Transcript
Ted Lain:
Guys, I've got some questions now from our audience. OK? So here we go. How to treat psoriasis of the ear canals? So do you use any of these products in the ear canals and was that part of the trial? I would imagine not, but if you have any pearls for psoriasis of the ear canals.
Zoe Diana Draelos:
Well, I like some of the corticosteroid oils, the otic as I mentioned for that. And there are some products because sometimes the ear canal can harbor fungus and you can actually get seborrheic dermatitis of the ear canal in addition to psoriasis. So I like some of the otic suspensions that contain a corticosteroid. Then they also contain an antifungal and they also contain an antibiotic. So it'd be a combination of neomycin, hydrocortisone, and the drops can be put into the ear at bedtime. And I find that very helpful because I think there's a lot of seboriasis.
Ted Lain:
Yeah, the sebopsoriasis.
Zoe Diana Draelos:
Where you get combination of seborrheic dermatitis. And maybe the inciting factor is Malassezia overgrowth as well. So I think some of the otic suspensions are very good. Neomycin, polymyxin B and then hydrocortisone. Provided your patient is not neomycin sensitive.
Ted Lain:
Right, right. Of course. Firas, any other pearl or tip?
Firas George Hougeir:
No, I use the otic products as well. I tend not to want to put things in people's ears even over the counter as much. We didn't have them in the study. Just because I'm not really a hundred percent sure how they react ultimately with that. They're difficult to treat, but the oils usually do reasonably well for these patients.
Ted Lain:
Yeah. I use a lot of the foams as well in the ears. The foams, when you apply it to a Q-tip and just gently roll it on the inside, that tends to work quite well. Also, and of course we know we have these non-steroidal foams now that are approved for psoriasis and seborrhea. So also another option. But great tips, guys. Now here's a question. I think this is a good question. What do you find helps the most with itching? And what about a regimen for patients with scalp involvement? So let's do the one with itching. What do you find for your psoriasis patients? Is there an OTC product that you really turn to for the itch of psoriasis? Or maybe it's what you did in the trial?
Zoe Diana Draelos:
Well, a lot of itching is due to barrier disruption and exposure of nerve endings. And so repairing the barrier, I think is really key there. One thing I do find helpful though for my psoriatic patients is to take the moisturizing cream and stick it in the refrigerator. And then take it out and put it on cold so you get that contrast and you introduce a new sensation, which is cold, which sometimes will quell the itch. So that's a quick tip that I might share.
Ted Lain:
I love that.
Firas George Hougeir:
We do that with the steroid creams as well. Pretty much any cream you're going to put in, if you put it in the fridge. As Zoe said, again, this extra sensation that gives them a little bit of relief while you're getting them where they need to be.
Ted Lain:
Yeah. For scalp involvement, Firas, in addition to your prescription therapies, any other OTCs that you found have worked very nicely?
Firas George Hougeir:
OTCs for the scalp itself, I tend to recommend shampoos that are very soft on it. Shampoos that are not going to make things worse. I think I try not to make things worse and at the same time as giving treatments that will actually help the disease process itself. I don't have it that I can think of, Zoe may think of something,g that I can think of that at least can help the scalp barrier from a shampoo standpoint.
Ted Lain:
Yeah. Zoe, what do you think?
Zoe Diana Draelos:
Well, I like to rotate shampoos. So some of the creosote removed tar shampoos are good anti-inflammatories, so that's one component of psoriasis. Then a lot of problem is the medication can't get to the scalp because the scaling is so thick. So a salicylic acid shampoo. And then zinc pyrithione is antifungal, and that's a third component that could be inciting. So rotating between a tar shampoo, a salicylic acid shampoo, and a zinc pyrithyine selenium sulfide shampoo. I find that very helpful. You can't combine all those ingredients into one shampoo because the monograph doesn't permit that. But I find if you rotate those, you get rid of the scale, you kill the fungus, and then you reduce inflammation. And so with those three OTC shampoo formulations, I think you can get enhanced results.
Ted Lain:
Yeah. And as I know, Zoe, you're very involved in some of these newer shampoo developments that are available over the counter, sulfate-free and are purposefully formulated to treat the scalp skin like facial skin, to really help prepare the support barrier function of the scalp. And so there are new formulations that can really help support that, as I mentioned, and maybe turn to those as well. Another question here, guys. Did the study evaluate the patient's microbiome? And what do you recommend for restoring the microbiome in psoriasis? I don't know. Firas, did you check the microbiome? I don't think there was any microbiome testing.
Firas George Hougeir:
No.
Ted Lain:
No, no. OK. And Zoe, how do you restore a microbiome in psoriasis patients?
Zoe Diana Draelos:
Well, the microbiome is not necessarily disturbed in psoriasis patients. We don't know of any organism triggers like staph aureus in atopic dermatitis.
However, you could indeed damage the microbiome. A lot of people using these hypochlorous acid kind of sprays and creams and ointments, and that can destroy the microbiome. But the microbiome is really robust. And if you're healthy, the microbiome will repopulate very, very, very quickly. But people talk about putting organisms on the skin, using live bacterial containing probiotics, for example, but only 4% to 16% of those organisms actually colonize the skin. It's very difficult to change the microbiome. And then of course, there's the gut skin axis where changes in the gut can change the microbiome in the skin. But there are a couple of challenges there. One is no one knows what a normal microbiome is. Your microbiome is your microbiome. It's unique to you. And why is that? Because it's governed by your immune system. And where do you get your microbiome? You get your microbiome from your mother when you pass through the birth canal.
So children are fully colonized with a full microbiome, like within 48 hours after birth. And that microbiome changes based on body location, puberty, age, et cetera. But it's really your microbiome that you got from your mom and you keep it for life. And there can be perturbations in it. Like you shake hands with someone who has MRSA and then you pick your nose and all of a sudden you're a MRSA carrier and then you scratch your nose and scratch your skin and now you have infantigenized MRSA. So there are things like that that happen, but really I think the microbiome is very ... Our understanding is very primitive and the microbiome is very deceptive. And I think our treatments for it are somewhat primitive. Every single microbiome modulating drug, bacterial type spray that's gone through phase two and phase three, all of them have failed.
Every single one of them failed. They have not split from placebo. So that tells you we have to really expand our understanding, our approach to the microbiome.
Ted Lain:
Yeah. Unlike atopic dermatitis, psoriatic lesions rarely get infected. And we believe that's true because of the increased load of antimicrobial peptides and beta defenses in the psoriatic plaques. And so whereas microbiome does come into play as Zoe talked about, you can kind of foretell an atopic flare by a dysbiotic slip into a majority of staph aureus, you can't do that with psoriasis. And so perhaps it's one of the inflammatory skin diseases where, again, as Dr. Draelos mentioned, the microbiome doesn't play as huge of a role. And we also know there are ways to support that microbiome and restoring that acid mantle is so important, which is why using something like Cetaphil Gentle skin cleanser, which is pH balanced, will do that. So I hope that answers that question. The final question here, guys, do you mean that the ... I can just see this person kind of fuming.
Do you mean that the use of lactic acid, coal tar, and salicylic acid are not recommended anymore for psoriasis?
Firas George Hougeir:
No. That's how easy we can answer. No, we're not saying that. What we're saying is that these can be in fact irritant to the barrier and can cause more skin barrier dysfunction. However, they are absolutely tools in our armamentarium and we have to use them and we use them the same way we use anything else actually. Zoe mentioned using some of these for the scalp. I think we just have to be aware that skin barrier and the skin health in and of itself, other than psoriasis, plays a role in the successful treatment. So when we use these, being aware of that, we should also be mindful of using OTC products or end products that could also help prepare the skin barrier concomitantly. That's how I would look at it from this study.
Ted Lain:
Yeah. Zoe, anything to add to that?
Zoe Diana Draelos:
Well, lactic acid is really helpful in those hyperkeratotic plaques, especially on feet. So I think you have to be careful where you put it. And so if you have a lot of hyperkeratosis, lactic acid, which is actually a postbiotic, it's a bacterial byproduct. We've been using it for years, so that's really a microbiome derived product, but very, very helpful on hyperkeratotic lesions on the knees, elbows, and feet. Would I use on the face? Absolutely not.
Firas George Hougeir:
No.
Zoe Diana Draelos:
I think the recommendations need to be patient and disease state-specific.
Ted Lain:
Totally agree. Guys, those are the questions. And I think you've done a fabulous job at both covering this wonderful publication as well as so much more. We've really covered the gamut of OTC skincare for psoriasis patients and how this publication, your publication, has really opened eyes and as I mentioned, are … given us lots of practical pearls to take into our clinic tomorrow. So thank you for this very important publication. Thank you for your work on these 46 patients. You only had, I think, four dropouts in the trial, which is unbelievable. And again, the title of this publication is the “Study of Adjuvant Sensitive Skin Cleansing and Moisturizing Regimen in Plaque Psoriasis.” It was published in the Journal of Drugs and Dermatology in July of 2025. I'm a bit embarrassed that I have missed it, but now I'm definitely fully aware of it. Again, my name is Ted Lain.
I'm a dermatologist in Austin. I've been moderating with your two absolute experts, Dr. Zoe Draelos in North Carolina, and of course, Dr. Firas Hougeir who practices in Georgia. Thank you so much for listening. And of course, we'll come back at you with more Practical Derm Roundtables. Thank you.
