The Impact of Non-Steroidal Topical Agents in Plaque Psoriasis

Brad Glick, DO, MPH: How do you envision these new nonsteroidal topical agents impacting our clinical practice for our patients with plaque psoriasis? How are they going to fit in the treatment landscape? What has your experience been? We went over that a little already. I’m going to throw out another question: are we seeing a paradigm shift? Mona?

Mona Shahriari, MD, FAAD: For me, nonsteroidals are the next generation. They’re going to represent a new standard of care because of their impressive efficacy; that once-daily dosing; the ability to use them for mild, moderate, or severe psoriasis on any affected area—the face, the groin, the trunk—for any duration of time. We aren’t concerned about local systemic adverse effects or tachyphylaxis, which makes them an incredible addition to our toolbox. I’m noticing that paradigm shift in my practice, where I’m reaching for them over my topical corticosteroids. As long as access isn’t a barrier, and that tends to be the biggest issue no matter what aspect of dermatology we’re prescribing medicines in. But the conversation with my patients is shorter, the adherence to therapy is better, and patients come back having an overall better experience because they don’t feel like a failure for putting the wrong stuff in the wrong place. They feel empowered to effectively treat their disease.

Brad Glick, DO, MPH: Steroid phobia does exist. We have to discuss it, and we have to channel the use of corticosteroids properly. This takes it away. Linda, what are your thoughts?

Linda Stein Gold, MD: We need a lot of tools in our toolbox. No one medication is going to be effective for 100% of patients. There will still be a role for potent topical steroids and midpotent topical steroids in patients who need to be clear tomorrow. Nothing works as quickly as a potent topical steroid. They’re always going to be a very important tool. But I think of them as a Band-Aid. This is a long-term, chronic problem. We might need them on a short-term basis, but these nonsteroidal options are the workhorse of the treatment options we have in front of us. The beauty is that we have several treatments to choose from. We need each of those treatments because our goal is to get our patients to a point when they no longer think about their psoriasis.

Michael Cameron, MD, FAAD: When we look at the time line of drug development for psoriasis, they came out in the 1950s and 60s. They looked at coal tar, saying “What?” We’re still using coal tar. We look at the use of topical steroids in psoriasis as crude, like how we look at coal tar now because it’s such a better instrument than a topical steroid. When you use clobetasol, it goes away but comes back right away. We’ve all seen now the remittive effect of tapinarof, for example. It behaves…like a class 1 steroid. We had the trials at Mount Sinai [Hospital], but what’s different from clobetasol is that it stays away for 3 to 4 months on average. You can make a compelling argument to the PBMs [pharmacy benefit managers] and the payer groups: we might keep the population off biologics for 3 to 4 months if we’re having this remittive effect.

I’m trying to answer your initial question. I get all my patients with psoriasis on these nonsteroidals when I can get access because that’s what I’d give my sister. It’s a better therapy than a topical steroid. It fits in the biologic space as an add-on but also in the mild to moderate space with Otezla or as monotherapy to try to keep patients off biologics.

Brad Glick, DO, MPH: When someone has a pretty good flare or mostly localized disease, do you think we’d go to our corticosteroid first? Then we can treat to complete with these new nonsteroidals. Mona?

Mona Shahriari, MD, FAAD: That’s definitely a possibility. But it’s going to vary from patient to patient based on that individual’s treatment goals. That’s another fair way to use these molecules.

Brad Glick, DO, MPH: What about monitoring? How do we monitor patients going on nonsteroidals or topicals in general? Broadly speaking, how do you assess efficacy, safety, and adherence?

Linda Stein Gold, MD: The wonderful news is that they don’t need close monitoring. There are no boxed warnings with these new medications, and there’s no blood monitoring. We know that these drugs have been studied on and off for an entire year. If we give patients a prescription and a refill and don’t hear from them, that’s probably a good thing. So I’m not worried about it. If my patient isn’t doing well or is having a reaction, they’re going to call me in a minute or send me a message on their Epic software. The good news is that these drugs are relatively safe and can be used. It’s not as if I gave them clobetasol propionate and I’m worried they’ve been using it on their eyelids and they’ve gone rogue—they feel they can use it wherever they want to. There’s a good safety factor here. I’m usually prescribing with confidence.

Brad Glick, DO, MPH: You know I asked this question because we have a topical Janus kinase inhibitor. Every once in a while, when I have the opportunity to speak about this product, someone will ask me, “Are you checking labs for your patients on topical ruxolitinib?” Of course, the answer is no. Mona, what are your comments on any monitoring, whether it’s adherence, because these are once-daily therapies. What are just some general thoughts as we close.

Mona Shahriari, MD, FAAD: I agree with Linda. This has made my life much easier. I can give them an effective medicine that doesn’t need high levels of monitoring. But if a patient calls me with concerns about adverse effects—like irritation, contact dermatitis, or anything that’s off—I ask them about how they’re using the medication. I found our patients are used to using medicines twice a day, so they may be using this 1 twice a day and not reading the directions on the label. We all know if you overuse a product, there’s a chance for irritation. I definitely double check that piece.

Transcript edited for clarity