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The Role of Topical Treatments in Plaque Psoriasis


Alexandra K. Golant, MD, and Mona Shahriari, MD, share thoughts on newer topical treatments as well as the role of topical treatments in managing plaque psoriasis.

Mona Shahriari, MD: And thus far we’ve had topical. So we’ve always thought we should go to a systemic agent. But it’s fantastic that, in the past year or two, we had the FDA approval of some newer topical agents that have changed the game. Because in systemics and injectables, we’ve seen an explosion over the past 20 years. But if you look at the innovation in the topical arena, it wasn’t until recently that we had a new mechanism of action or highly efficacious medications that raise the bar in terms of what a topical…could do for our patients. So how do you approach this new realm of topicals that we have?

Alexandra K. Golant, MD: There was a huge disconnect. We had decades where…we were almost overloaded with options…. What has been interesting and rewarding about practicing in this newer topical era is challenging the expectations of how clear we can get someone with these efficacious new topicals. [They] are not only superseding what we had before in terms of efficacy but also providing a better patient experience with once-daily dosing and a safe profile that makes counseling and patient acceptance of the treatment excellent. How about for you?

Mona Shahriari, MD: For me, topicals have always been a cornerstone when it came to treating my patients with psoriasis, either using them as monotherapy or using them in combination with a systemic therapy… for mild, moderate, or severe disease. But the reality was we had the steroidal agents, and we had our nonsteroidals. And each category had some pros, but also left something to be desired. So my biggest grief with my steroids was that they worked well, but they were broadly immune suppressive. They were not targeted for that specific mechanism of psoriasis. They had limitations on how long I could use them. And then if I use them for prolonged periods, especially in those sensitive areas, like the face, the intertriginous areas, I’d be worried about local or systemic adverse effects. But the flip side, my historic nonsteroidal [agents], my vitamin D analogues, my vitamin A derivatives. The vitamin A derivatives were very irritating, so often I had to have to use a steroid to calm down the irritation. Well, that’s defeating the purpose of not using a steroid. And then the vitamin D analogues, they did great, especially in the sensitive areas from a tolerability standpoint. But why did they take forever to kick in? So again, I’d find myself reaching for a steroid in conjunction to expedite the process. There was this need for something that worked well, was safe to use everywhere, and that had a more favorable dosing regimen of once a day. So that’s what this new space is bringing us.

Alexandra K. Golant, MD: When I reflect back on my training of the topical regimens that we used to give our patients—steroidal options and nonsteroidal—everyone had their own recipe. But this was rotational therapy, and it was before we were fully on an electronic medical record. So it was often me writing by hand, OK, you’re going to start with this for 2 weeks, and then you’re going to go to weekends only or 2 days a week only and then incorporate this…. Patients would come back. “Oh, yes, this is my clobetasol, or my high potency topical steroid. I use that on my eyelids.” They would completely reverse what our instructions had been. And you can understand why. So I laugh now that we have these options where you can say this, you can use anywhere. It’s head to toe, it’s once a day, it’s a thin layer…. It could not be easier…, which I love. And to tie it back to a topic that we touched on earlier in the conversation regarding [a patient with skin of color] and trying to treat patients more inclusively. We know for example, that this patient population is so prone to dyspigmentation, in particular with the topical steroids, and hypopigmentation. When you see enough of it, it is a true phenomenon. And I’d be very hesitant to prescribe large quantities of topical steroids to these patients, seeing sometimes the adverse events. I love that there’s freedom from that as well, that you don’t have to fear the cutaneous [adverse] effects of misapplications or inappropriate applications or a bad dyspigmentation effect.

Mona Shahriari, MD: To add on that, our pediatric patients, they also get psoriasis. And I know for my patients, especially the ones who are between age 6 to 12 [years], those are the ones who want to do the regimen themselves because they are big girls and big boys now. But sometimes they may overuse the product, they may use it in the wrong area. And to your point earlier, we’re sending them home with this convoluted regimen that an adult can’t follow. Now I’m expecting a child to be able to follow this…. Hopefully, we’re going to get some FDA approvals [for younger patients] for these drugs down the road. But I know that if they use it in any area that they’re not supposed to, or I didn’t know about them having psoriasis in, [then I know] they’re not going to have any [adverse] effects. It helps me sleep better at night.

Alexandra K. Golant, MD: I completely agree…there’s probably no more defined population than adolescents. So to say, “Twice a day, do this convoluted regimen,” it’s not going to happen. It doesn’t happen…. One question that comes to mind is…with the amount of options that we have, how do you find your topicals fitting into your practice? How do you use them? Are you using them as monotherapy? When are you using them as monotherapy vs as an add-on to a patient who potentially is on a systemic or for a totally treatment-naïve patient? What does that look like for you?

Mona Shahriari, MD: Some people who have psoriasis, they’re going to want that topical agent. Whether you want to start them on a systemic, you have to wait for that insurance approval to go through. They just waited 4 to 6 months to see you. So they’re not going to walk out of the office without any sort of treatment. Topicals are still my first line. But what I’m noticing is with the advent of these newer nonsteroidal agents that do have that high level of efficacy, the infrequent application of once a day, and that more tolerable safety profile, I’m choosing them over my topical corticosteroids. And in my personal practice, I’m seeing a paradigm shift as long as access is not an issue because we all know that can be one of the biggest barriers. Because not only am I simplifying the discussion for myself in the office, but also I’m empowering my patient to effectively treat their disease. As you said, when…they come back and you tell them you weren’t supposed to put clobetasol on their eyes, they feel so defeated, as though you told them they did the worst thing in the world. Now I can empower them to effectively treat their disease. And I use these topicals not only as monotherapy but also as add-on therapy with my systemic agents. Because even though they weren’t specifically studied like that, when you look at the labels, we’re not seeing any reason why they can’t be combined with our systemics, including our orals and biologics for psoriasis. You could use it as touch-up paint to clear up a bit of breakthrough psoriasis or sometimes I might be quick to pull the trigger and switch to another systemic. Hopefully, with the topical, I can keep them on the systemic longer and save my prior authorization for a new agent.

Alexandra K. Golant, MD: Yes. And I’ve also used them in similar settings…. When you get experienced using these new agents, it really challenges your prior conceptions of how clear you could get someone on a nonsteroidal. You see it when you look at the data from the clinical trial programs of these agents. A patient who, at least during my training, I would have said this would never be a patient who would clear. And I mean clear on a nonsteroidal; it happens. These are very targeted high-science agents that flip the preconceived notions of how we use these agents. The concept of starting with a high-potency topical is not always the case anymore. [This,] as you put it really beautifully, is empowering to these patients, to simplify the regimen and give them the confidence that they know how to treat their disease. And to simplify things. We all benefit from that.

Mona Shahriari, MD: And also to your point, we overestimate the effect of topical corticosteroids because we’ve had them forever, and we have a lot of experience with them. But when you look at the data, our patients using topical corticosteroids, a lot of them are not getting completely clear. I don’t know why we’re not willing to let go of this agent. But with these nonsteroidals, and we can go through the data in more detail, efficacy is pretty darn good with that favorable safety profile. So once people start to try these, they’ll start to notice that paradigm shift as well.

Alexandra K. Golant, MD: Yes. And we know from the data—even claims-based data—that psoriasis topicals are prescribed to more than, let’s say, 90% of patients with psoriasis, so they’re being used. I feel better sending somebody home with something that I don’t care if you’re using it on your eyelid, on your groin, in your axilla, or on your extensor surface like a shin or an elbow; it is safe. And that it is safe in combination with anything else you might be using. So that has been for me a home run moment in the office when you can also give someone something new to try. That also is an exciting moment, especially with these patients who have been around the block and experimented with a lot of these treatments.

Transcript edited for clarity.

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