Psoriasis Topical Approaches Conflict of Interest Statement Investigator and/or consultant for the following companies which market or are developing products for psoriasis: David M. Pariser, MD Private Practice and Department of Dermatology Eastern Virginia Medical School Norfolk, Virginia Galderma Abbott/AbbVie Eli Lilly Stiefel Pfizer Leo Pharma Amgen Centocor/Janssen Biotech Celgene Merck Bohenger Ingleheim Conflict of Interest Statement I own no patents or equity interest in any companies marketing or developing products for psoriasis I do not do promotional speaking I am not a member of any speakers bureaus If I make any recommendations that are of label I will identify Which patients are candidates for topical therapy? Limited body surface area: 10% 5% 3% Specific locations: Scalp, face, flexural folds, genitalia, palms, soles Inverse psoriasis Hard to treat areas: elbows, knees, lower legs Persistent plaques in anyone receiving systemic or phototherapy The Psoriasis Treatment Toolbox When evaluating a patient with psoriasis Topical Treatments Oral Systemic Agents Methotrexate Cyclosporine Acitretin Other immunosuppressants Apremilast Phototherapy UVB PUVA Excimer Laser Biologic Agents Etanercept Adalimumab Infliximab Ustekinumab Secukinumab Ixekizumab Patients with psoriasis should be considered by the clinician to fall into one of two categories Psoriasis treatable solely with topical agents Psoriasis which will need a systemic approach Traditional systemic, biologic and/ or phototherapy Often combined with each other and with topicals Give up the classification of mild/moderate/severe 1
Psoriasis Treatable Topically Psoriasis Requiring a Systemic Approach Systemic therapy needed Don t waste time with topicals alone Limited Surface Area but topical alone just won t do No chance for topicals alone 2
Corticosteroids Vitamin D Analogs Calcineurin Inhibitors Retinoids Others: tar, salicylic acid Combinations Let s Talk Topicals Cream Lotion Ointment Gel Foam Spray Tape But first: Vehicles It s all about the base Corticosteroids Most often used topical agent Available in cream, lotion, gel, ointment, foam, spray and tape Are given a potency ranking based on vasoconstrictor assay Higher potency corticosteroids for plaques on scalp, trunk and extremities Lower potency for face, neck and intertriginous areas Adverse effects: hypopigmentation, atrophy, striae, telangiectasia Vitamin D Analogs Calcipotriene May be a first line treatment Often used in combination with corticosteroids Available in cream, ointment as single agent Combination betamethasone calcipotriene product available in ointment and foam Calcineurin Inhibitors tacrolimus and pimecrolimus Commonly used to treat psoriasis on the face, neck, intertriginous areas and genitalia although off label FDA approved to tret atopic dermatitis Available as ointment (tacrolimus) or cream (pimecrolimus) Steroid sparing agent. Retinoids Vitamin A derivative Tazarotene is the only topical retinoid approved for psoriasis Available in cream and gel Reduces epidermal proliferation Major problem is irritation Use together with topical corticosteroid may reduce irritation Pregnancy category X 3
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