Tailoring Topical Psoriasis Treatment

The management of patients with psoriasis is both an art and a science. Customizing care for each individual often yields the most effective results. Topical treatments, whether creams or ointments, may be used alone for mild to moderate disease or in combination with other therapies for more severe disease.

Personalizing treatment starts with identifying the patient’s main concerns, Laura K. Ferris, MD, of the University of Pittsburgh Medical Center, told Practical Dermatology® magazine. “My patients complain of being embarrassed about the appearance of their skin, the flaking, and the itching,” she said. An open-ended conversation with patients is essential when discussing psoriasis treatment options, according to Dr. Ferris.

STRATEGIES FOR SUCCESS

If patients opt for topical therapy, Dr. Ferris recommends asking whether they are willing to apply an agent twice or just once a day. Other factors include how quickly the patient wants results, which areas of the body are involved, and what other medications and conditions they have. “It is important to ask about symptoms and signs of psoriatic arthritis in psoriasis patients,” she emphasized.

Adherence to topical therapy can be challenging for patients, Dr. Ferris said. She makes a point to ask patients which areas of skin are involved. “Many patients have genital psoriasis or intertriginous psoriasis, and sometimes, they will only admit this when directly asked,” she remarked.

“I really like the new topical agents roflumilast and tapinarof because they are not greasy, can be used on any body part, and are applied once a day,” added Dr. Ferris. Especially for patients with intertriginous psoriasis, roflumilast has data showing very high efficacy and safety, she noted. She tries to limit the use of topical steroids for psoriasis, given the chronic nature of the disease.

To help determine a personalized treatment plan, Dr. Ferris sees patients every 3 months until they are on a stable regimen, then sees them once a year if treatment consists of only a topical therapeutic.

The right topical agent can also help to customize an overall plan in combination with oral therapy, according to Dr. Ferris.

“I always give my patients who are on systemic therapy a topical therapy to go with it,” she said. “The fact is that psoriasis will occasionally flare with stress, illness, and seasonally. I want my patients to have something they can use to address these flares.”

CHALLENGES WITH TOPICAL TREATMENT

“Most psoriasis patients have had the experience of not clearing on a topical,” said Dr. Ferris. In this situation, she generally describes to them the safety of topical therapy and its benefits for treating mild to moderate disease.

“For patients who report negative experiences with topical steroids, I offer them newer topicals that are easier to use and have more elegant formulations than the ointments they may have used in the past,” she said.

AESTHETICS AND EFFECTIVENESS

“Psoriasis patients want a topical agent that is not sticky, gooey, or damaging to their clothing,” Zoe Diana Draelos, MD, told Practical Dermatology® magazine. “Having psoriasis is a burden, and then using aesthetically unpleasing topical agents is a further burden.” Dr. Draelos is a dermatologist in private practice in High Point, North Carolina, and a researcher on several trials of psoriasis medications.

“Developing a personalized plan means listening to the patient’s needs and then selecting from the excellent psoriasis armamentarium to meet those expectations,” she said. Informed by conversations with patients, “I choose a topical therapy based on the location, type, and severity of psoriasis,” she stated.

It is important to recognize when a topical therapy is not working. “A topical medication must show some improvement in 4 weeks,” Dr. Draelos said. “The psoriasis may not be gone, but there should be some positive therapeutic response. I see my patients back in 4 to 6 weeks to make adjustments.”

Like Dr. Ferris, Dr. Draelos has found that topical and oral therapies can complement each other when treating psoriasis, especially at the outset. “Initiating therapy with a topical and an oral simultaneously is often a good strategy because the topical therapy can improve appearance and sensory issues while the oral psoriasis medication starts to work,” she said. “Once the oral works, the dermatologist can reevaluate to determine if the oral is providing the treatment results required and the topical can be discontinued.”

Barriers to successful topical therapy include patients’ reluctance to take the time to apply topical agents. This tends to be more common among individuals with large areas of involvement, Dr. Draelos said. “I think it is critical to assess the patient’s needs and prescribe topicals, orals, and injectables to meet those needs,” she commented.

Patients who do not want anything systemic should use topicals. Those who do not wish to rub on a cream, however, are not good candidates for topical agents and should use an oral or injectable medication, said Dr. Draelos. “Listening to the patient and accurately assessing what treatments they will and will not use will allow the dermatologist to remove barriers to treatment and improve compliance,” she stated.

MAKING THE MOST OF TOPICAL THERAPY

A common complaint that Adam Friedman, MD, hears from patients with psoriasis is that topicals “don’t work.” Dr. Friedman is a professor and chair of dermatology and director of translational research at George Washington University in Washington, DC.

“Patients, if not provided education on the disease state and realistic expectations with respect to topical therapy, may assume that recurrence of an affected area is, in fact, failure of the topical,” he said. “Providing counseling at the onset and a management strategy for ongoing use of a topical can help overcome this perception.”

Steroid phobia is a legitimate concern for many psoriasis patients, Dr. Friedman noted. “Concerns regarding skin thinning and lightening may dissuade patients from using topical steroids correctly, but counseling in advance, and providing handouts, can be helpful in alleviating these concerns,” he remarked.

When it comes to topical steroids, his motto is “go strong or go home.” Dr. Friedman explained, “I tend to lean on higher-potency topical steroids to knock out disease faster. Many of the side effects of steroids relate to chronicity of use, rather than strength, so the faster you clear the plaque and halt daily use, the better.”

If insurance coverage permits, he favors halobetasol propionate and tazarotene lotion, 0.01%/0.045%, and recommends daily use. “This combination class 1 steroid and retinoid hit multiple underpinnings of disease, while each limits the side effects of the other,” Dr. Friedman explained. He has also been prescribing tapinarof cream, which he said appeals to patients seeking a nonsteroidal option and has a remitting effect once a plaque has cleared.

COST CONSIDERATIONS

Patient access may be the biggest struggle to success with topicals, according to Dr. Friedman. “We have multiple new combination and novel topical therapies, which are very effective but limited by insurance coverage and cost,” Dr. Friedman said.

Psoriasis care can be expensive, and insurance coverage can be inconsistent. Corticosteroids are relatively inexpensive and often effective as antiinflammatories, especially for patients with mild to moderate disease, according to the National Psoriasis Foundation’s patient website. Topical corticosteroids are available as ointments, creams, lotions, gels, foams, sprays, and shampoos, so most patients can find a vehicle that works for them. Over-the-counter topical steroids can play a role in psoriasis management if more expensive therapies are not feasible.

Dr. Friedman asks patients to contact him in 3 to 4 weeks with an update on their current therapeutic regimen. “I tell them I don’t expect clearance, but I want to know there is some improvement,” he said. “This expectation of check-in improves adherence and strengthens the patient-physician connection.”

In his experience, topical therapy alone rarely addresses the global picture for patients with psoriasis, given the systemic nature of the disease. Customizing topicals is essential for success, but an overall combination strategy involving topicals and orals/biologics is necessary in most cases, he said.

Dr. Draelos has served as a researcher for AbbVie, Arcutis Biotherapeutics, Bausch Health, Bristol Myers Squibb, Eli Lilly, and Novartis.

Dr. Ferris has served as an investigator for AbbVie, Amgen, Arcutis Biotherapeutics, Boehringer Ingelheim, Bristol Myers Squibb, DermTech, Eli Lilly, Janssen, Novartis, and UCB. She has served as a consultant for AbbVie, Amgen, Arcutis Biotherapeutics, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant Sciences, and DermTech and as a speaker for Boehringer Ingelheim and Bristol Myers Squibb.

Dr. Friedman has served as a consultant for Bristol Myers Squibb, Dermavant Sciences, Janssen, and Ortho Dermatologic and as a speaker for Bristol Myers Squibb and Janssen.