PracticalDermatology

Despite recent advances in the systemic treatment of psoriasis, topical agents represent a mainstay treatment for a majority of patients with mild to moderate and even more severe disease. With the growing milieu of available topical agents, physicians and patients are given many choices in treatment selection.

Ahead, Linda F. Stein Gold, MD, director of dermatology clinical research at the Henry Ford Hospital in Detroit, offers insight on optimizing regimens and also shares her perspective on the current and future state of care in the topical arena.

Can you describe the role of topical therapy in psoriasis treatment and provide your assessment of the current block of available topical treatments?

“Over 80 percent of psoriasis patients have localized disease that is amenable to topical therapy alone,” says Dr. Stein Gold. “Even patients who have moderate to severe disease who are on systemic treatments benefit from topical therapy for resistant lesions.” However, despite the significant role that topical therapy plays in the treatment of psoriasis, there is great potential for improvement, both in terms of new molecules that are safe and effective and in how clinicians use available agents.

“Topical treatments are effective but there is room for more effective and safe treatments,” says Dr. Stein Gold. While there are not any obvious holes in the topical treatment armamentarium, Dr. Stein Gold would like to see more molecules that are not only safe and effective, but also fast-acting, easy to apply, and preferably nonsteroidal. Moreover, the buzz of activity in the pipeline for topical psoriasis agents is encouraging, Dr. Stein Gold observes. “Several new modules are in the pipeline now, including phosphodiesterase inhibitors and Janus Kinase (JAK) inhibitors, both of which have potential to be major players in the future,” she says.

What’s the role of combination treatment in the topical arena? Are there any particular combinations that you’ve found effective for certain types of psoriasis or for treating certain areas of the body?

Combination treatment is generally more effective than monotherapy, notes Dr. Stein Gold. “The current gold standard is topical corticosteroids used with topical vitamin D analogues,” she says. “The combination has been shown to be more effective than either agent as monotherapy and this limits the exposure to potent topical corticosteroids.”

Another somewhat less common combination regimen that Dr. Stein Gold recommends is topical tazarotene and topical corticosteroids. “As a monotherapy, tazarotene can be quite irritating, but when coupled with a topical corticosteroid, the irritant effects of tazarotene are often reduced and the efficacy is increased,” says Dr. Stein Gold. However, one of the reasons this combination is not called upon frequently, Dr. Stein Gold points out, is that tazarotene is classified as a pregnancy category x drug and is contraindicated for a pregnant woman. “Therefore, if you are using this agent in female patients of childbearing age, the patient should first take a pregnancy test,” says Dr. Stein Gold.

Can you explain the basic elements of achieving good outcomes with topical therapy and how the relationship with patients plays a role in that?

“Setting appropriate expectations is critical for treatment of any disease,” says Dr. Stein Gold. “It can take several weeks to reach a good clinical effect, and maintenance therapy is often necessary to maintain the effect.” It is important to convey this to patients. In addition, vehicle is important for patient compliance, which is especially true for treating the scalp, says Dr. Stein Gold. “If an agent is easier to use, the patient is more likely to use it.” She explains. “If it’s not compatible with clothing, leaves marks on a patient’s clothes, and isn’t cosmetically elegant, it likely will not be used.”

When it comes to communicating with patients, Dr. Stein Gold emphasizes the importance of stressing that the medications prescribed will not be curing them, but controlling them. “It’s important to tell patients that psoriasis is a chronic disease and that it will come back if they do not take their medication appropriately.”

Given these conditions, Dr. Stein Gold observes that continuing to use a product after the psoriasis has been controlled, even on a less frequent basis, can be important in preventing future flares. “There is good evidence to suggest that maintenance therapy can prolong remission,” says Dr. Stein Gold.

Do you have any strategies for boosting adherence for patients who may be less likely to take their medication?

“Keeping the regimen as simple as possible often helps patients to adhere with the treatment plan,” says Dr. Stein Gold. One way of enhancing compliance, she notes, is through the use of fixed combination products, such as calcipotriene/betamethasone diproprionate (Taclonex, LEO Pharma).

“When you want the patient to have multiple agents, a fixed combination product offers patients a more direct path toward achieving that,” says Dr. Stein Gold. “Fixed combinations essentially put more control in the hands of physicians to ensure that patients are receiving the drug as directed.”

Do you have a take-home tip for your colleagues on how to manage patients with psoriasis with topical therapy?

Dr. Stein Gold emphasizes the importance of maintenance. “Some physicians feel that they can give their patients a ‘drug holiday,’ but psoriasis is a chronic disease, and we have to treat chronically,” says Dr. Stein Gold. “With the appropriate maintenance therapy, we will be more likely to find success in treatment.”

In addition, Dr. Stein Gold observes that patient education at any level is critical to care. “It is very important for patients to understand that we are controlling—not curing— their condition.”

Linda F. Stein Gold, MD, is the director of dermatology clinical research and a division head of dermatology at the Henry Ford Hospital in Detroit, MI.