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Treatment Selection in Plaque Psoriasis


Experts in dermatology discuss newer topical treatments, such as tapinarof, in the management of plaque psoriasis.

James Q. Del Rosso, DO: What about the quickness of response? When patients come in, they obviously want their psoriasis to get better as quickly as possible. Let’s go back to you, Brad. In terms of selecting therapies, let’s say the patient has 3% or 4% body surface area [BSA], with some plaques on the extremities but not necessarily the groin area or the scalp. We can talk about some of those areas a little more. In trying to get it under control faster, in the nonsteroidal world, what are your considerations?

Brad Glick, DO, FAOCD: I’ll answer the question by first saying that our go-tos are still corticosteroids. But as we’re learning more about nonsteroidal anti-inflammatory topicals, we may see a little paradigm shift. To answer the question, I might use a high-potency corticosteroid, particularly in the absence of areas that are difficult to treat.

James Q. Del Rosso, DO: Sensitive areas.

Brad Glick, DO, FAOCD: Yes, like thescalp or groin area. Of course, we have vehicles we use in the scalp fairly well. But 1 thing we didn’t talk about is dosing frequency. We have entries of these psoriasis topical treatments that are nonsteroidal. They’re only once a day. The compliance factor comes into our decision-making tree now. Some of the older products may have worked well once daily, but they weren’t studied that way. But a patient who comes in with 3% or 4% BSA, mostly in the bony prominences, is probably still going to go to a corticosteroid first. In our conversations we’ll even talk about the use of these nonsteroidals. Not even so much at the front end, which is possible even for the patient you described, but also as rotational therapy, so we can minimize the use of corticosteroids. If we can keep patients on these maintenance therapies, like tapinarof, over a long period of time, that’s great. I might use it in the beginning, but I’d probably still start with corticosteroids. The beauty of the new nonsteroidal agents is that they work fairly quickly, within the first couple of weeks. With some patients in the clinic I’ve seen these agents work faster, even within the first week.

Not to get away from your case, but when you add in that I can’t take that patient on clobetasol and have them use it in another location, then I have to choose a second therapy and write a second prescription. That’s the other beauty that’s part of the conversation. But my go-to is corticosteroids, at least in many of the patients, throwing in the possibility that access may be an issue.

James Q. Del Rosso, DO: In the early part of it, right?

Brad Glick, DO, FAOCD: Yes.

James Q. Del Rosso, DO: Because there’s going to be a point in time when you have to think about how long they are going to be using it. Are you saying that in that patient you’re going to use a high-potency or a super-potent corticosteroid and then switch to the nonsteroidal. Is that something that you do?

Brad Glick, DO, FAOCD: In an older day, I would have gone to a topical vitamin D analog. Depending on location, sometimes I’d even use topical calcineurin inhibitors.

James Q. Del Rosso, DO: The problem with topical calcineurin inhibitors with psoriasis, though, is that all the data showed—even in intertriginous psoriasis, where individuals tended to use them—that they’re extremely slow compared with these newer agents.

Brad Glick, DO, FAOCD: And irritating. I would say irritating as well.

James Q. Del Rosso, DO: They can be irritating but extremely slow compared with the newer agents that we have, like tapinarof, that can be used and get a quicker response. But what about the tolerability side of it with these newer agents? As far as utilizing them, the patient is going to get a quick effect, but they’re not going to necessarily have irritation or stinging or burning. What’s your sense on that, Ben?

Benjamin Lockshin, MD, FAAD: I think of this as a Venn diagram of safety, efficacy, tolerability, and obviously access to these medications. Earlier we alluded to the fact that our biggest concern with steroids is patients using the wrong location and having adverse events. But the other side of the coin is that some of the medications we use, like topical retinoids, which have moved toward the fringe aspect of treating psoriasis, are limited by their tolerability. Having something that’s 1-stop shopping, that you can give to them and say, “Use it wherever you want”—because no matter where you use it, it’s going to be tolerated well, be safe and effective—is really nice because we all have patients who come in with a big bag of their creams and lotions.

James Q. Del Rosso, DO: Dump it out.

Benjamin Lockshin, MD, FAAD: Yes. All the boxes are gone, so they don’t know exactly where they go. They’re like, “I’ve been using everything everywhere.” This changes things.

James Q. Del Rosso, DO: They’re all pretty much the same type of medicine. The different corticosteroids, maybe a vitamin D and a moisturizer, whatever—they’re variations on the same theme.

But which 1 are you using on the face? They happen to pick up the clobetasol, but which 1 are you using on the groin? They happen to pick up the clobetasol.

Benjamin Lockshin, MD, FAAD: Don’t you love when they say, “It works great.” I was like, “Obviously it works great in your eyelids. It’s a class 1 steroid. But don’t use it there.

James Q. Del Rosso, DO: Exactly.

Transcript edited for clarity

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