Clinical Literature Review: Topical Treatments for Psoriasis

Treatment of Intertriginous Psoriasis: From the Medical Board of the National Psoriasis Foundation

Kalb RE, Bagel J, Korman NJ, et al
J Am Acad Dermatol. 2009;60:120-124

A task force of the National Psoriasis Foundation Medical Board sought to formulate a consensus on therapy for intertriginous psoriasis. A MEDLINE search was performed, and the results were graded according to levels of evidence developed by Shekelle and colleagues.^[1] The treatment recommendations are divided into first- and second-line treatment options, with the first-line treatment options divided further into those that are appropriate for short-term use and those that may be used on a more long-term basis.

The recommended short-term first-line therapy for intertriginous psoriasis is low- to mid-potency topical corticosteroids. The recommended long-term first-line therapy is topical calcipotriene or one of the immunomodulating topical agents (tacrolimus or pimecrolimus). Kalb and colleagues stated that the risks of topical corticosteroids applied to intertriginous areas can be minimized when used either for a limited time (2-4 weeks) or at the lowest strength used intermittently over a longer period of time. Because steroid-sparing medications are associated with fewer long-term risks, agents such as tacrolimus, pimecrolimus, and calcipotriene are recommended for long-term use; however, they are less efficacious and have an increased potential to cause local irritation. The combination of a low- to mid-potency topical steroid plus either calcipotriene, a topical immunomodulator, or an antimicrobial agent was considered first-line as well, although the recommendation was based on anecdotal evidence only.

All subsequent treatment options for intertriginous psoriasis were based on anecdotal evidence. Second-line treatment recommendations include emollients and tar-based products. Alternative third-line treatments include dithranol, excimer laser, topical retinoids, and topical salicylic acid, all of which should be used with caution. When the aforementioned treatment options have failed, systemic medications have been used by some experts with benefit, but no studies to date have been conducted on systemic treatment specifically for intertriginous psoriasis.

Viewpoint

Intertriginous, or inverse, psoriasis is defined as psoriasis located at areas of the skin fold. Areas of involvement include axillae, intragluteal fold, perianal skin, retroauricular folds, genital folds, abdominal folds, and inframammary folds. This condition, the actual incidence of which is unknown, has historically been treated with low-potency topical steroids. However, at these more sensitive locations, there is a much higher risk for topical steroid side effects, such as atrophy, striae, and telangiectasias.

This review provides a much needed scientifically validated treatment consensus for intertriginous psoriasis, an often neglected type of psoriasis. The treatment recommendations elucidate the importance of nonsteroidal medications (calcipotriene, tacrolimus, pimecrolimus) in the treatment of intertriginous psoriasis. Unfortunately, in practice, the calcineurin inhibitors are not as efficacious as topical steroids; furthermore, patients often complain of skin irritation, especially at sensitive locations, leading to cessation of the agent.

One promising option for intertriginous psoriasis is the new vitamin D₃ agent calcitriol. As the naturally occurring active form of vitamin D₃, this agent has similar efficacy in psoriasis compared with calcipotriene but with apparently fewer side effects. It is one of the only vitamin D₃ products shown to be well tolerated in clinical trials when used in sensitive skin-fold areas.^[2] This agent has been approved for topical use at up to 200 g per week.

This article offers a helpful consensus on the treatment of intertriginous psoriasis; however, the amount of literature on the topic is sparse and the quality of the studies varies tremendously. Further studies are needed.

The Role of Online Support Communities: Benefits of Expanded Social Networks to Patients With Psoriasis

Idriss, SZ, Kvedar JC, Watson AJ
Arch Dermatol. 2009;145:46-51

The authors sought to determine the demographics, usage patterns, attitudes, and experiences of people with psoriasis who use online support sites. Responses were evaluated from a 29-item, cross-sectional, Web-based survey completed by a total of 260 subjects from 5 online psoriasis support groups (the National Psoriasis Foundation Forum, the Psoriasis Help Organization, the Psoriasis Google Group, the MSN Psoriasis Group, and the Yahoo-based Psoriasis Philippines Online Community Inc.). Demographic data showed a predominance of white (75.7%), middle-aged (mean age, 40.1 years), college-educated (84.3%) women (60.4%).

Data collected relating to general experiences with online communities included reasons for use of online support groups, length of use, frequency of log-in, and types of online activities. Online support sites were most often used by responders because of the availability of resources (95.3%) and convenience (94%), followed by access to good advice (91%) and lack of embarrassment when discussing personal issues (90.8%). Online activities included posting messages (65%), replying to messages (64.6%), and searching for information (63.1%). Overall, more responders preferred to ask questions (51.9%) rather than answer questions or offer advice (46.1%) while participating in online support groups.

Data were also collected on whether participation in online psoriasis support groups had affected participants' severity and perception of psoriasis, quality of life, and thoughts on sources of support. Two thirds of responders (65.7%) felt that they had gained a sense of control over their psoriasis from their participation in the online support group, while almost half perceived improvements in their quality of life (49.5%) and psoriasis severity (41%). Of note, when asked to rate the usefulness of various sources of support, physicians ranked second to the Internet (51.9% vs 86.5%), followed by family, friends, and face-to-face groups (41.1%, 37%, and 18.1%, respectively). The study authors concluded that online support groups offer users an educational resource and an important means of psychological and social support.

Viewpoint

The benefits of online support groups for medical conditions such as diabetes, heart disease, and back pain have been demonstrated.^[3,4] This is the first study to scientifically evaluate user characteristics and perceived benefits of online support groups in the field of dermatology, specifically psoriasis.

One piece of information from this study stands out: The Internet is seen as a more useful source of support for patients than are physicians. This demonstrates, first, that we as physicians may be failing to address the psychosocial/emotional needs of patients and, second, that the Internet acts as both a source of knowledge and education for our patients and a form of social and emotional support.

Dermatologists should familiarize themselves with the indicators of psychosocial and emotional disturbances and address them accordingly. However, even as a board-certified psychiatrist and dermatologist, I [Dr. Koo] can attest to the fact that in a busy dermatology practice, addressing patients' psychosocial and emotional issues is often difficult. Perhaps this study offers an answer: Much as we prescribe medications for the physical aspects of psoriasis, we should also consider "prescribing" options that will address the social and emotional aspects of psoriasis, such as the online support groups mentioned in this study. The benefit to patients may be enhanced further by physician involvement in these online communities, which has yet to become reality.

This study is limited because the data cannot be generalized to all patients with psoriasis, as the sample of convenience does not necessarily reflect psoriasis patients as a whole. Also, "prescribing" participation in online support groups would only be beneficial to the computer-literate patient population.

Comparing Clobetasol Propionate 0.05% Spray to Calcipotriene 0.005% Betamethasone Dipropionate 0.064% Ointment for the Treatment of Moderate to Severe Plaque Psoriasis

Menter A, Abramovits W, Colón LE, Johnson LA, Gottschalk RW
J Drugs Dermatol. 2009;8:52-57

This article describes a multicenter randomized study comparing the efficacy and safety of clobetasol propionate (CP) spray with a combination calcipotriene-betamethasone dipropionate (C-BD) ointment for the treatment of moderate-to-severe plaque-type psoriasis. Ninety-three patients were randomized to receive either twice-daily treatment with the CP spray or once-daily treatment with the C-BD ointment. Evaluations were performed at baseline, week 2, week 4 (end of treatment), and week 8 (4 weeks post-treatment). Efficacy was determined using both overall disease severity and investigator global assessment, while impact on quality of life was assessed using the Psoriasis Quality of Life Questionnaire (PQOL-12 items). Severity of adverse events, including erythema, scaling, dryness, and stinging or burning, were reported by participants according to a 4-point scale: 0 = none; 1 = slight presence; 2 = definite/obvious presence; 3 = intense/marked presence.

Results demonstrated that 75% of patients treated with CP spray achieved a "clear" or "almost clear" rating per the overall disease severity scale after 4 weeks of treatment, compared with 45% of patients treated with C-BD ointment (P = .003). Using the investigator global assessment scale, more of the CP-treated patients were "clear" or "mild" (73%) compared with the C-BD-treated patients (65%) at 4 weeks; however, this result did not quite reach statistical significance. At week 8, after 4 weeks of no therapy, significantly more of the patients treated with CP spray (14%) compared with those receiving C-BD ointment (8%) maintained treatment success of "clear" or "almost clear" per the overall disease severity scale. Using the investigator global assessment scale at week 8, 41% of spray-treated patients were "clear" or "mild" compared with 24% of ointment-treated patients. Changes in quality-of-life scores, based on the mean decrease in PQOL-12, consistently showed better quality-of-life improvement with CP compared with C-BD at 4 weeks (36.1 points for CP spray, 30.8 for C-BD ointment) and 8 weeks (15.9 points for CP spray, 10.1 for C-BD ointment). Adverse events, reported by less than one third of patients, were similar for both treatment groups (31% for CP spray, 33% for C-BD ointment) and most commonly included erythema (10%; 12%), scaling (20%; 21%), and dryness (41%; 42%); 33% and 19% of adverse events were considered possibly, probably, or definitely related to treatment with CP spray and C-BD ointment, respectively. No serious adverse events were reported.

Viewpoint

This study is the first of its kind to compare clobetasol spray with combination calcipotriene-betamethasone ointment. The authors showed that clobetasol spray was more efficacious for moderate-to-severe plaque psoriasis both during and after treatment compared with calcipotriene-betamethasone ointment. Both treatments had a similar safety profile.

However, clobetasol spray is limited to a maximum of 1 month of use per treatment course. It is important for clinicians to have a clear idea of what to do after that 1-month period is up. Options include, but are not limited to, sequential therapy and pulse therapy. In sequential therapy, the initial improvement achieved as a result of clobetasol spray can be maintained with the use of nonsteroidal topical medications. This transition off topical steroid medications and to nonsteroidal medications is considered the transitional phase. An example of sequential therapy is the use of nonsteroidal medications on weekdays and clobetasol spray on weekends. Eventually, the patient should be transitioned so that he or she can be maintained only on nonsteroidal medications. This is considered the maintenance phase of sequential therapy. Another possibility is to use clobetasol spray as a "pulse therapy." The patient would alternate between the use of clobetasol spray for 1 month and a nonsteroidal topical medication for 1 month, enabling the patient to have a "steroid holiday." Calcipotriene-betamethasone ointment may be helpful for patients who are using less potent topical steroids and/or nonsteroidal medications between treatment courses with clobetasol spray.

References

1. Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ. 1999;318:593-596.
2. Ortonne JP, Humbert P, Nicolas JF, et al. Intra-individual comparison of safety and efficacy of calcitriol 2mcg oint and calcipotriol 50mcg ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or flexural areas. Br J Dermatol. 2003;148:326-333
3. Ritter P, Lorig K, Laurent D, Matthews K. Internet versus mailed questionnaires: a randomized comparison. J Med Internet Res. 2004;6:e29.
4. Lorig KR, Laurent DD, Deyo RA, Marnell ME, Minor MA, Ritter PL. Can a back pain email discussion group improve health status and lower health care costs? Arch Internal Med. 2002;162:792-796.

Source : http://cme.medscape.com/viewarticle/702806