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Long-term topical management of psoriasis: the road ahead

Read time: 25 mins
Last updated:3rd Nov 2020
Published:3rd Nov 2020

Could topicals be the key to long-term control of plaque psoriasis?

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In a recent Journal of Dermatological Treatment article1, eight global dermatology experts share their viewpoints on treating psoriasis and outline why they think the role of topicals in long-term management should be reconsidered. 

Topicals are usually the first treatment someone with plaque psoriasis will receive. Around 8 in every 10 cases are mild-to-moderate, which can be treated with topicals, and current guidelines recommend topical therapies as first-line treatment. But despite some development in the area, a lack of discussion around the role of topicals in long-term management of plaque psoriasis was identified.

The authors of this expert opinion article take a detailed look at the existing guidelines and evidence for topicals in maintenance treatment, highlight potential challenges, and give their reasons why the use of topicals in the long-term management of plaque psoriasis deserves to be rethought.

Key take-outs

  • Plaque psoriasis is a chronic relapsing condition with periods of remission
  • Topicals are widely available and represent an important part of the long-term management options in the treatment of plaque psoriasis
  • Despite most plaque psoriasis patients being treated with topicals at some point, there is a lack of clinical data and official guidance on how to optimise long-term management using them
  • Innovative topical vehicles have come onto the market, but there is still a lack of new treatments or strategies
  • Expert opinion supports topicals in long-term management strategies for mild-to-moderate plaque psoriasis

Expert view

Experts and various guidelines from around the world suggest that topicals are suitable in the long-term management of mild-to-moderate, relapsing and remitting plaque psoriasis.

In France and Asia, expert opinion recommends a twice-weekly or weekend application of topicals in maintenance therapy; in a European consensus, a two-compound product, is recommended once or twice a week after the initial treatment.

Current UK and German guidelines also recommend topicals in maintenance therapy, but stop short of specifying details like frequency of application.

  • NICE guidelines state that topical agents can be used when needed to maintain satisfactory control, in patients who are still responding to therapy after the initial treatment period.
  • German guidelines recommend topical maintenance therapy with corticosteroids, tazarotene or vitamin D3 derivative.

Supporting evidence

Randomised Controlled Trials (RCTs)

The authors noted a gap in clinical evidence for topicals in long-term management, with few published studies or RCTs investigating treatments for more than 6 months. 

The review article highlights six studies of note:

A 12-week study of calcipotriol plus betamethasone dipropionate (Cal/BD) gel in scalp psoriasis following complete remission, which found twice-weekly application to be more effective and associated with a lower rate of relapse versus on-demand treatment.

A 16-week prospective, open-label study of adjuvant Cal/BD foam in psoriasis patients with an inadequate response to biologic therapy, which showed treatment with Cal/BD foam led to improvement in every measure of disease activity. Patients received once-daily Cal/BD foam for 4 weeks, followed by twice-weekly use on consecutive days for 12 weeks.

The PRO-Long study, a long-term observational analysis of either Cal/BD gel or Cal/BD body ointment used once daily for up to 52 weeks, which demonstrated a significant increase in the proportion of patients with ‘mild’ or ‘very mild’ disease at Weeks 24 and 36 compared to baseline which was sustained until Week 52, and greater patient-reported satisfaction with the gel, which was considered easier to use, faster to apply and more convenient than the body ointment.

A retrospective study following patients for 3-years initially treated with a topical, which found that maintaining patients on an effective topical treatment helped abate the need for a switch to oral treatments and biologics.

An observational, retrospective analysis in two, local Italian health units, reported that using fixed-combination topicals can improve patient adherence to treatment, and decrease the likelihood of switching to biologics.

PSO-TOP, a large European investigator-initiated study of the effect of interventions on patients/HCP interactions in patients with mild-to-moderate plaque psoriasis receiving Cal/BD gel once daily for 8 weeks and then ‘as needed’ for an additional 56 weeks, which demonstrated that patient management techniques such as conversation guidance, information, telephone or email help desks, and treatment reminders, helped to significantly improve Physician Global Assessment (PGA) score alongside treatment.

Ongoing studies

PSO-LONG, a Phase III study to investigate the efficacy and safety of a twice-weekly maintenance regimen with Cal/BD foam compared with vehicle in the prevention of relapse in subjects with psoriasis vulgaris.

Future challenges

The authors agreed on eight factors (or unmet needs) they believe important to the success and improvement of long-term plaque psoriasis management with topicals. 

  • Improving adherence
  • Optimising application frequency
  • Developing new formulations
  • Developing combined treatments
  • Dealing with corticosteroid phobia
  • Addressing concerns on tachyphylaxis
  • Cost-effectiveness of treatment
  • Addressing management of difficult-to-treat areas

Terminology and varying treatment regimens

There are several treatment regimens currently used in long-term management with topicals, which are listed below:

  • On demand/as needed - continuous use and then switch to ‘as needed’ after the patient is clear/almost clear
  • Tapering - continuous use followed by a gradual reduction in the number of doses/potency
  • Proactive (preventative) applications – continuous, once or twice a week application on previously affected areas
  • Treat-to-target - an approach mainly relevant to systemic therapies, where treatment is customised to achieve a prespecified therapeutic goal

Proactive, long-term management (for up to 12 months) with topical calcineurin inhibitors (TCIs) is well established in atopic dermatitis. Even though approval in plaque psoriasis is lacking, the authors say that long-term management strategies with TCIs in atopic dermatitis may provide rationale and support for similar approaches in plaque psoriasis.

A focus on treatment goals

The authors recommend PGA of 0 or 1 (clear or almost clear), and/or Dermatology Life Quality Index (DLQI) 0 or 1 as an optimal treatment goal for patients with mild-to-moderate plaque psoriasis.

An improvement in Psoriasis Area and Severity Index (PASI) score of 90% or better (almost clear or clear skin) is considered a treatment success by the EMA, but PASI can be an impractical disease measure in the context of mild-to-moderate plaque psoriasis - difficult to calculate and interpret, time consuming, and not especially relevant to patients with less severe disease. 

Conclusions

The authors wrap up their review with an acknowledgement that data on long-term plaque psoriasis management with topicals is currently scant, but state that “long-term management should be considered mandatory to ensure patients receive appropriate proactive treatment which may help optimise adherence and long-term outcomes”.

They also remind healthcare professionals of the importance of involving patients in decisions around topical management of their disease, particularly in the long-term setting.

Reference

  1. Segaert S, et al. Long-term topical management of psoriasis: the road ahead. J Dermatolog Treat 2020 https://doi.org/10.1080/09546634.2020.1729335.
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This content has been developed in collaboration with LEO Pharma A/S who provided some of the content. Medthority received educational funding from the sponsor in order to help provide its healthcare professional members with access to the highest quality medical and scientific information, education and associated relevant content. MAT-36002. Date of preparation October 2020.

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