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underdiagnosed because of a failure to connect skin and joint symptoms; however, dermatologists indicated they did not always discuss the possibility of PsA with psoriasis patients. According to dermatologists, 20.0% of their psoriasis patients complained of joint symptoms, which is lower than the 44% of psoriasis patients in the MAPP survey who indicated joint pain.8 In addition, 16% and 26% of patients with psoriasis alone reported symptoms possibly resembling enthesitis and dactylitis respectively.8 According to dermatologists, only 33.0% of psoriasis patients complaining of joint pain had a confirmed diagnosis of PsA. Consistent with previous reports,14 this may indicate that patients are not being fully assessed and diagnosed with PsA despite the presence of joint symptoms, although joint pain may be attributable to a number of conditions other than PsA. Dermatologists most often cited differentiating PsA from other rheumatologic or musculoskeletal diseases as the greatest challenge in managing PsA, whereas rheumatologists most often cited delayed referral. Educating dermatologists on the importance of discussing symptoms of pain, such as joint, back or foot pain, with psoriasis patients and when to refer patients to a rheumatologist may be helpful in increasing PsA identification. The current findings further indicate that many patients with moderate-to-severe disease may be undertreated, especially in the dermatology setting.15 Only 39.1% of dermatologists reported their moderate-to-severe psoriasis patients were receiving conventional oral (19.5%) or biologic (19.6%) therapy, and 54% indicated they would prescribe topical therapies as monotherapy for their moderate-to-severe psoriasis patients. Treatment rates in PsA patients were higher, with approximately 65% of dermatologists reporting conventional oral (35.2%) or biologic (30.6%) use. The main reasons for not initiating or maintaining these therapies were related to concerns about long-term safety, tolerability and efficacy, as well as costs (biologics). In addition, physician responses indicate that the most burdensome aspects of biologic therapy were related to the time requirements for patient education and management and prior authorization requirements. Dermatologists and rheumatologists reported higher treatment rates compared with patients surveyed in MAPP.8 This may be due to the fact that patients could participate in the MAPP survey whether or not they were under the care of a physician, and may not have been treated because they were not seeing a physician for their disease. Challenges related to current therapies also may impact treatment rates. Many dermatologists and rheumatologists felt that the management of psoriasis and PsA was complicated, time-consuming and challenging. Approximately half of the dermatologists and one quarter of the rheumatologists felt that patients leaving their practice because of frustration or dissatisfaction with current therapies was an important issue. In the patient survey, many patients cited not seeing an HCP in the past 12 months because they did not think the HCP could help, and because of frustration, low expectations, and/or dissatisfaction with current therapies.8 Furthermore, dermatologists and rheumatologists often perceive the management of PsA as challenging. Patients are typically seen by multiple HCPs, and psoriasis and PsA are associated with a number of comorbidities that can make treatment more complex.

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