Interview Transcript - General Practitioner #2
Date: October 20, 2025
Interviewee Type: HCP (General Practitioner)
Location: Urban Community Health Clinic, Detroit, MI
Years in Practice: 10 years
Specialty: Family Medicine
Psoriasis Patient Volume: ~35 patients with psoriasis

Interview Content:

Interviewer: Thank you for speaking with us. Can you describe your practice setting?

HCP: I work at a federally qualified health center in Detroit. We serve a primarily low-income, uninsured or underinsured population. About 60% of my patients have Medicaid, 20% are uninsured, and 20% have some form of commercial insurance. I see all ages and all conditions - it's true primary care. "Psoriasis is definitely something I see, but it's not the most common skin condition. I probably have 35 patients with psoriasis of varying severity."

Interviewer: How do you typically manage psoriasis in this population?

HCP: With a lot of creativity and pragmatism. My first-line is always generic topical steroids - triamcinolone, clobetasol. I'll add moisturizers, coal tar products if patients can tolerate the smell. "For patients who don't respond to topicals, I should refer to dermatology, but access is a huge issue. The closest dermatologist who takes Medicaid has a 4-month wait. For uninsured patients, there's a free clinic, but that's a 6-month wait." So sometimes I end up managing moderate psoriasis myself out of necessity.

Interviewer: What systemic therapies do you use?

HCP: I've used methotrexate for about 10-15 patients over the years. It's cheap - about $20-30 a month for generic - and I'm familiar with it from managing rheumatoid arthritis patients. The efficacy is hit or miss. Maybe half of my patients get significant improvement, the other half see minimal benefit. "The side effects are rough - nausea, fatigue, mouth sores. I always prescribe folic acid to help with that. And I'm vigilant about liver monitoring because in this population, many patients have hepatitis C or alcohol use disorder."

Interviewer: Have you prescribed biologics?

HCP: Never. Biologics are completely out of reach for my patient population. "The list price is $70,000-80,000 a year. Even with copay assistance programs, which my Medicaid patients don't qualify for, it's not accessible." And honestly, I wouldn't feel comfortable managing biologics. I don't have the training, and I don't have the support staff to do the prior authorizations and monitoring. It's just not feasible in my setting.

Interviewer: Do any of your patients get referred to dermatology and end up on biologics?

HCP: Very few. I refer maybe 5-10 patients a year to dermatology. Of those, maybe 2-3 actually make the appointment - the rest are lost to follow-up, can't afford the copay, or can't get time off work. "Of the ones who do see dermatology, I think only one or two have ever been started on a biologic. The barriers are just too high - insurance denials, cost, complexity of administration."

Interviewer: What are the biggest barriers to psoriasis treatment in your population?

HCP: Cost, access, and health literacy. Cost is obvious - my patients are living paycheck to paycheck. A $50 copay for a specialist is a dealbreaker for many. Access - long wait times, limited transportation, taking time off work. "And health literacy - many of my patients don't understand that psoriasis is a chronic condition that requires ongoing treatment. They think, 'I'll use this cream for a week and it'll go away.' When it doesn't, they get frustrated and stop treatment."

Interviewer: How do you educate patients about psoriasis?

HCP: I keep it simple. "I explain that psoriasis is an immune system problem that causes skin cells to grow too fast. It's not contagious, it's not your fault, and it's treatable but not curable." I show them pictures of what their skin could look like with treatment to give them hope. I emphasize that they need to use their creams consistently, not just when they're flaring.

Interviewer: Do you screen for psoriasis comorbidities?

HCP: Yes, definitely. Psoriasis is associated with obesity, diabetes, hypertension, cardiovascular disease - all of which are already highly prevalent in my patient population. "I make sure my psoriasis patients get annual blood pressure checks, lipid panels, diabetes screening. I ask about joint pain because psoriatic arthritis is common." If I find these comorbidities, I treat them aggressively because they're probably at higher risk than the general population.

Interviewer: Have you heard of Dermovia?

HCP: No, I haven't. Is that a new psoriasis medication?

Interviewer: Yes, it's a biologic that's been on the market for about 18 months. It's an IL-17 inhibitor dosed every 12 weeks.

HCP: Okay. Honestly, I don't keep up with new biologics because they're not relevant to my practice. "My patients can't access them, and I don't prescribe them. If I have a patient who needs that level of treatment, I refer to dermatology and let them handle it." I focus my continuing education on things that directly impact my day-to-day practice - hypertension guidelines, diabetes management, substance use disorder treatment.

Interviewer: If biologics became more affordable or accessible, would you consider prescribing them?

HCP: Maybe, but I'd need a lot of support. I'd need training on how to choose the right biologic, how to dose it, what labs to monitor, what side effects to watch for. "I'd need protocols that are clear and evidence-based. And I'd need specialist backup - someone I could call or email with questions." Community health centers are chronically understaffed. Adding another complex medication class to my plate would require resources we don't have.

Interviewer: What about oral medications like apremilast or deucravacitinib? Are those more feasible?

HCP: Potentially. Oral medications are less intimidating than injectables. But cost is still an issue. "I looked up apremilast once for a patient - it's like $4,000-5,000 a month. That's not happening for my population without serious patient assistance." If there were generic oral psoriasis drugs that were affordable, I'd definitely consider using them.

Interviewer: What role does phototherapy play in your practice?

HCP: I don't have access to phototherapy in my clinic. Some of the hospital-based dermatology clinics offer it, but again, patients have to be able to get there 2-3 times a week, which is a huge barrier for working patients or those without reliable transportation. "I've had maybe one or two patients successfully complete a course of phototherapy. For most, it's just not practical."

Interviewer: How do you manage patients who are frustrated with their psoriasis treatment?

HCP: I validate their frustration. "I say, 'I know this is incredibly frustrating. You're dealing with a chronic condition that affects how you look and feel, and the treatment options we have access to are limited.'" I try to set realistic expectations - we might not get your skin completely clear, but we can make it better. I emphasize consistency with topicals and lifestyle modifications like weight loss, stress reduction, and avoiding alcohol.

Interviewer: Do lifestyle modifications help?

HCP: They can, but the impact varies. Weight loss can definitely help - obesity is associated with worse psoriasis and lower response to treatment. Reducing alcohol and smoking can help. "Stress reduction is huge, but easier said than done. My patients are dealing with financial stress, housing insecurity, food insecurity. Telling them to 'reduce stress' can feel tone-deaf." I try to connect them with social services, mental health support, anything that might help with the underlying stressors.

Interviewer: Have you seen patients whose psoriasis significantly impacts their mental health?

HCP: Absolutely. Psoriasis can be devastating psychologically. "I've had patients who won't go out in public, who won't date, who avoid family gatherings because they're so self-conscious about their skin. I screen for depression and anxiety in all my psoriasis patients." If they're struggling, I'll start them on an antidepressant or refer to behavioral health. Sometimes treating the depression improves their psoriasis indirectly because they're more motivated to use their treatments consistently.

Interviewer: Do you collaborate with dermatologists on any of your patients?

HCP: Not as much as I'd like. The dermatologists in this area are overwhelmed, and communication can be challenging. "I'll send a referral and might get a consultation note back 3-4 months later. If I have an urgent question, I can try calling, but it's hard to reach them." An ideal system would have embedded dermatology support - like a dermatologist who consults on complex cases via telemedicine or comes to the clinic once a month. That doesn't exist in my setting.

Interviewer: Have you used telemedicine for dermatology consultations?

HCP: There's a teledermatology service we can use for certain conditions, but it's more for things like rashes, suspicious moles, acne. For psoriasis management, especially if systemic therapy is needed, they usually recommend in-person dermatology, which brings us back to the access problem. "Telemedicine is helpful for some things, but it doesn't solve the fundamental access and cost barriers."

Interviewer: What would improve psoriasis care for your patient population?

HCP: A few things. First, more affordable medications. Generic topicals help, but for moderate-to-severe psoriasis, we need effective systemic options that don't cost $80,000 a year. Second, better access to dermatology - shorter wait times, more providers who accept Medicaid. "Third, embedded specialist support for primary care. If I had a dermatologist I could easily consult with, I'd feel more confident managing moderate psoriasis myself. Fourth, addressing social determinants of health - housing, food security, transportation - because those impact patients' ability to engage in treatment."

Interviewer: Have you had any success stories with psoriasis treatment?

HCP: Yes, a few. I have a patient, a 38-year-old man with moderate plaque psoriasis. "We tried multiple topicals with minimal success, then I started him on methotrexate. Within three months, his skin was maybe 60-70% improved. Not perfect, but life-changing for him. He told me he felt confident enough to start dating again." Those moments remind me why I do this work, even when the resources are limited.

Interviewer: What about patients who don't respond to anything you try?

HCP: That's really hard. I've had patients where I've exhausted my options - tried multiple topicals, tried methotrexate, referred to dermatology but they couldn't get in or couldn't afford it. "At that point, all I can do is keep supporting them, keep advocating for access, keep trying to connect them with resources. It's frustrating because I know there are treatments that would work, but they're out of reach."

Interviewer: How do you handle the emotional toll of those situations?

HCP: It's difficult. Primary care in an underserved community is deeply rewarding but also emotionally exhausting. "You see people suffering from conditions that are treatable, but the system fails them. I try to focus on what I can control - providing compassionate care, advocating for my patients, connecting them with resources." I also lean on my colleagues for support. We debrief difficult cases, share resources, remind each other that we're doing the best we can with what we have.

Interviewer: Do you think primary care physicians should be trained to prescribe biologics?

HCP: I think it depends on the setting. In resource-rich settings with support staff, protocols, and specialist backup, maybe. "In community health centers like mine, I think the focus should be on improving access to dermatologists and making effective treatments more affordable. I don't think the solution is to push more complex medication management onto already overwhelmed primary care physicians." We need systemic changes, not just shifting responsibility.

Interviewer: What's your impression of the pharmaceutical industry's role in psoriasis treatment?

HCP: Mixed feelings. On one hand, the pharmaceutical industry has developed incredible medications that can transform lives. On the other hand, the pricing is obscene. "$80,000 a year for a biologic that costs a fraction of that to manufacture is unconscionable. The patient assistance programs are Band-Aids that don't address the fundamental problem." I'd like to see more investment in developing affordable treatments and making existing treatments accessible to everyone, not just those with good insurance.

Interviewer: If you could change one thing about psoriasis care, what would it be?

HCP: Make effective treatments affordable and accessible to everyone. "Psoriasis is a treatable condition. We have the medications. But they're priced out of reach for the majority of my patients. That's not a medical problem, it's a policy and economic problem." If we solved that, we could dramatically improve quality of life for millions of people with psoriasis.

Interviewer: Any final thoughts on managing psoriasis in primary care?

HCP: Just that primary care physicians are doing the best we can with limited resources. "We're managing complex, chronic conditions across multiple organ systems in patients with significant social and economic barriers. Psoriasis is one of many conditions we juggle." I appreciate specialist expertise, and I wish we had better collaboration and communication between primary care and dermatology. But ultimately, the system needs to change to support both primary care physicians and patients in accessing the care they need.

Interviewer: Thank you so much for your time and candid insights.

HCP: You're welcome. I hope this sheds light on the realities of primary care in underserved communities.