New Guidelines For Managing Psoriasis With Topical Therapies
The American Academy of Dermatology (Academy) has released new guidelines of care for the management and treatment of psoriasis with topical therapies based on an extensive review of scientific literature on the subject and recommendations of recognized psoriasis experts. This is the Academy’s third of six sections of the guidelines of care for psoriasis, with two previously published sections focusing on general recommendations for the treatment of psoriasis and psoriatic arthritis with an emphasis on the class of treatments known as biologics.
Published online in the Journal of the American Academy of Dermatology, the new psoriasis guidelines present the latest recommendations for treating patients with psoriasis with topical agents. While nearly 7 million Americans are affected by psoriasis, the majority of patients (approximately 80 percent) have limited disease involving less than 5 percent of the body’s surface area. Studies have shown that these patients are good candidates for topical therapies which usually provide high degrees of safety and efficacy.
“The AAD evidence-based guidelines provide physicians with the framework for determining if a topical therapy alone or in conjunction with ultraviolet light, systemic or biologic medications will effectively manage a patient’s condition,” said dermatologist C. William Hanke, MD, FAAD, president of the Academy. “However, treatments should be tailored to meet individual patients’ needs, which vary depending on body location, characteristics of the psoriasis being treated and patient preferences.”
Psoriasis is a chronic skin condition which usually begins before age 35 and is characterized by thick, red, scaly patches that itch and bleed. Although it is a genetic disease, it is not completely understood how it is inherited. However, there are at least eight chromosomes to date that researchers have identified as being linked to the genetic transmission of the disease. In addition, a number of environmental factors play an important role in the development of psoriasis, including drugs, skin trauma, infection and stress. Although psoriasis has been previously thought to be a disease affecting primarily the skin and the joints, a growing body of research suggests that psoriasis patients are at an increased risk of developing serious medical conditions, including cardiovascular disease and diabetes, particularly when their psoriasis is severe. Recent evidence has even suggested an increased overall risk of mortality in patients with severe psoriasis, especially those who have auto immune and cardiovascular diseases.
Based on a comprehensive analysis of the most current studies on topical therapies for psoriasis – including corticosteroids, vitamin D analogues, combination calcipotriene/betamethasone propionate ointment, tazarotene, tacrolimus and pimecrolimus – the Academy’s guidelines address patient expectations, method of application, use of concurrent therapies, length of use, application amount and patient compliance. In addition, specific recommendations for and precautions about these topical therapies used alone or with other widely used therapies in patients with more extensive psoriasis also are outlined.
According to these guidelines, topical therapies can be used safely and effectively in the majority of patients with mild to moderate psoriasis. However, topical therapies should not be used exclusively without other complementary treatments in cases of moderate to severe psoriasis or when the condition is limited but hard to manage.
Dermatologists emphasize the importance of matching patient expectations with practical considerations. For example, patients who want continual clearance of psoriasis with no visible lesions inevitably will be disappointed with topical therapy because of the need for a continuous intense topical regimen that can be very difficult to achieve and maintain. Others may prefer only intermittent treatment with little interest in spending considerable time managing their condition.
“It is important to determine each patient’s goals and then develop a strategy to help fulfill his or her expectations, while also being practical and realistic,” said Dr. Hanke.
Method of Application
The choice of the therapy’s vehicle (the form in which the medicine is delivered) can significantly alter the use and penetration of the medication and, as a result, alter its effectiveness. Several vehicle types for topical medications are available: ointments, creams, solutions, gels, foams, tape, sprays, shampoos, oils and lotions. The guidelines advise that while different vehicles are indicated for different body sites, the optimal choice should be based on what vehicle the individual patient is most likely to use on a regular basis.
“Areas with hair such as the scalp can be treated with solutions, foams, shampoos, sprays, oils, gels or other vehicles, with individual patients having different preferences among these options,” said Dr. Hanke. “Some patients may prefer a less greasy preparation, perhaps a cream for daytime use, and may be willing to use an ointment, which is more effective but less cosmetically appealing, at night.”
Use of Concurrent Therapies
In some cases, topical medications can be used concurrently to take advantage of varied mechanisms of action. When this is the case, patients may be instructed to apply the various medications at separate times throughout the day, and physicians also need to be aware of compatibility issues among the prescribed medications.
Length of Use
The use of topical therapies can be both intermittent and long-term. For example, it is generally recommended that more potent agents should be used on a short-term basis to allow for clearing of psoriasis, after which patients should be instructed to use these agents intermittently for long-term management. It was determined that this strategy may pose less risk of side effects than continuous treatment. On the other hand, patients who require continuous topical treatment should be instructed to use the least potent agent that can adequately control the condition or be transitioned to a topical agent that is associated with the lowest long-term risk.
“Although topical agents for psoriasis are usually well tolerated without significant side effects, it is important that patients receive regular examinations by their dermatologists – whether they use medications over the long term or intermittently – as unsupervised use of potent topical medications is not recommended,” said Dr. Hanke.
In terms of the amount of topical medication that generally should be applied to affected skin, dermatologists refer to the “fingertip unit” as the recommended guidance. One fingertip unit is approximately 500 mg, and recommendations for the number of units needed to cover affected areas are offered. For example, three fingertip units are required to adequately cover psoriasis on the scalp, whereas eight fingertip units are needed for the entire leg and foot. This method provides a means for patients to more accurately dose their topical medications.
Lastly, dermatologists agree that poor compliance (or adherence) to topical treatment of psoriasis is a major issue for the majority of patients. “Many factors contribute to the lack of adherence to a topical treatment regimen, including frustration with a medication’s efficacy, the inconvenience of applying medication daily and poor choice of the medication’s vehicle,” said Dr. Hanke. “We strongly encourage physicians to consider measures to improve patient adherence, including choosing topical medications with adequate potency to achieve a favorable clinical response and working with the patient to select the preferred vehicle.”
Other Topical Treatments
The guidelines also outline other topical treatments – such as non-medicated topical moisturizers, salicylic acid, anthralin, coal tar and various combination therapies – as adjunctive therapies that could, in some cases, enhance other topical treatments.
“Establishing an effective treatment regimen is crucial in managing not only the psoriasis, but patients’ adherence to their medications and overall satisfaction with their outcomes,” added Dr. Hanke. “These guidelines are intended to further our understanding of how topical therapies can be used to successfully manage and treat psoriasis in most patients, but dermatologists and patients need to continually review all of the available options to ensure the best chance for long-term management of the condition.”