliximab and one for adalimumab, but they haven’t set the price yet, so we haven’t started using them. In Malaysia, we have a very limited budget for biologics. To apply for government funding, you have to have failed all conventional systemic agents first. The choice of biologic then depends on what the practicing dermatologist deems most useful.
Georgi Tchernev (Romania): Romania is a European country, but nobody considers us to have problems because we’re one of the poorer countries. However, we’re full of surprises! For instance, we have all or almost all biologics available, including biosimilars. This is one of the first surprises. If you ask about how we use them and look at the statistics, you’ll find that only 10% of the market is occupied by biosimilars, and the other 90% by bio-originals. This is something surprising, and we probably don’t know the answer yet. But of course, you can think of an intervention, and maybe as Ee Shye Tunn was saying, if someone in a position to make decisions looks at the figures, they might have a second thought, because we can use these drugs and reduce costs. It’s not such a big difference, but it is a difference.
Mark Lebwohl (Canada): If I can just add very quickly, all our patients in Canada who were on either etanercept or adalimumab had to be switched to the biosimilar. That was a mandatory switch. So, we currently have basically no more patients on Humira or Enbrel; they have all been switched to biosimilars. And I anticipate a ustekinumab biosimilar will be available very soon, so there should be a lot of switches from Stelara to the biosimilar as well.
Audience Member: Can you imagine how much an adalimumab biosimilar costs in Italy? One box, two vials, 47 euros—the same price as methotrexate! So, Italy is also a fantastic country; that’s really great.
Biggest Challenges in Treating Psoriasis Patients
Question: If you look at your own practice or your own region, what are the biggest challenges when treating psoriasis patients in your country, your practice, and your region?
Mark Lebwohl (Canada): Thank you very much. Obviously, there are always some challenges. One particular challenge for me is when a patient I treat for psoriasis suddenly starts developing eczematous reactions, or if a patient I treat systemically for eczema starts developing psoriatic lesions. This becomes a problem. I actually have some patients whose psoriasis cleared but then started developing eczema, and they wanted their psoriasis back because they were more symptomatic with the eczematous lesions. I’m sure you’ve seen this in your practice. The challenge for me is finding the right combination treatment for these patients because then the cost becomes very, very high. In my view, the best approach would probably be to have these patients on a biological agent for their psoriasis and probably a JAK inhibitor for their eczema. I think this would be a perfect combination if the price were good; that would be absolutely fantastic. So, we have to work on the cost of these potential combinations.
André Vicente Esteves de Carvalho (Brazil): I’ll talk about Brazil; I can’t speak for the rest of South America. The first challenge, I believe, is trying to change our directives in the public healthcare system. We shouldn’t have to use an anti-TNF anymore, and we should be able to choose whatever we want because tuberculosis is an endemic disease here, similar to Malaysia. The second challenge is poly-failure patients, those with multiple treatment failures. This is something we’re starting to see now; we still have a huge reservoir of naive patients. Another big thing, I think, is the mild patient; they’re a challenge now because we don’t have many excellent topical therapies for mild patients.
Ee Shye Tunn (Malaysia): For me, the cost in Asia is the main challenge. In general, our patients have very minimal access to the newer targeted therapies, so cost is extremely important. If a TNF inhibitor becomes 45 euros, I will use a TNF inhibitor, because we know how to take care of our patients. It’s just that if we have a biologic where we don’t have to worry about TB, we would go for that. But if the cost is so low, it would mean that more patients would have access to a targeted treatment.
Georgi Tchernev (Romania): The question was honest, and I will give an honest answer. Apart from what our colleagues said about costs, I have some problems with “middle-class” drugs, let’s say. We have problems because we are no longer finding acitretin; we have problems because we are no longer finding sorafenib. So, you want to start a patient with systemic therapy, you know you have good drugs, but they are not available. Also, for instance, with methotrexate, you can still get subcutaneous injections, but you don’t have tablets. I don’t know what’s happening; maybe it’s a general conspiracy in the world. But you see that you have to start with topical therapy and then jump to very advanced biologics, but the middle treatments are missing. What is happening? I don’t know.
