Expert panel: Psoriasis treatment part art, part science; physician 'artistry' needed

National report - The treatment of psoriasis is a complicated process in which the dermatologist has to be "a little bit of an artist," according to Steven Feldman, M.D.

In addition to being able to categorize the disease for treatment purposes and being familiar with available treatment options, the dermatologist must be mindful of the patient's psychological state, says a panel of experts at a "Meet the Psoriasis Experts" discussion sponsored by Galderma at the 66^th Annual Meeting of the American Academy of Dermatology.

Tailor to individual

Many patients are noncompliant with their regimen owing to dissatisfaction with the type of vehicle used for delivery of topical medications, which will be used to some degree in all patients with psoriasis regardless of disease severity. Therefore, choosing the appropriate vehicle is of utmost importance, Dr. Feldman says. He is professor, department of dermatology, pathology and public health services, and director, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, N.C.

About 40 percent of patients report being noncompliant with their medications. Adherence studies show that compliance drops dramatically over the first three to four days and then declines steadily afterward.

Treatment 'bothers'

Indeed, focus groups have identified 17 bothersome aspects of psoriasis, many of which are related to treatment, Dr. Feldman says.

"One third are related to the treatments we've been using traditionally," he says. "These are unpleasant odors, stains on clothing or furniture, time lost from work, medication side effects, and the monetary cost of treatment."

Lotions add to topical choices

With all of the buzz lately centered around the biologics for the treatment of psoriasis, newer forms of topical treatments are often overlooked, yet 80 to 85 percent of patients with psoriasis have localized disease that is treatable with topical therapy.

Newer vehicles such as lotions and foams are cosmetically more acceptable than the traditional topicals, Dr. Bikowski says. The lotions have been at least as effective as the creams in clearing lesions in patients with moderate to severe psoriasis. The data show that newer formulations can provide high initial efficacy without occlusion, which is a departure from the traditional perspective of the role of vehicles.

In a comparison of clobetasol propionate 0.05 percent lotion (Clobex Lotion, Galderma), which has a propylene glycol vehicle to enhance penetration of the active ingredient, and clobetasol cream 0.05 percent (Temovate Cream, Glaxo-Wellcome) in patients with moderate to severe psoriasis, 75 percent of the patients assigned to clobetasol lotion remained clear four weeks after stopping their medicine, compared with 50 percent of the patients assigned to clobetasol cream.