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| Interview Transcript - General Practitioner #3 | |
| Date: October 20, 2025 | |
| Interviewee Type: HCP (General Practitioner) | |
| Location: Military Medical Center, San Antonio, TX | |
| Years in Practice: 14 years | |
| Specialty: Family Medicine | |
| Psoriasis Patient Volume: ~65 active duty and veteran patients with psoriasis | |
| Interview Content: | |
| Interviewer: Thank you for your time. Can you describe your practice setting? | |
| HCP: I'm a family medicine physician at a military treatment facility. I see active duty service members, military retirees, and their family members. My practice is a mix of routine primary care - physicals, chronic disease management - and deployment-related issues - PTSD, traumatic injuries, environmental exposures. "Psoriasis is fairly common in my population. I'd estimate I have about 65 patients with psoriasis, ranging from mild to severe." | |
| Interviewer: How does managing psoriasis in a military population differ from civilian practice? | |
| HCP: A few key differences. First, active duty service members with moderate-to-severe psoriasis can face fitness-for-duty questions. Severe psoriasis can be disqualifying for certain deployments or job assignments. "Second, military healthcare has its own formulary and referral system. We have good access to dermatology on base, usually within 2-4 weeks. Third, cost isn't a barrier the way it is in civilian practice - TRICARE covers most treatments, including biologics, without significant out-of-pocket costs." | |
| Interviewer: How do you decide when to refer to dermatology? | |
| HCP: My threshold is pretty low. If a patient has more than 5% body surface area involvement, if topicals aren't working after 4-6 weeks, or if the psoriasis is affecting job performance or quality of life, I refer. "For active duty members, I'm especially proactive because uncontrolled psoriasis can affect their career. If a pilot has severe hand psoriasis that affects their grip, or a Marine has foot psoriasis that prevents them from wearing boots, that's a mission readiness issue." | |
| Interviewer: Have you prescribed biologics yourself? | |
| HCP: No, I leave biologic management to dermatology. But I'm very involved in coordinating care - making sure patients get their labs done, monitoring for side effects, managing intercurrent infections. "I have probably 15-20 patients on biologics for psoriasis, prescribed by dermatology. I see them regularly for primary care, so I'm part of the team." | |
| Interviewer: What biologics do you see dermatology prescribing most often? | |
| HCP: It varies. I've seen patients on adalimumab, ixekizumab, secukinumab, risankizumab, guselkumab. "I've definitely seen Dermovia prescriptions in the past year - maybe 5-6 of my patients are on it. The quarterly dosing seems appealing for active duty members who might deploy or go on temporary duty assignments." | |
| Interviewer: Can you tell me more about how Dermovia fits into military healthcare? | |
| HCP: Dermovia is on the TRICARE formulary, which means it's covered without prior authorization for most patients. "That's a huge advantage over civilian insurance, where prior auth can take weeks. Our dermatology department can prescribe Dermovia, and the patient can pick it up from the base pharmacy or have it delivered, usually within a few days." For active duty members, self-administration can be an issue if they're in field training or deployed, so the quarterly dosing helps minimize that concern. | |
| Interviewer: Do patients self-inject or come to the clinic? | |
| HCP: It's mixed. For active duty members who are stateside and not deploying, most self-inject at home. "For those who are about to deploy or who prefer clinic administration, we can do it at the base clinic. The quarterly schedule makes clinic administration much more feasible." I've had patients come in for their Dermovia injection right before a 6-month deployment, which gives them coverage for half their deployment. | |
| Interviewer: What happens if a patient runs out of medication while deployed? | |
| HCP: That's a real concern. Depending on where they're deployed, they may or may not have access to their biologic. "For shorter deployments - 3-4 months - and with quarterly dosing, we can often time it so they get their injection right before they leave and right after they return. For longer deployments - 9-12 months - it's trickier." Some deployed locations have pharmacy support for biologics, others don't. In those cases, patients might have to interrupt treatment, which can lead to flare-ups. | |
| Interviewer: How do flare-ups during deployment get managed? | |
| HCP: Usually with topicals and sometimes oral steroids if needed. "I've had patients email me from deployment saying their psoriasis is flaring. I'll prescribe clobetasol or triamcinolone, which the deployed pharmacy can usually provide. If it's severe, they might get sent back to a larger base with dermatology support." It's not ideal, but we make it work. | |
| Interviewer: Does psoriasis ever lead to medical discharge? | |
| HCP: Rarely, but it can. If psoriasis is severe, refractory to treatment, and interferes with job performance or deployment readiness, it can be grounds for a medical evaluation board. "I've seen maybe two cases in my career where psoriasis was a contributing factor to medical separation. Usually, we can manage it well enough to keep service members on active duty." | |
| Interviewer: What about the mental health impact of psoriasis in military populations? | |
| HCP: It's significant. Military culture is very appearance-focused - uniform standards, physical fitness, being mission-ready. "Having visible psoriasis can be stigmatizing. I've had young Marines who are self-conscious about their plaques, worried about being seen as 'weak' or 'defective.'" I screen all my psoriasis patients for depression and anxiety. If I identify mental health concerns, I refer to behavioral health or prescribe antidepressants if appropriate. | |
| Interviewer: How effective have biologics been for your patients? | |
| HCP: Very effective. I've seen dramatic transformations. "One of my patients, an Army sergeant, had severe plaque psoriasis covering 40% of his body. Dermatology started him on a biologic - I think it was ixekizumab - and within four months, he was 95% clear. He went from being on a medical profile to being fully deployable." Another patient on Dermovia had similar results - went from moderate-severe psoriasis to almost completely clear in about three months. | |
| Interviewer: Have you seen any serious side effects with biologics? | |
| HCP: A few. I've had one patient develop pneumonia while on a biologic, requiring hospitalization. Another had recurrent upper respiratory infections - like five or six colds in one winter. "We worked with dermatology to decide whether the infection risk outweighed the benefit. In that case, we switched to a different biologic with a different mechanism, and the infections decreased." I've also seen candida infections - oral thrush, one case of esophageal candidiasis that required hospitalization. | |
| Interviewer: How do you counsel patients about infection risk with biologics? | |
| HCP: I'm very upfront. "I explain, 'This medication suppresses part of your immune system to control your psoriasis. That means you're at higher risk for infections - colds, flu, thrush, possibly more serious infections like pneumonia. You need to practice good hygiene, avoid sick contacts, and call us immediately if you develop fever, severe cough, or other concerning symptoms.'" Most patients accept that risk for clear skin, but it's important they understand. | |
| Interviewer: Do you vaccinate patients before starting biologics? | |
| HCP: That's usually handled by dermatology, but I double-check vaccination status. Military members generally have good vaccine coverage - we're required to get annual flu shots, and most have been vaccinated against a range of diseases for deployment readiness. "I make sure they're up to date on pneumonia vaccine, shingles vaccine if they're over 50, COVID vaccine. We avoid live vaccines once they're on the biologic." | |
| Interviewer: What about screening for latent infections before starting biologics? | |
| HCP: Yes, we screen for TB, hepatitis B, and hepatitis C. Military members may have been exposed to TB during overseas deployments, so that's important. "If we find latent TB, we treat it before starting the biologic. If we find active hepatitis, we get infectious disease involved to make sure it's controlled before immunosuppression." | |
| Interviewer: How do you monitor patients on biologics long-term? | |
| HCP: Dermatology sets the schedule - usually every 3-6 months. But I see patients more frequently for primary care, so I'm checking in on their psoriasis at those visits too. "I ask, 'How's your skin? Any new symptoms? Any infections?' I review their recent labs - CBC, CMP - and make sure there are no concerning trends." If I see something worrisome, I notify dermatology immediately. | |
| Interviewer: What's the typical duration of biologic treatment in your population? | |
| HCP: It varies. Some patients have been on the same biologic for years with maintained response. Others lose response after 12-18 months and switch to a different biologic. "Active duty members who separate from military service have to transition their care to the VA or civilian healthcare, which can disrupt treatment. That's always a concern - will the VA cover the same biologic? Will there be a lapse in treatment during the transition?" | |
| Interviewer: How well does the transition from military to VA healthcare work for psoriasis patients? | |
| HCP: It depends. The VA is generally good about covering biologics, but the specific formulary might be different. "I've had patients on Dermovia while active duty who transitioned to the VA and had to switch to a different IL-17 inhibitor because Dermovia wasn't on the VA formulary at that facility. Any time you switch biologics, there's a risk of loss of efficacy or new side effects." I try to facilitate warm handoffs - send comprehensive records, talk to the VA provider if possible. | |
| Interviewer: Do you see differences in psoriasis treatment response based on deployment history or service-related factors? | |
| HCP: That's an interesting question. I haven't noticed systematic differences, but I do think stress plays a role. "Service members dealing with PTSD, combat exposure, or high operational tempo tend to have worse psoriasis, possibly because stress is a known trigger. Treating the underlying PTSD or anxiety sometimes helps the psoriasis indirectly." There's definitely a mind-body connection. | |
| Interviewer: How does psoriasis intersect with other military-specific health issues? | |
| HCP: Psoriasis is associated with metabolic syndrome, and unfortunately, military retirees have high rates of obesity, diabetes, and cardiovascular disease. "I'm vigilant about screening my psoriasis patients for these comorbidities and treating them aggressively. A 50-year-old retiree with psoriasis, obesity, and prediabetes is at very high cardiovascular risk." I also see overlap with musculoskeletal issues - psoriatic arthritis is common, and distinguishing it from deployment-related joint injuries can be challenging. | |
| Interviewer: What role does primary care play in psoriatic arthritis management? | |
| HCP: I'm usually the first to suspect it. If a patient with psoriasis develops joint pain, stiffness, swelling, I'll order X-rays and inflammatory markers and refer to rheumatology. "Psoriatic arthritis can be really debilitating, especially for active duty members whose jobs are physically demanding. Early diagnosis and treatment are critical." The biologics used for psoriasis often work for psoriatic arthritis too, which is convenient. | |
| Interviewer: How do you educate patients about the chronic nature of psoriasis? | |
| HCP: I explain that psoriasis is a lifelong condition that requires ongoing management, similar to diabetes or hypertension. "I say, 'With the right treatment, you can have clear skin and a normal quality of life. But this isn't something you treat for a few months and then stop. You'll need to stay on treatment long-term to maintain your results.'" Most military members are used to following treatment plans and taking medications, so adherence is generally good. | |
| Interviewer: Have you seen patients try to stop their biologic after achieving clearance? | |
| HCP: Yes, occasionally. Usually it's because they're concerned about long-term side effects or they just don't like the idea of being on a medication indefinitely. "I counsel them that stopping will likely lead to relapse within weeks to months. If they still want to try, we do a trial off medication and monitor closely. More often than not, they relapse and we restart." It's a learning experience. | |
| Interviewer: What are your thoughts on the current state of psoriasis treatment? | |
| HCP: I think we're in a great place scientifically. The biologics are incredibly effective - we can get most patients to 80-90% clearance or better. "The advantage in military healthcare is that access and cost aren't the barriers they are in civilian practice. Our patients can generally get the medications they need without fighting insurance companies." The challenge is managing patients through transitions - deployments, separations from service - and addressing the psychosocial impact of the disease. | |
| Interviewer: How familiar are you with Dermovia specifically? | |
| HCP: I know it's an IL-17 inhibitor, dosed every 12 weeks, relatively new on the market. I've seen good results in the handful of patients I have on it. "The quarterly dosing is nice for active duty members. The efficacy seems solid - I've seen patients go from moderate-severe psoriasis to clear or near-clear." I trust our dermatology team to choose the right biologic for each patient, so I don't get too deep into the specifics of why they pick one over another. | |
| Interviewer: Would you recommend Dermovia to a colleague? | |
| HCP: I'd recommend that colleagues work with dermatology to determine the best biologic for each patient. Dermovia seems like a good option, especially for patients who value less frequent dosing. "But I'm not a dermatologist, so I wouldn't presume to say it's better or worse than other biologics. My role is to support the patient and coordinate with specialists." In military medicine, we have the luxury of good specialist access, so we should use it. | |
| Interviewer: Any final thoughts on psoriasis management in military healthcare? | |
| HCP: Just that military healthcare has advantages - good insurance coverage, timely specialist access, comprehensive pharmacy support - but it also has unique challenges like deployments and transitions out of service. "Primary care physicians in the military need to be aware of psoriasis as a condition that can affect readiness and mental health. We should screen for comorbidities, facilitate specialist care, and support patients through the complexities of military life." Psoriasis is treatable, and our service members deserve the best care we can provide. | |
| Interviewer: Thank you for your time and insights. | |
| HCP: You're welcome. I hope this perspective from military medicine is valuable. | |