Based on a comprehensive analysis of the latest research on topical psoriasis medications (including corticosteroids, vitamin D analogs, calcipotriol and betamethasone propionate ointments, tazarotene, tacrolimus and pimecrolimus), the new AAD guidelines address patient expectations, use, combination therapy, duration of therapy, dosing and patient compliance in topical psoriasis therapies. In addition, the new guidelines include specific recommendations and considerations for treating patients with more severe psoriasis with topical therapies alone or in combination with other treatments.
According to the guidelines, topical therapies can be used safely and effectively in most patients with mild to moderate psoriasis, while they cannot be used alone in cases of moderately severe or refractory focal psoriasis.
Patient expectations
The appropriate choice of topical therapy should meet both patient expectations and clinical realities. For example, patients who want complete and continuous disappearance of psoriatic lesions may be disappointed by topical therapies, which require long-term, high-dose medications that are difficult to achieve; others prefer intermittent treatment with little attention to disease.
AAD President and dermatologist Professor Hanke believes it is important to understand each patient’s goals and develop a realistic, individualized treatment plan to help patients achieve their expectations.
Method of use
The choice of dosage form can significantly alter drug usage and permeability, and thus the effectiveness of treatment. Common topical dosage forms include ointments, creams, solutions, gels, foams, tapes, sprays, shampoos, oils, and lotions. The guidelines suggest that although different dosage forms are appropriate for different areas of the lesion, the ideal choice is to select the dosage form based on the patient’s wishes.
According to Professor Hanke, in areas with hair (such as the scalp), solutions, foams, shampoos, sprays, oils, gels or other dosage forms can be used depending on the patient’s needs; some patients may prefer less greasy preparations, so creams can be used during the day and ointments that are more effective but less aesthetically pleasing can be used at night.
Combination therapy
For some patients, multiple medications may be combined depending on their mechanism of action. Patients may need to use different medications at different times of the day as prescribed, which requires the physician to understand the compatibility of the different medications.
Duration of treatment
Topical treatments may be administered intermittently or over a long period of time. For example, it is generally recommended that the more potent agents be used for a short period of time to eliminate psoriatic lesions and then intermittently for a longer period of time to reduce the risk of side effects from long-term continuous treatment. Patients who require continuous topical therapy should be given a less potent agent that can control clinical symptoms or be switched to a long-term agent with minimal risk of side effects.
According to Prof. Hanke, although topical agents are often well tolerated by patients and often have no significant side effects, patients with long-term or intermittent use should be checked regularly and unsupervised use of potent agents is not recommended.
Dosage
Fingertip units” are commonly used to guide the dosing of topical preparations. One fingertip unit is approximately 500 mg, and the recommended number of units is the number that will cover the affected area. For example, three fingertip units are sufficient to cover scalp psoriasis, while an entire leg and foot would require eight fingertip units. This method provides patients with a more accurate method of determining the dose of topical medication.
Patient compliance
Poor patient compliance is the main reason for the poor outcome of topical treatments in most patients, says Prof. Hanke, adding that a number of factors are associated with poor patient compliance, including frustration with the effectiveness of the medication, inconvenience with daily dosing, and poor choice of medication application. He suggested that physicians should make efforts to improve patient compliance, including selecting topical preparations that are strong enough to achieve good clinical outcomes and working with patients to choose the right dosage form.
Other topical treatments
The guidelines also state that other topical treatments, such as non-pharmacological moisturizers, salicylic acid, dithranol and various combinations, may be used in combination in some cases to improve the effectiveness of topical treatments.
Professor Hanke said that establishing an effective treatment strategy is important not only for the treatment of psoriasis, but also for patient compliance and overall prognosis satisfaction. Guidelines have been developed to improve the success of topical therapies in treating patients with psoriasis, but it is important that practitioners and patients continue to explore all available treatments to ensure the best long-term treatment options.
In conclusion, Professor Hanke believes that the AAD guidelines provide a framework for physicians to make decisions about whether topical agents alone or in combination with UV phototherapy, systemic or biological agents are effective in treating psoriasis; however, treatment should also be individualized according to the patient’s condition, such as the location and characteristics of the psoriasis and the patient’s wishes.