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For people with psoriasis, there are no formal guidelines for discontinuing biologics. Still, while the safety of these drugs is well-documented, discontinuation can and should be considered based on cost, risks, and patient preferences.

Writing in an editorial for the , three dermatologists make the case that every treatment plan -- including the choice of biologic and the potential discontinuation of treatment -- should be individualized.

Co-author Steven Feldman, MD, PhD, is a professor of dermatology with Wake Forest University School of Medicine and a dermatologist and skin pathologist with Atrium Health Wake Forest Baptist in North Carolina. Feldman recently discussed the paper with the Reading Room. The exchange has been edited for length and clarity.

What led you and your colleagues to write this editorial?

Feldman: Biologics are revolutionary in the management of psoriasis and other skin diseases. They are so effective that, nowadays, you get people who are completely cleared up and then wonder if they need to continue the medicine.

The standard thinking is that like diabetes and insulin, you have to keep people on the drug or else their disease comes back. But the disease doesn't always come back.

For example, we don't really know how long people could go without dupilumab for their eczema once the eczema clears completely.

Patients may worry about long-term risks of biologics, even though these do seem very safe. And certainly everybody worries about the costs of these treatments. So we wondered, "Do you need to stay on the therapy? Can you stop?" We tried to explore those questions in our editorial.

Do you think the high safety profile of biologics prevents a more robust discussion over when or whether people might discontinue their use?

Feldman: I think just one of the reasons we haven't addressed this sooner is because these drugs are so safe. When they're that safe, there isn't a real compulsion to stop therapy. But because of the costs of the drugs, we should still really want to know if they are still needed.

What was your overarching input for clinicians on all these topics?

Feldman: The bottom line is that we don't know. We don't have enough data to say with any certainty whether a patient on a particular biologic who's completely clear and doing well should spread out their doses or stop entirely.

We have so many options now. If a drug somehow becomes more immunogenic and ineffective in a patient who is doing well and who decides to spread out doses, there are a lot of other drugs that can be used. So now, probably more than ever before, it may be reasonable for patients who want to spread out their doses or try a period off to do so.

Patients don't always do what we tell them as far as continuing the medication after their skin clears. They spread out their doses anyway. So some of this phenomenon is happening in our patients whether we like it or not.

What is the best way to discern patient preferences and work with them to make sure that they're adhering properly?

Feldman: The foundation of all of medical care and the foundation of having good shared decision-making is for the doctor to appear to be trustworthy. What affects the patient's ability to work with you is their perception of you. You want to be -- and to appear to be -- a caring, empathetic, trustworthy person. In this setting, patients will feel comfortable discussing with you their ideas about cutting back on treatment and other issues.

I also think its helpful to be open to what patients want to do with treatment and to have some tactics for discerning how they are actually taking their medication. For example, I would never ask a patient, "Are you taking the medicine regularly every two weeks?" Because they might feel obligated to tell me yes. Instead, I like to ask patients, "Are you refrigerating the extra doses?" They think I'm asking about refrigeration when I'm actually asking whether they're taking all their doses.

The ideally compliant patient will say, "No, I use them exactly the way that I'm supposed to. I don't have any extra." But almost nobody says that.

What are the next steps?

Feldman: We desperately need studies that tell us what would happen to people when they spread out their doses or discontinue therapies when they're doing really well. Such studies are going to be very helpful for our long-term practical advice to patients and hopefully will help reduce the cost of these revolutionary treatments that are so great for our patients.