The Evolution of Topical Formulations in Psoriasis

Bonnie Kuehl, PhD; Neil H. Shear, MD, FRCPC, FACP


Skin Therapy Letter. 2018;23(4) 

In This Article

Abstract and Introduction


Most people with mild-to-moderate psoriasis manage their disease with topical therapies. However, adherence to topical treatment remains a challenge, as the daily application creates a significant treatment burden. New topical therapeutic options need to offer higher efficacy and better patient acceptability, including easier application, to reduce treatment burden and enhance patient adherence. Topical foam vehicles are innovative alternatives to creams and ointments, addressing many patient challenges with traditional vehicles. Well-designed foam vehicles are easily spread over large areas of the skin, while importantly not leaving a greasy or oily film on the skin after application. Calcipotriol/betamethasone diproprionate aerosol foam is a new psoriasis treatment option that is rapidly effective, offers greater efficacy versus ointment and gel formulations, and has been shown to increase patient treatment satisfaction. Hence, by addressing the several crucial unmet clinical needs in patients with mild-to-moderate psoriasis, this optimized foam formulation is poised to improve treatment follow-through.


Psoriasis is an immune disorder that most commonly manifests itself with visible plaques on the skin, resulting in considerable morbidity for those affected. The World Health Organization characterizes psoriasis as "a chronic, non-communicable, painful, disfiguring and disabling disease for which there is no cure."[1] The majority of patients are classified as having mild-moderate disease with an estimated 20% having moderate-severe disease.[2] In a multinational survey (US, Canada, France, Germany, Italy, Spain, UK), dermatologists acknowledged that psoriasis is undertreated with an ongoing unmet treatment need for patients.[3] In the survey, dermatologists reported not initiating or maintaining treatment due to concerns regarding the long-term safety, tolerability and efficacy of currently available therapies.[3] The MAPP survey (population-based survey of psoriasis and/or psoriatic arthritis patients in North America and Europe) revealed that the majority of psoriasis patients are undertreated; >80% of patients with ≥4 palms body surface area (BSA) were receiving no treatment or topical treatment only. Further, 57% who received oral therapy and 45% who received biologic therapy discontinued treatment, citing safety/tolerability concerns and a lack/loss of efficacy.[4]

As with any chronic disease, patient adherence to topical psoriasis therapy is low. The high burden of treatment and the substantial effort required to maintain ongoing therapy leads to treatment fatigue. According to published data, approximately 75% of patients[3] with psoriasis vulgaris (plaque psoriasis), regardless of severity, manage their disease with topical therapies, which may lead to quicker treatment fatigue as the daily treatment regimen can be cumbersome and time consuming.[2] Studies in medication adherence in psoriasis have shown that 39–73% of patients do not use their medication as prescribed.[5–7] Factors influencing adherence include patient specific characteristics, disease-related characteristics, treatment satisfaction, cosmetic acceptability and complexity of treatment protocols.[8] Studies also report that cosmetic acceptability is a key contributor to adherence, with adherence being reduced if treatments are perceived as messy to apply and sticky on the skin.[9] There is evidence that low adherence to psoriasis therapies may be related to insufficient instruction on how to use the drug, misperceptions regarding possible adverse events (AEs) and mistaken expectations about the speed and degree of improvement.[1]

A challenge to the use of currently available topical therapies is that many patients fail to achieve complete or almost complete clearance of their psoriasis.[10] Increasing awareness of the burden of psoriasis and the psychosocial impact of the disease have underscored the clinical need for a topical therapy that is easy to use, cosmetically appealing, rapidly efficacious with short-term use, as well as be able to induce sustained efficacy for long-term maintenance.[8,10]