Use of Topical Therapy in Mild-to-Moderate Plaque Psoriasis


Mona Shahriari, MD, reviews the efficacy data of topical treatments in the treatment of plaque psoriasis, and Linda Stein Gold, MD, discusses unmet needs in the plaque psoriasis treatment landscape.

Brad Glick, DO, MPH: Topical therapies are considered first-line treatment for the management of plaque psoriasis. We’ve been talking about that for the last several minutes. What do we know about the effectiveness of topical treatment in mild to moderate plaque psoriasis? In terms of body surface area [BSA] involvement, symptoms, special body areas, and real-world data. Mona, I’ll start with you.

Mona Shahriari, MD, FAAD: We had a real-world study that looked at some systemic-naïve patients who had a mild to moderate definition of psoriasis. They had a BSA of less than 10%. They started topical therapy for their psoriasis. After about 7 months on that regimen, about 14% of patients got to a PASI [Psoriasis Area and Severity Index] 75, 40% got to a PASI 50, and importantly, 50% had no BSA reduction. This tells us that a lot of our patients with the agents we’ve had in the past aren’t getting a meaningful improvement, whether it’s talking about BSA or symptoms. Especially when you’re looking at some of those special sites, that study showed us that most of the patients had residual psoriasis in special sites—the palms, the soles, the scalp, the face—even after 7 months of therapy. For a lot of our patients, these sites are devastating from a psychosocial standpoint. With the scalp, for example, it’s hard to get a topical in there to effectively treat it. There’s definitely an unmet need when it comes to topical treatments to effectively treat this disease.

Brad Glick, DO, MPH: Linda, from that Kaplan study last year, what are those gaps? What are the unmet needs where this topical therapy approach to plaque psoriasis is concerned?

Linda Stein Gold, MD: Every 1 of us has a patient with plaque psoriasis who walks into our office with a bag of medications. They’ve been to their dermatologist, who thinks they’re doing such a good job because they say, “This 1 is going to go on your tough areas, and you’re going to use it for 2 weeks only. This 1 is going on your sensitive areas, and you can use it as long as you want. This 1 is for when you’re not so bad, but you can’t use that it for too much time.”

What happens is that my patients come home and are incapacitated by fear because they can’t remember what you said. All they remember is, “My doctor gave me some creams.” They don’t remember where to put any of them. We set our patients up for failure because it’s too complicated. Simplify the regimen: 1 thing you can use on multiple body surface areas, 1 thing you can use for an extended period of time, 1 thing that’s not going to bleach out your skin and cause profound adverse effects. That’s where the gap has been. We need to find something that’s efficacious, safe, and well tolerated and that can be used on multiple body surface areas and for long periods of time.

Brad Glick, DO, MPH: What Linda is saying is rather than using multiple topicals for different locations, it makes me want to ask the question, what’s the ideal topical agent? Mona, tell me your thoughts.

Mona Shahriari, MD, FAAD: I agree with Linda’s comment about 1-stop shopping. If a patient comes in with a bag of products, they come back in 6 weeks putting that high-potency steroid on the face. Nobody remembers the complex regimen that we told them. To simplify the regimen and empower our patients to effectively treat the disease, that perfect topical is easy to use with once-a-day dosing. They can use it on any affected area, from head to toe, whether we’re dealing with a thick plaque on the elbow or a thin plaque on the eye for any duration of time—2 weeks, 12 weeks, 1 year. Don’t worry about tachyphylaxis and local and systemic adverse events. It needs to be effective and cosmetically elegant with good, local tolerability. Nobody wants a phone call about burning and stinging of another cream.

Transcript edited for clarity

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