Raj Chovatiya, MD, PhD, and Neal Bhatia, MD, kicked off their session, “The Use of Steroids in Topical Psoriasis Therapy,” by addressing the question: Why do we need another topical therapy? Lack of efficacy was one of the reasons.

Dr Bhatia discussed the implications of using just steroids, including a negative impact on epidermal differentiation and deterioration of the skin barrier in just 3 to 4 days. “Within that time frame, they may see results, they may see reduction of itch, but it’s just a bandage and not a remedy,” he stated.

Better topical medication adherence is associated with better treatment outcomes. “Adherence is a key part of the equation that is often overlooked,” Dr Chavotiya commented. Topical medications present a particularly unique burden. They are cumbersome; even healthy individuals cannot adequately treat their whole skin surface. Most patients want ease of use and good tolerability without staining; unpleasantness is one of the worst aspects of the treatments. Topicals are also time consuming.

Next, they moved to retinoids and steroids, which “have very similar anti-inflammatory activities.” Tazarotene is used in topical psoriasis therapy instead of other retinoids:

• Tazarotene binds to all three retinoic acid receptors (RARs).
• Topical tazarotene inhibits inflammation-associated proteins.
• Trifarotene has 20-fold selectivity for RARg over RARa and RARb, whereas tretinoin and adapalene are lesss specific and better for acne.
• Tretinoin and adapalene have not been thoroughly studied for psoriasis.

Combinations with topical therapies make sense in palmoplantar psoriasis, the nails and scalp, recalcitrant plaques, intertriginous areas, and pregnant patients. “Vitamin D fits the mold of what is safe and what is easy when it comes to compatibility with topical steroids but also what it’s doing to the process of everything else,” said Dr Bhatia. Vitamin D interferes with the pathophysiology of psoriasis, has increased efficacy when used in combination, and offers regimen flexibility and ease of administration.

Dr Chavotiya then addressed poor adherence, with recommendations such as:

• Consider nonadherence when topicals “fail.”
• Limit prescription complexity.
• Stick to a reasonable body surface area.
• Get the patient involved.

There are still multiple studies required to validate gold-standard measures of adherence, accurately identify predictors of adherence, and rigorously test interventions to improve adherence.

Lastly, Dr Bhatia iterated the steps to approaching the treatment:

• Step 1: Understand what the patient wants.
• Step 2: Assess the patient.
• Step 3: Review the data.
• Step 4: Arrive at a treatment plan.

He emphasized that adherence is not an all-or-nothing phenomenon:

• Accounting for topical medication adherence is complex but crucial in a chronic condition like psoriasis.
• Consider the entire journey of a topical medication, from provider to patient, when optimizing adherence.
• Make evidence-based decisions when working with your patient to select the right treatment.
• Communication underlies everything.

Reference
Chovatiya R, Bhatia N. The use of steroids in topical psoriasis therapy. Presented at: Fall Clinical Dermatology Conference 2022; October 20–23, 2022; Las Vegas, NV.