Patient Perspectives on Unmet Needs in Topical Psoriasis Therapy 

Despite the advantages of topical treatment, nonadherence (including overuse and underuse) affects up to 50% of patients, and therapy overuse is often incited by the desire for rapid clearance, ineffectiveness, and unclear instructions.^1-3 Unfortunately, topical corticosteroid overuse increases risk of steroid-related adverse events (AEs).^4,5 Conversely, reasons for topical therapy underuse include ineffectiveness, time-consuming treatment regimens, fear or occurrence of side effects, and undesirable formulations.¹ Patients may also become dissatisfied when skin clearance doesn’t occur as expected or when psoriasis returns after stopping treatment.⁶

Understanding how patient characteristics, experiences, and preferences influence adherence and satisfaction can help develop safer and more effective treatment plans.^1,7 This study presents the results of an online survey developed by Bausch Health Companies Inc (Bridgewater, NJ) and disseminated via the National Psoriasis Foundation MyStudies e-newsletter. The survey included 28 multiple-choice and open-ended questions about the duration of psoriasis treatment, the types of treatment and number of prescription topicals used, treatment satisfaction, and experiences with flaring and recurrent lesions. Participation was optional, and all respondents consented to participation.

Results

A total of 362 participants completed the online survey. Most were White (85.1%) and aged ≥45 years (74.3%). Participants were heavily treatment experienced, with 82.4% having used ≥3 different topical psoriasis treatments, and 89.2% having used additional therapies alongside topicals in the last 12 months, including oral treatment, biologic treatment, nonprescription treatment, or phototherapy. 

More than half of all participants (55.5%) had lived with psoriasis for ≥16 years, and 35.9% had been using topical psoriasis treatments for ≥16 years. When participants were asked how satisfied they were with their current prescription treatment, their answers were well distributed between 1 (not at all satisfied) and 7 (extremely satisfied; Figure 1).

Of the participants who expressed some level of dissatisfaction or neutrality (1-4, 64.1%), 33.2% did not express dissatisfaction to their provider. Over one-fourth of respondents (27.6%) did not visit their dermatology provider routinely, 15.5% felt uninformed about current treatment options, and 30% to 40% reported not receiving explanations on correct application, possible side effects, and other options when initiating new treatment (Figure 2). 

Nearly half of participants (47.2%) reported experiencing skin thinning or atrophy at some point during treatment (Figure 2). Other side effects included burning or stinging at the application site (42.8%), red or itchy skin (41.4%), skin discoloration (32.3%), and light sensitivity (23.2%). After experiencing a side effect, only 24.6% of participants reached out to their dermatology provider as soon as possible, and 30.6% decreased or discontinued use of their topical treatment without first consulting with a dermatology provider. In response to flares or plaques recurring between dermatology provider visits, 27.3% of participants stated that they continued using treatment beyond the recommended time frame. A substantial proportion of participants also reported that they used leftover topicals from prior prescriptions (21.3%).

When participants were asked to rank aspects of topical therapy from least to most important, 41.2% and 17.1% ranked quick skin clearance and maintenance of skin clearance as the most important factors, respectively (Figure 3A). Additionally, 30.7% and 28.2% of participants ranked “may not be able to completely clear the amount of plaques you have” and “may cause your skin to atrophy or become thin” as “extremely concerning,” respectively (Figure 3B).

Participants also expressed extreme concern about not being able to use the product for the time needed to achieve complete clearance (22.1%). 

Figure 4 consists of lists of representative participant perspectives. 

Discussion

In this survey, 40% of participants were dissatisfied with topical treatments and commonly had side effects such as skin atrophy, burning, or stinging. However, because these issues can arise with any topical therapy and because burning and stinging at baseline may be disease related, clinicians should counsel patients before selecting a treatment. Participants also prioritized efficacy over safety, preferring treatments that work effectively without compromising skin health. To address this, clinicians must find a delicate balance between meeting patient expectations and “doing no harm” regarding skin health. Additionally, nonadherence and misuse were often driven by dissatisfaction with treatment outcomes, highlighting the importance of open communication and careful consideration when selecting topical therapy. 

Combining potent topical corticosteroids with other ingredients can balance efficacy and safety concerns and promote patient satisfaction.^1,2,8 Further, topical therapies without duration-of-use limitations may promote patient adherence and enable continued use until clearance is achieved. For example, a long-term study of one such topical, fixed-combination halobetasol propionate (0.01%) and tazarotene (0.045%) lotion (HP/TAZ), reported periods of remittance in a substantial portion of participants who achieved total skin clearance,⁹ along with manageable side effects and low rates of skin atrophy (0.7%).¹⁰ Additionally, HP/TAZ is more effective than its individual components and is not limited by the prescribing information for duration of use.^11,12 Recent research also suggests that use of a ceramide-containing moisturizer prior to HP/TAZ application may mitigate irritation.¹³ Future topical formulations may incorporate novel active ingredients or delivery systems to further optimize the balance of efficacy, safety, and patient satisfaction.

 Taken together, healthcare professionals should prioritize patient education, provide realistic treatment expectations, and offer combination therapies that balance efficacy and safety concerns to promote satisfaction, adherence, and disease control. 

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2. Fouéré S, Adjadj L, Pawin H. How patients experience psoriasis: results from a European survey. J Eur Acad Dermatol Venereol. 2005;19(suppl 3):2-6.

3. Bewley A, Burrage DM, Ersser SJ, Hansen M, Ward C. Identifying individual psychosocial and adherence support needs in patients with psoriasis: a multinational two-stage qualitative and quantitative study. J Eur Acad Dermatol Venereol. 2014;28(6):763-770.

4. Horn EJ, Domm S, Katz HI, et al. Topical corticosteroids in psoriasis: strategies for improving safety. J Eur Acad Dermatol Venereol. 2010;24(2):119-124.

5. Draelos ZD, Fowler JF, Cornelison R. A randomized, parallel group, open label, multicenter study to assess the potential for adrenal suppression and systemic drug absorption following multiple dosing with clobetasol propionate cream (Impoyz™), 0.025% versus clobetasol propionate (Temovate®). SKIN. 2018;2(6).

6. Florek AG, Wang CJ, Armstrong AW. Treatment preferences and treatment satisfaction among psoriasis patients: a systematic review. Arch Dermatol Res. 2018;310(4):271-319.

7. Engel PV, Smith B, Javadi SS, Wu JJ. It’s Time to Consider a New Topical Algorithm for Psoriasis. J Am Acad Dermatol. 2024;90(2):e84-e85. PMID: 37813190.

8. Elmets CA, Korman NJ, Prater EF, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021;84(2):432-470.

9. Lebwohl MG, Stein Gold L, Del Rosso JQ, Green L, Jacobson A. Posttreatment maintenance of therapeutic effect with fixed-combination halobetasol propionate 0.01%/tazarotene 0.045% lotion for moderate-to-severe plaque psoriasis. J Dermatolog Treat. 2022;33(4):2068-2074.

10. Lebwohl MG, Stein Gold L, Papp K, et al. Long-term safety and efficacy of a fixed-combination halobetasol propionate 0.01%/tazarotene 0.045% lotion in moderate-to-severe plaque psoriasis: phase 3 open-label study. J Eur Acad Dermatol Venereol. 2021;35(5):1152-1160.

11. Kircik LH, Papp KA, Stein Gold L, et al. Assessing the synergistic effect of a fixed combination halobetasol propionate 0.01% and tazarotene 0.045% lotion in moderate-to-severe plaque psoriasis. J Drugs Dermatol. 2019;18(3):279-284.

12. Duobrii [package insert]. Bridgewater, NJ: Bausch Health US, LLC; 2020.

13. Kircik L, Jacobson A. Halobetasol propionate 0.01% and tazarotene 0.045% lotion with a ceramide-containing moisturizer in adults with psoriasis. J Drugs Dermatol. 2024;23(2):50-53.

Ted Lain, MD

• Executive Director, Austin Institute for Clinical Research

Andrea Murina, MD

• Associate Professor of Dermatology, Tulane School of Medicine, New Orleans, LA

Emil Tanghetti, MD

• Dermatologist, Center for Dermatology and Laser Surgery, Sacramento, CA

Abby Jacobson

• Senior Medical Director, Bausch Health Companies Inc, Bridgewater, NJ