This transcript has been edited for clarity.
Steven R. Feldman, MD: Hi. I'm Dr Steve Feldman and welcome to Medscape InDiscussion. Today, we're talking about psoriasis and the most important things to know about psoriasis treatment — using topicals. First, let me introduce my guest. She's a dermatologist and assistant professor at Queen's University Ontario, and she serves as medical director at the Skin Center for Dermatology and the Skin Research Center. A prolific researcher, she's published about 100 Medline referenced articles on psoriasis, as well as psoriasis treatment guidelines. I'm honored to present Dr Melinda Gooderham. Welcome.
Melinda Gooderham, MD: Thanks, Dr Feldman. Happy to be here.
Feldman: Let's just start off with some fun fact with our listeners that the people just don't know about you.
Gooderham: I guess it's fun for me because I love to travel the world, and this job of being a dermatologist who does clinical research has given me the opportunity to travel all over the world and I actually filled a 10-year passport in 4 years.
Feldman: That's awesome. What were some of your favorite places?
Gooderham: Israel, amazing. Taiwan, amazing. Every place has such a different thing to offer. Any place in South America. I love food and I love drink, so anywhere I can go to try something new is open to me.
Feldman: That's great. Dermatology has been very good to me too. One of my favorite places that dermatology took me was Iran. Have you gotten to go to Iran?
Gooderham: No, I have not been there yet.
Feldman: The food there you will enjoy it. I hope you get the chance.
All right. Let's move on to psoriasis. What is the role of topicals in psoriasis?
Gooderham: Topicals play such an important role for the whole spectrum. Whether you have mild disease, moderate, or severe, topicals will play a role for localized disease. In a mild patient who has 3% or less body surface area (BSA), our first line of treatment is going to be topical therapy. But then we have the moderate or severe patient for whom, although topical therapy may not be most practical, we're going to use some systemic therapy, we're going to combine that with topicals.
Feldman: What are some of the challenges of prescribing topical treatments?
Gooderham: The number one challenge is probably patient adherence. You can have the most amazing topical but, as I tell my patients, if it's sitting in your cupboard and not on your skin, it's not going to do anything. The main thing is getting patients to apply the topical and there's so many factors that affect that.
Feldman: There are a lot of topical options, too. Is choosing topicals a challenge?
Gooderham: That is one of the issues that factors into adherence. There are so many factors, such as the vehicle that the topical comes in; where on the body you can apply it; the cosmetic acceptability of the product. Even in patients with limited disease, if they have several different areas involved — special sites, such as the face, the scalp, the groin — they'll all need a different topical to use. The more complicated the regimen is that you give the patient, the less likely it is that they'll be able to follow it.
Feldman: Let's give some brass-tacks advice. If somebody has a patient and they've got elbow and knee psoriasis, what kind of topical should we be thinking about prescribing?
Gooderham: For the body, first-line agents are cornerstone topical corticosteroids. One thing for our listeners, if we have a wide range beyond just dermatologists such as primary care, is that body psoriasis needs a potent or superpotent topical corticosteroid. Giving a topical corticosteroid that's not strong enough can frustrate the patient; they'll lose faith in the treatment. That's one important takeaway: For the body, elbows, and knees, you need something potent or superpotent from the steroid class.
Feldman: Something like clobetasol or betamethasone?
Feldman: Are you prescribing a cream or an ointment for those patients?
Gooderham: It depends on the patient and the discussion you have with them about what they're willing to apply. It gets back to what will the patient use. Some patients prefer an ointment. Some don't; they find it too greasy. For my own practice, I use a lot of combination products with a potent or superpotent topical corticosteroid. So betamethasone dipropionate mixed with calcipotriol, or you could have halobetasol mixed with tazarotene. I find that combination products, when you want something potent, offers some other advantages like improved efficacy or reduction in side effects, whether it's irritation or skin atrophy. Some of the combination products check more boxes on the list.
Feldman: We have moisturizers to use for dry places and corticosteroids — the potent ones — and I presume milder corticosteroids for face and genital area. You mentioned having vitamin D and vitamin A analogs so we can use them. Any other topicals we should be thinking about?
Gooderham: Currently, we have some off-label use for topical calcineurin inhibitors; although they're approved for atopic dermatitis, we often use them in the sensitive areas — as you mentioned, the face, the groin, the skin folds. Tacrolimus and pimecrolimus, we will use off-label. Crisaborole, which is a PDE4 [phosphodiesterase 4] inhibitor. They often play a role in our management at this point. But looking to the future, we're going to have some more options that are not steroids — where we won't have to use multiple different agents for different body areas.
Feldman: One of the treatments that I used to recommend a lot before we had so many options was topical tar and now I've started coming back to it once we learned about aryl hydrocarbon receptors.
Gooderham: I just compounded something with LCD the other day for a patient because they were reminiscing of their older dermatologist who used to give them some tar products. The problem with tar is the odor, the messiness. With the aryl hydrocarbon target — with tapinarof — we're going to be able to have that efficacy without the downside of the odor and the messiness that tar brought us.
Feldman: Just for those who don't know what LCD is, do you mind?
Gooderham: Sure. LCD stands for liquor carbonis detergens. It's an extract from tar that makes it a little easier to use than tar.
Feldman: If you had a new patient, what would you ask them that would help you decide what topicals to prescribe for them?
Gooderham: I like to find out what they've already tried before. Was it a white cream? Was it a greasy ointment like Vaseline? And they'll often tell you right off the bat, "The last treatment I used was too greasy. It got all over my sheets, it got all over my clothes." You know right away that those patients are not going to tolerate another ointment if you give them that. One other thing, over the past decade or so in the psoriasis topical treatment landscape, there have been new vehicles. We've had topical corticosteroids for years. But in the past few years, we've come up with different ways of applying them to improve adherence, which is such an issue. Things like foams, sprays, optimized lotions that don't leave that greasy feeling, because that's one of the deterrents for adherence of therapy.
Feldman: Do sprays make a difference compared with the ointments?
Gooderham: If the spray is made properly — and you can get some improved absorption with sprays — I find that they do need to either be combined with a moisturizer or some formulas that have a moisturizer built into it. But we do have this dry, scaly plaque with psoriasis. If you spray on a solution, you may not be able to help with that scaling as much as an ointment, which is a bit more occlusive.
Feldman: I tend not to prescribe a moisturizer with the spray because I'm not so sure you really need to moisturize anymore. If you look at the spray studies, I don't think they incorporated a moisturizer in those studies, I think they just let people spray the stuff on.
Gooderham: Once they start working and you control the inflammation, you're not going to be producing more scale. But if a patient is complaining about the dryness or the cracking or whatever, I will recommend moisturizer, but it's not part of my regular routine. The spray that I use has a moisturizer as part of it, so it's not much of an issue. The only problem, I will say, about a spray is that it's almost too easy to use. So I find that for the most part, with an ointment — obviously in the back of my mind, I'm always worried about side effects and atrophy and things like that — I just don't see that because I think people aren't adherent enough. But when you give someone an easy-to-use spray, they tend to use it quite a bit. That's when I start to see some atrophy showing up because it is so tolerated — they're a little more adherent.
Feldman: Are there particular settings where you tend to see those atrophy side effects more often?
Gooderham: Yes. When they are using topicals in more sensitive areas. You give someone a spray for their knees and then when they notice something showing up in their groin or in the axilla, they may just start to use the spray there, even though you may have told them at their visit to not put it on a sensitive area. Sometimes patients forget, and there may be a time lapse between the last time you saw them and when they are developing new areas. For sure, in some of the sensitive areas, you can see more atrophy. But I have even seen some elbows and knees with excessive steroid use showing some atrophy of the skin, telangiectasias.
Feldman: We have to worry when we see patients, certified public accountant, architects, engineers, the kind of people who bring you these multicolored Excel spreadsheets showing you everything they're doing. Because if you tell them to do something twice a day, they might actually do it. And if you don't give them a stop point, maybe they would develop atrophy more often.
Gooderham: Yeah. I'll never forget the one case in medical school — before I was even in dermatology — of a woman who came in with basically bilateral black eyes and she'd been applying clobetasol to her face for many years. Amyloidosis was even on our differential with her presentation until we found out the cause was the clobetasol she was using on her face.
Feldman: Patients do the darndest things. Do you have any tips, tricks, general approaches that you use to educate people about the use of their topicals?
Gooderham: I do tell them it's important to really stick to the course for the first month or two and make sure that they are putting it on every day while there's still some visible lesions there. But since, we've had some studies, like the PSO-LONG study, that told us once the skin is under control, you can go down to a reduced application, so maybe twice weekly for maintenance. I try to counsel them on that: Use it every day for a month. We really need to get control of it. Don't stop too early. But then once it is under control, back off to twice a week ongoing for maintenance.
Feldman: If someone came in with limited scalp involvement and you thought topicals were appropriate, would you give that same advice, or would you change it in any way?
Gooderham: Yep, pretty much similar advice. With some topical oils it depends on insurance and what's going to be covered. We work with what we have access to. There are some topical scalp oils, oily gel, that we'll apply. We can use a spray in some of these areas and then I will try to get them to use it on a on a regular basis. If it's really localized on the scalp, sometimes patients get very frustrated with washing out product from their hair. There are times where I may even use intralesional triamcinolone in a very localized plaque.
Feldman: Yeah. Very good adherence with intralesional therapy. Treating the scalp with topicals is like the mother of all adherence problems.
Feldman: I try to keep that treatment exceptionally simple. Instead of telling people to follow up in a month, I encourage them to follow up in 3 days. Because I figure if I tell them it's just 3 days… Well if the dentist told me, "I'm worried about your teeth, Steve, I want you to floss every day. I'm going to see you back in 3 days," I'd probably floss really well for those 3 days.
Gooderham: Yes. More frequent follow-up, when scheduling allows it. I've even tried following up with the nurse if I don't have room in my schedule, so patients know that there's some accountability. Because we find that accountability with clinical trials. I tell that to patients in my general clinic. I say, "When we used this in the clinical trial and patients came every week and we weighed their tubes and we watched how much they were using, it really worked well." Prescribers have to think about use in the real world. Going away for the weekend and not bringing your topical with you or staying over at a friend's house and forgetting it, or just taking a day off here and there, you're not going to get the same results.
Feldman: Yeah. People do use the medicines better in studies when you bring them back every week to follow their progress than when you say that you'll see them in 2 or 3 months.
Accessibility of some of these products is an issue. I love the spray because some people find it so easy. But where I am, the spray is often more expensive than the clear liquid. One of my favorite tricks to share is to just order the generic solution, get a spray bottle at the dollar store and put it in the spray bottle, and you're good to go. Do you have any other tricks for making sure the treatments are affordable for patients?
Gooderham: It is very tricky, and I know it's a bit of a different landscape in the States compared to Canada. We're having some generics available, so there's some insurance plans that will substitute the generic, which is great if that's what their access is. We also do try to work a bit with some of the companies on a compassionate use: If somebody doesn't have insurance, will be able to get them some access to some products. I like to use combination topical products but these are typically more expensive. In those patients who don't have insurance, who are paying cash, I will often go to a generic steroid with a little more advice on how to use it properly. One of the reasons I got into clinical trials in the first place was to help patients access therapies through clinical research, and that's been rewarding.
Feldman: I have the sense that when you choose a topical therapy for somebody with limited psoriasis and they don't get better, it's probably because they didn't use the medicine, which makes me wonder, Are the new topicals that are in development, for which there's so much enthusiasm, really going to help? Because the only people who are going to get them are people who aren't putting on their topicals.
Gooderham: That's a great point. I mean, what I'm hoping with the new topicals is some features that might make it easier to use and easier to stick to the plan. So topical corticosteroids, twice a day application. The newer nonsteroidals are once a day application, so that will help.
Number two is the fear of side effects with topical corticosteroids because even if you counsel a patient in your office — I'm not sure if it's the same in the US as in Canada — by the time they get to the pharmacy, sometimes the pharmacist scares them with, "You can't use this for more than 2 weeks." This is a chronic disease, and once 2 weeks is over, they still need to use it to some degree. They're not using it because they're afraid of the side effects. With the new topicals that are nonsteroidal, there won't be the same atrophy. There aren't the same tolerability issues that we might see with topical calcineurin inhibitors, such as burning or stinging. Those features will encourage their use. Patients won't have to feel [conflicted] every time they use it.
Then there is the speed of onset. Steroids do work quickly, but some of these new treatments also work quickly, and that's also encouraging for patients to stay on. If you're using a steroid that's not strong enough, for example in a primary care setting, and the patient is a little reluctant to use a more potent topical steroid so the primary care provider prescribes hydrocortisone or something, they're going to put that on, but it's not going to help. In the patient's mind steroids aren't going to work for them, even though they've only used a very mild steroid on their psoriasis.
Feldman: You mentioned primary care. Primary care doctors are at the forefront of seeing these patients. Many people with psoriasis out there probably never get to dermatology. What practical advice do you have for primary care doctors seeing patients with psoriasis?
Gooderham: They've got a lot to keep on top of. They've got diabetes, they've got hypertension. They have all these things with all new medications coming out. I know it is a challenge, but my advice would be to keep up with something like Medscape or podcasts or however you like to get your education — but keep up on what's new.
The other thing is not using the proper topical. Using one that is too mild can affect adherence because then patients lose that confidence that this is going to work. Primary care providers should not be so afraid of the more potent topical steroids that patients are fearful to use them. Frequent follow-up that you mentioned is also important for adherence of therapy because that's all going to relate to the success of the patient.
Finally, if they are not responding to a topical and you're sure that there is proper adherence, then refer them for systemic therapy. Now, instead of diagnosing a patient with mild or moderate to severe psoriasis, we're starting to make the division of topical-responsive and topical-nonresponsive. The question becomes who deserves a systemic therapy for psoriasis? It's used when topical therapies fail. But we need to make sure that patients first had an adequate trial on topicals.
Feldman: A new patient with psoriasis comes to the primary care doctor with psoriasis on the elbows and knees. Would you recommend betamethasone dipropionate cream or ointment? Whichever the patient would be willing to use?
Gooderham: Very reasonable.
Feldman: If there were some scalp involvement, a little bit of fluocinonide solution or an oil product if they were willing to put an oil on?
Feldman: Dermatologists are always being told to ask patients with psoriasis about joint pain. We'd probably tell the primary care doctor do the same?
Gooderham: I would. I find every time I give a lecture to primary care providers about the systemic inflammation of patients with psoriasis and the associations — one third of patients with psoriasis having psoriatic arthritis — I get a flood of new consults. Every time you give a lecture, for about 2 months you get an influx of all these consults, and then they quiet down again. It's reminding them that these patients do have other comorbidities that we need to address. Not just joint pain, but cardiovascular disease, metabolic syndrome, and other comorbidities that these patients might have.
Feldman: Any advice for US dermatologists about how to improve the topical outcomes of our patients with psoriasis?
Gooderham: Same principle. Stay up to date on what's available on the new vehicles. I know we're all busy in our clinics, but if you can come up with some system with your patients to have a touch-base, whether it's in the clinic or not, touch base with your patients a bit earlier.
Feldman: That's excellent advice. I give my patients my cell phone number and tell them, "Call me this week and let me know how it's doing." That lights a fire under them to fill the prescription. What's the most important idea you want to pass along to our listeners before we wrap up?
Gooderham: Educating yourself, understanding the different strengths of topical steroids in primary care, even if you just pick one or two in each potency so you know where to go. Keep a little cheat sheet in your office. I have a lot of residents who come through and they make these little cheat sheets. Know what the different vehicles are and know what is available through insurance. That's one other problem: giving a patient the prescription that they're not going to be able to afford. And then they get to the pharmacy and then they're too embarrassed to tell you they couldn't afford it. Make sure you understand what is accessible for that patient and what they're willing to use because the best treatment is the one that they can access and the one that they're going to use.
Feldman: Right. So a little hydrocortisone cream for the mild. You suggest that we should be comfortable with triamcinolone 0.1%for intermediate, and then have a betamethasone or a clobetasol for the more severe disease. Lastly, tell us about one of your mentors and the best pieces of advice you got from them.
Gooderham: Well, so many mentors and so much advice. You probably remember Stuart Maddin?
Feldman: Very well.
Gooderham: Legendary Stuart Maddin, an amazing trailblazer in Canada. Probably one of the first dermatologists to use a topical steroid. He'd tell you about grinding up the adrenal glands and going to a conference in England in the '50s. It was amazing to hear his stories. He once told me — he didn't use the word burnout — but he knew even back then: He said, "You can't do 5 days a week of patient care for the rest of your life. You need to find something else, whether it's research or whether it's medical education, you need to have something else to focus on. And that will keep you happily treating patients." That's the best advice that I've had from my mentors.
Feldman: That's great advice. Preventing burnout is something we all should be paying attention to these days.
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Cite this: Topical Prescribing Tips for Better Psoriasis Outcomes - Medscape - May 05, 2022.