Topical Therapies for Psoriasis: The Revolution in Vehicles, Combinations, and Novel Agents
Linda F. Stein Gold, MD
Biologics have transformed the experience of psoriasis for the minority of patients who require systemic therapy. The universe of topical therapies that serves most patients with psoriasis1,2 also has changed and improved in recent years.
New Vehicles Increase Potency
Vehicles in topical therapies affect the absorption of the active agent. Delivering the same topical corticosteroid with different vehicles changes its potency, ie, how rapidly the corticosteroid is absorbed. For example, betamethasone dipropionate 0.05% in an ointment is considered a class I super potent steroid, whereas the same ingredient at the same concentration in a spray is a class III steroid. As a lotion, betamethasone dipropionate is a class V mid- or lower-mid-potency steroid.3 But potency cannot be predicted by the vehicle alone. The effect of the vehicle on potency may vary with the drug; potency depends on the interaction of the agent and the vehicle.
The potency classification system for corticosteroids is based on the vasoconstrictor effect,4 which assesses how well a medication passes through the stratum corneum, through the epidermis, through the dermis, and deeper into the lower dermis into the systemic circulation. The vasoconstriction test does not measure how well the drug stays in the skin. The measure of potency has become somewhat archaic as it does not capture the mechanism of some newer vehicles, which deposit the therapeutic agent into the epidermis and dermis, at the site of action. For topical medications with these advanced formulations, the measure of potency may underestimate the agent’s efficacy.5 Considering betamethasone dipropionate again, the emollient spray formulation (class III) has demonstrated similar efficacy to that of a super potent formulation (augmented betamethasone dipropionate 0.05% lotion) in patients with psoriasis.6
Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail or you may print it out at that time.
The online post-test and evaluation can be accessed at https://tinyurl.com/HDS19Supp.
Inquiries about continuing medical education (CME) accreditation may be directed to the University of Louisville Office of Continuing Medical Education & Professional Development (CME & PD) at [email protected] louisville.edu or 502-852-5329.
CME/CE Accreditation Statements
Physicians: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Louisville School of Medicine and Global Academy for Medical Education, LLC. The University of Louisville School of Medicine is accredited by the ACCME to provide continuing education for physicians.
The University of Louisville School of Medicine designates this enduring activity for a maximum of 2.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Joint Provider Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by Postgraduate Institute for Medicine and Global Academy for Medical Education, LLC. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the health care team.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 2.5 contact hours. Designated for 2.4 hours of pharmacotherapy credit for advanced practice nurses.
Dermatologists can benefit from education on recent developments in many areas of clinical practice. In psoriasis treatment, nearly all patients are prescribed topical therapies. New medications using improved vehicles and fixed-dose combinations have become available, and more are in development. New research linking psoriasis and risk of cardiovascular disease has provided a better understanding of the underlying pathological mechanism and the potential benefit of anti-inflammatory treatment. Recent epidemiologic data on atopic dermatitis in adults have important implications for diagnosis and treatment. In acne treatment, several efficacious systemic treatments are underutilized, and education on their risks and benefits may improve clinical practice. In the treatment of skin cancer, dermatologists should consider several systemic treatments in addition to surgery. Finally, a new botulinum toxin became available recently, and others are in development.
At the conclusion of this activity, participants should be better able to:
- Describe recent data on psoriasis treatment, including new vehicles for topical treatments, fixed-dose combination therapies, and investigational topical medications
- Review the relationship between psoriasis and cardiovascular disease (CVD) and the potential effects of psoriasis treatment on CVD risk
- Describe current research on the temporal patterns of atopic dermatitis onset and resolution and the differences in diagnosis and treatment approach for adult and pediatric patients
- Analyze the efficacy and safety of systemic therapies for acne
- Assess the current nonsurgical treatments for basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and localized melanoma
- Review the options for confirming the diagnosis and data on the use of topical and systemic treatments in the management of onychomycosis
- Assess the advantages and disadvantages of available botulinum toxins used to address patient concerns about facial aging
Individuals in a position to control the content of this educational activity are required to disclose: (1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients with the exemption of nonprofit or government organizations and non–health-carerelated companies, within the past 12 months; and (2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.
Nathaniel J. Jellinek, MD, has indicated he has nothing to disclose.
Michael S. Kaminer, MD, has indicated he is a Consultant for Artic Fox, Cutera, Cytrellis, Endo, L’Oréal, Soliton, and Zeltiq.
Alan Menter, MD, has indicated he is on the Speakers Bureau for AbbVie, Celgene, Eli Lilly, Janssen, Novartis, and OrthoDoc.
Jonathan I. Silverberg, MD, PhD, MPH, has indicated he is on the Speakers Bureau for Regeneron/Sanofi; is a Consultant, and/or Advisory Board member for AbbVie, AnaptysBio, Asana, Dermavant, Eli Lilly, Galderma, GlaxoSmithKline, Glenmark, Kiniksa, LEO, Menlo, Pfizer, Realm, and Regeneron Sanofi; and has received Grant/Contracted Research Support from GlaxoSmithKline.
Linda F. Stein Gold, MD, has indicated she is on the Speakers Bureau for Galderma, LEO, Mayne, Pfizer, Sanofi/Regeneron, Taro, and Valeant; is a Consultant for Foamix, Galderma, LEO, Mayne, Menlo, Pfizer, Sanofi/ Regeneron, Sol-Gel, Taro, and Valeant; and has received Grant/Contracted Research Support from Foamix, Janssen, LEO, Menlo, Pfizer, and Valeant.
Christopher B. Zachary, MBBS, FRCP, has indicated he is a Consultant for Allergan, Candela, Sciton, and Solta.
University of Louisville CME & PD Advisory Board and Staff Disclosures: The University of Louisville CME & PD Advisory Board and office staff have nothing to disclose, with the following Board Member exceptions: Sathya Krishnasamy, MD – Novo Nordisk (Grant Funding); Ashlee Bergin, MD – Merck Pharmaceuticals (Speaking); Michael Sowell, MD – Amgen (Speaking) and Impax Pharmaceuticals (Grant Funding); Rainer Lenhardt, MD – CSL Behring, Mallinckrodt, and Merck (Speaking).
CME/CE Reviewers: Courtney R. Schadt, MD, Assistant Professor of Medicine, Chief of Dermatology, University of Louisville School of Medicine, Louisville, Kentucky, has nothing to disclose.
Postgraduate Institute of Medicine planners and managers have nothing to disclose.
Global Academy for Medical Education Staff: Shirley V. Jones, MBA; Eileen A. McCaffrey, MA; and Margaret McLaughlin, PhD, have nothing to disclose.
Off-Label/Investigational Use Disclosure
This CME/CE activity discusses the off-label use of certain approved medications as well as data from clinical trials on investigational agents. Such material is identified within the text of the articles.
- Menter A, Korman NJ, Elmets CA, et al, for the American Academy of Dermatology. Guidelines of care for the management of psoriasis and psoriatic arthritis. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 2009;60(4):643-659.
- van de Kerkhof PC, Reich K, Kavanaugh A, et al. Physician perspectives in the management of psoriasis and psoriatic arthritis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis survey. J Eur Acad Dermatol Venereol. 2015;29(10):2002-2010.
- Kircik LH, Bikowski JB, Cohen DE, Draelos ZD, Hebert A. Vehicles matter: formulation development, testing, and approval. Part 1 of 2. Supplement to Practical Dermatology. 2010 March:1-16.
- Humbert P, Guichard A. The topical corticosteroid classification called into question: towards a new approach. Exp Dermatol. 2015;24(5):393-395.
- Basse LH, Olesen M, Lacour JP, Queille-Roussel C. Enhanced in vitro skin penetration and anti-psoriatic effect of fixed combination calcipotriol plus betamethasone dipropionate in an innovative foam vehicle. J Invest Dermatol. 2014;134:S33. Abstract 192.
- Fowler JF Jr, Hebert AA, Sugarman J. DFD-01, a novel medium potency betamethasone dipropionate 0.05% emollient spray, demonstrates similar efficacy to augmented betamethasone dipropionate 0.05% lotion for the treatment of moderate plaque psoriasis. J Drugs Dermatol. 2016;15(2):154-162.
- Kerdel FA, Draelos ZD, Tyring SK, Lin T, Pillai R. A phase 2, multicenter, double-blind, randomized, vehicle-controlled clinical study to compare the safety and efficacy of a halobetasol propionate 0.01% lotion and halobetasol propionate 0.05% cream in the treatment of plaque psoriasis.J Dermatolog Treat. 2019;30(4):333-339.
- Koo J, Tyring S, Werschler WP, et al. Superior efficacy of calcipotriene and betamethasone dipropionate aerosol foam versus ointment in patients with psoriasis vulgaris—a randomized phase II study. J Dermatolog Treat. 2016;27(2):120-127.
- Stein Gold L. What’s new in topical therapy. Presented at: 43rd Annual Hawaii Dermatology Seminar; February 17-22, 2019; Waikoloa, HI. Oral presentation.
- Duobrii [package insert]. Bridgewater, NJ: Bausch Health Americas, Inc; April 2019.
- Sugarman JL, Weiss J, Tanghetti EA, et al. Safety and efficacy of a fixed combination halobetasol and tazarotene lotion in the treatment of moderate-to-severe plaque psoriasis: a pooled analysis of two phase 3 studies. J Drugs Dermatol. 2018;17(8):855-861.
- Kircik LH, Papp KA, Stein Gold L, Harris S, Pharm TL, Pillai R. Assessing the synergistic effect of a fixed combination halobetasol propionate 0.01% and tazarotene 0.045% lotion in moderateto- severe plaque psoriasis. J Drugs Dermatol. 2019;18(3):279-284.
- Sugarman JL, Gold LS, Lebwohl MG, Pariser DM, Alexander BJ, Pillai R. A phase 2, multicenter, double-blind, randomized, vehicle controlled clinical study to assess the safety and efficacy of a halobetasol/tazarotene fixed combination in the treatment of plaque psoriasis. J Drugs Dermatol.2017;16(3):197-204.
- Smith SH, Jayawickreme C, Rickard DJ, et al. Tapinarof is a natural AhR agonist that resolves skin inflammation in mice and humans. J Invest Dermatol. 2017;137(10):2110-2119.
- Negishi T, Kato Y, Ooneda O, et al. Effects of aryl hydrocarbon receptor signaling on the modulation of TH1/TH2 balance. J Immunol. 2005;175(11):7348-7356.
- Robbins K, Bissonnette R, Maeda-Chubachi T, et al. Phase 2, randomized dose-finding study of tapinarof (GSK2894512 cream) for the treatment of plaque psoriasis. J Am Acad Dermatol. 2019;80(3):714-721.
- Punwani N, Burn T, Scherle P, et al. Downmodulation of key inflammatory cell markers with a topical Janus kinase 1/2 inhibitor. Br J Dermatol. 2015;173(4):989-997.
- Eucrisa [package insert]. Palo Alto, CA: Anacor Pharmaceuticals, Inc; October 2017.
Linda F. Stein Gold, MD, has indicated she is on the Speakers Bureau for Galderma, LEO, Mayne, Pfizer, Sanofi/Regeneron, Taro, and Valeant; is a Consultant for Foamix, Galderma, LEO, Mayne, Menlo, Pfizer, Sanofi/Regeneron, Sol-Gel, Taro, and Valeant; and has received Grant/Contracted Research Support from Foamix, Janssen, LEO, Menlo, Pfizer, and Valeant.