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Topical vs Systemic Therapy in Plaque Psoriasis


Dawn L. Sammons, DO, FAOCD, FAAD, shares her approach to using topical vs systemic therapy in plaque psoriasis, focusing on patient preference as the driving factor for treatment selection.

James Q. Del Rosso, DO: Dawn, I have a question for you. When you’re looking at a patient with psoriasis, you’re trying to determine whether you’re going to manage this with topical therapy alone, initiate systemic therapy, or utilize them in combination. Even with a lot of systemic therapies, patients carry some persistent plaques. Topical therapy is going to be utilized in the vast majority even when they’re on a systemic therapy. How do you make that initial choice of what direction you’re going to go?

Dawn L. Sammons, DO, FAOCD, FAAD: A lot of that is based on patient preference. We have a conversation with the patient as a partner in the decision-making. We have patients who present who have 10% or 15% BSA [body surface area], and they look at me and say, “I want to start with something topical.” It’s nice that we have topicals that we can utilize. We have topicals with new direction that we were talking about, that we can utilize in some patients to help get them there. Years ago, my only option was to give them topical steroid or vitamin D analog. Neither was great.

James Q. Del Rosso, DO: That was a quick breakthrough. Remember? Vitamin D analog.

Dawn L. Sammons, DO, FAOCD, FAAD: When they came in combination, that was even more exciting. It has a lot to do with the patient. I have patients who have very minimal disease, but it’s very upsetting to them. They don’t want to do a topical. In that situation, I’m open to utilizing a systemic. But I agree wholeheartedly: even my patients who are on biologics and doing well, every 1 deserves and needs to have some topical at home that they can utilize when they have a flare. I’m super happy about some of the new drugs like tapinarof. The beauty is that I don’t have to worry about where the flare is and where they’re putting that medication.

James Q Del Rosso, DO: And how long they’re using it.

Dawn L. Sammons, DO, FAOCD, FAAD: And how long they’re using it. I just had a patient come in who had been given betamethasone by a past dermatologist to utilize if he had flares. Guess where his flares have been for the last 6 months? In the groin. I was like, “We don’t want to keep doing that.” That was a great patient in that case. I switched him to tapinarof and I said, “You can use this wherever you want to use it.” I’m not worried about any skin sensitivity or thinning of the skin. I was worried about those things with the steroid. In those cases, you can do a combination. But a lot of that is driven by patients. My goal is to be as aggressive as the patient wants me to be. I’m open to doing systemics even in some of the cases where the patient doesn’t have as great of a body surface area. Severity has to do with how the psoriasis impacts our patient and their life. That’s different from patient to patient, not just a number.I have a lot of gentlemen who, if they have psoriasis in the genitals only, are going to look at me and go, “Dr Sammons, this is severe.”

James Q. Del Rosso, DO: Get rid of this now.

Dawn L. Sammons, DO, FAOCD, FAAD: We have to treat that.

Transcript edited for clarity

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