Optimizing Topical Therapies for Treating Psoriasis:

Faculty and Disclosure InformationOptimizing Topical Therapies for Treating Psoriasis:A Consensus ConferenceCME SPONSORSHIP STATEMENTThis activity is jointly sponsored by Postgraduate Institutefor Medicine and Millennium CME Institute, Inc.This activity is supported by an educational grant fromGalderma Laboratories, LP.Intended AudienceThis activity has been designed to meet the educational needsof physicians, registered nurses, and healthcare providersinvolved in the management of patients with psoriasis.Statement of Need/PROGRAM OVERVIEWThis article is designed to provide useful tips and to helpguide dermatologists through the practical challenges oftreating psoriasis patients with topical medications as partof both initial and maintenance therapies.Learning ObjectivesAfter completing this activity, the participant should bebetter able to:• Identify the severity of a patient’s psoriatic disease.• Discuss topical treatment strategies for psoriasis onvarious areas of the body.• Select appropriate topical vehicle and dose for differenttypes of psoriasis.• Explain approaches to improve patient adherence totreatment regimens.• Outline psoriasis treatment guidelines for differentpopulation types.• Identify strategies for long-term maintenance therapyfor psoriasis.FacultyJoshua A. Zeichner, MD; Mark G. Lebwohl, MD; AlanMenter, MD; Jerry Bagel, MD; James Q. Del Rosso, DO;Boni E. Elewski, MD; Steven R. Feldman, MD, PhD; LeonH. Kircik, MD; John Koo, MD; Linda Stein Gold, MD; andEmil Tanghetti, MD.Dr. Zeichner is Assistant Professor of Dermatology, TheMount Sinai Medical Center, New York, New York.Dr. Lebwohl is Professor and Chair, Department ofDermatology, The Mount Sinai Medical Center, New York,New York.Dr. Menter is Director of Psoriasis Research, BaylorResearch Institute, Dallas, Texas.Dr. Bagel is Clinical Associate Professor of Dermatology,Columbia University College of Physicians and Surgeons,New York.Dr. Del Rosso is Dermatology Residency Director, ValleyHospital Medical Center, Las Vegas, Nevada.Dr. Elewski is Professor of Dermatology, University ofAlabama School of Medicine, Birmingham.Dr. Feldman is Professor of Dermatology, Wake ForestUniversity School of Medicine, Winston-Salem, North Carolina.Dr. Kircik is Associate Clinical Professor of Dermatology,The Mount Sinai Medical Center, New York, New York, andthe Indiana University School of Medicine, Indianapolis.Dr. Koo is Professor of Clinical Dermatology and ViceChairman, Department of Dermatology, University ofCalifornia at San Francisco School of Medicine.Dr. Stein Gold is Director, Dermatology Clinical Research,Henry Ford Health System, Detroit, Michigan.Dr. Tanghetti practices in Sacramento, California.DISCLOSURE OF CONFLICTS OF INTERESTPostgraduate Institute for Medicine (PIM) assesses conflictof interest with its instructors, planners, managers, andother individuals who are in a position to control the contentof continuing medical education (CME) activities. All relevantconflicts of interest that are identified are thoroughly vettedby PIM for fair balance, scientific objectivity of studiesutilized in this activity, and patient care recommendations.Postgraduate Institute for Medicine is committed toproviding its learners with high-quality CME activities andrelated materials that promote improvements or quality inhealthcare and not a specific proprietary business interest ofa commercial interest.The faculty reported the following financial relationships orrelationships to products or devices they or their spouse/life partner have with commercial interests related to thecontent of this CME activity:Dr. Zeichner is an advisory board member for Promius Pharma.Dr. Lebwohl is a consultant for and has received honorariafrom Abbott Laboratories; Allostera Pharma Inc; Amgen Inc;Astellas Pharma Inc; Biosynexus Incorporated; CambridgePharma; Can-Fite BioPharma; Celgene Corporation; CentocorOrtho Biotech Inc; DermaGenoma, Inc; DermiPsor Ltd; Ethicon,Inc; Helix BioMedix, Inc; Novartis Pharmaceuticals Corporation;Pfizer Inc; and Stiefel, a GSK company. He also has lectured forand has received honoraria from Ranbaxy Laboratories Ltd.2 CUTIS ® www.cutis.com

Faculty and Disclosure InformationDr. Menter is an advisory board member, consultant,investigator, and speaker for, and has received grants andhonoraria from Abbott Laboratories; Amgen Inc; AstellasPharma Inc; Centocor Ortho Biotech Inc; and Genentech,Inc. He also is an advisory board member, consultant,investigator, and speaker for, and has received honorariafrom Warner Chilcott and Wyeth Pharmaceuticals, and is aninvestigator for and has received grants from Allergan, Inc;Asubio Pharmaceuticals, Inc; Celgene Corporation; DUSAPharmaceuticals, Inc; Novartis Pharmaceuticals Corporation;Novo Nordisk; Pfizer Inc; Promius Pharma; and SyntrixBiosystems, Inc. Dr. Menter also is a consultant and investigatorfor and has received grants from Eli Lilly and Company; is anadvisory board member, consultant, and speaker for and hasreceived honoraria from Galderma Laboratories, LP; and is aconsultant and investigator for and has received grants andhonoraria from Stiefel, a GSK company.Dr. Bagel is a consultant and speaker for AbbottLaboratories; Amgen Inc; Centocor Ortho Biotech Inc;Galderma Laboratories, LP; LEO Pharma; The NeoStrataCompany, Inc; and Stiefel, a GSK company.Dr. Del Rosso is a consultant and speaker for CoriaLaboratories, Ltd; Galderma Laboratories, LP; Intendis, Inc;Medicis Pharmaceutical Corporation; Ranbaxy LaboratoriesLtd; and Stiefel, a GSK company.Dr. Elewski is an advisory board member and consultantfor Centocor Ortho Biotech Inc; Galderma Laboratories,LP; and Intendis, Inc. She also is a consultant for NovartisPharmaceuticals Corporation and has received researchgrants from Abbott Laboratories; Amgen Inc; CentocorOrtho Biotech Inc; Galderma Laboratories, LP; Intendis, Inc;Novartis Pharmaceuticals Corporation; and Novo Nordisk.Dr. Feldman is a consultant and speaker for and hasreceived grant support from Abbott Laboratories; AmgenInc; Astellas Pharma Inc; Bristol-Myers Squibb Company;Centocor Ortho Biotech Inc; Galderma Laboratories,LP; PharmaDerm; Stiefel, a GSK company; and WarnerChilcott. He also has received grant support from Hoffmann-La Roche Ltd; Ortho-McNeil-Janssen Pharmaceuticals,Inc; and sanofi-aventis. Dr. Feldman also is a consultantfor, has received research support from, and has stockoptions with PhotoMedex, Inc; is a consultant for and hasreceived grant support from Coria Laboratories, Ltd, andValeant Pharmaceuticals International; is a speaker for andhas received grant support from 3M Pharmaceuticals; isa consultant and speaker for and has received researchsupport from Novartis Pharmaceuticals Corporation; isa consultant for and has received grant support fromPeplin Inc; has received royalties from Informa and XlibrisCorporation; and is a majority stockholder for MedicalQuality Enhancement Corporation. He also is a consultantfor Caremark LLC; Kikaku America International; Medscape;Merck & Co, Inc; and Suncare Research Laboratories, LLC.Dr. Kircik reports the following relationships: investigatorand speaker for 3M Pharmaceuticals; speaker for AbbottLaboratories; advisory board member, consultant, investigator,and speaker for Allergan, Inc; consultant, investigator, andspeaker for Amgen Inc; speaker for Assos Pharmaceuticals;investigator and speaker for Astellas Pharma Inc; investigator forAsubio Pharmaceuticals, Inc; investigator for Bayer HealthCare;advisory board member for Biogen Idec; investigator for Biolife;investigator for Breckinridge Pharmaceutical, Inc; investigatorfor Centocor Ortho Biotech Inc; advisory board memberand consultant for Colbar Life Science, Ltd; consultant,investigator, and speaker for CollaGenex PharmaceuticalsInc; investigator for Combinatrix; advisory board member,consultant, investigator, and speaker for Connetics Corporation;investigator for Coria Laboratories, Ltd; speaker for DermikLaboratories; investigator for Dow Pharmaceutical Sciences,Inc; investigator for DUSA Pharmaceuticals, Inc; speaker forEmbil Pharmaceutical Corporation Ltd; advisory board memberfor EOS Pharmaceutical Corporation; advisory board memberand investigator for Ferndale Laboratories, Inc; advisory boardmember, consultant, investigator, and speaker for GaldermaLaboratories, LP; advisory board member, consultant,investigator, and speaker for Genentech, Inc; investigator forGlaxoSmithKline; investigator for Healthpoint, Ltd; speaker forInovail; advisory board member, consultant, and investigatorfor Intendis, Inc; advisory board member, consultant, investigator,speaker, and stockholder for Johnson & Johnson; consultantfor Laboratory Skin Care, Inc; consultant, investigator, andspeaker for LEO Pharma; consultant for Medical InternationalTechnologies; investigator for Medicis PharmaceuticalCorporation; speaker for Merck Serono; consultant forMerz Pharma; advisory board member and investigatorfor NanoBio Corporation; consultant and investigator forNovartis Pharmaceuticals Corporation; investigator for NucrystPharmaceuticals Corporation; investigator for Obagi MedicalProducts, Inc; investigator and speaker for Onset Therapeutics;advisory board member, consultant, investigator, and speakerfor Ortho Dermatologics; investigator and speaker forPharmaDerm; investigator for Pfizer Inc; advisory board member,consultant, and investigator for Promius Pharma; investigatorfor QLT Inc; investigator for Quatrix; investigator for SanofiPasteur Biologics Co; advisory board member, consultant,investigator, and speaker for SkinMedica, Inc; advisory boardmember, consultant, investigator, and speaker for Stiefel, aGSK company; investigator for Tolerrx, Inc; speaker for TriaxPharmaceuticals, LLC; consultant, investigator, and speakerfor UCB; speaker for Valeant Pharmaceuticals International;advisory board member, investigator, and speaker for WarnerChilcott; and consultant for ZAGE.Dr. Koo is an advisory board member, investigator, andspeaker for Abbott Laboratories; Amgen Inc; AstellasPharma Inc; Galderma Laboratories, LP; and LEO Pharma.He also is an advisory board member and investigator forPhotoMedex, Inc; an investigator for Teikoku Pharma USA;and a speaker for Centocor Ortho Biotech Inc.Dr. Stein Gold is an advisory board member and researcherfor Galderma Laboratories, LP, and Stiefel, a GSK company,and is a speaker for Coria Laboratories, Ltd.Dr. Tanghetti is a consultant for Allergan, Inc; DUSAwww.cutis.comVOLUME 86, SEPTEMBER 2010 3

Faculty and Disclosure InformationPharmaceuticals, Inc; Galderma Laboratories, LP; ObagiMedical Products, Inc; and Stiefel, a GSK company.The planners and managers reported the following financialrelationships or relationships to products or devices theyor their spouse/life partner have with commercial interestsrelated to the content of this CME activity:The following PIM planners and managers—Jan Hixon, RN,BSN, MA; Trace Hutchison, PharmD; Julia Kimball, RN,BSN; Samantha Mattiucci, PharmD; Jan Schultz, RN, MSN;and Patricia Staples, MSN, NP-C, CCRN—hereby state thatthey or their spouse/life partner do not have any financialrelationships or relationships to products or devices with anycommercial interest related to the content of this activity ofany amount during the past 12 months.The following Millennium CME Institute, Inc, planners andmanagers—Tim Robinson, Jason Brown, and Nicole Gray—hereby state that they or their spouse/life partner do not haveany financial relationships or relationships to products ordevices with any commercial interest related to the contentof this activity of any amount during the past 12 months.METHOD OF PARTICIPATION AND REQUESTFOR CREDITThere are no fees for participating and receiving CME credit forthis activity. During the period September 30, 2010, throughAugust 31, 2011, participants must read the learning objectivesand faculty disclosures and study the educational activity.Postgraduate Institute for Medicine supports “green” CMEby offering your request for credit online. If you wish toreceive acknowledgment for completing this activity, pleasecomplete the posttest and evaluation at www.cmeuniversity.com. On the navigation menu, click on Find Post-test/Evaluation by Course and search by course ID 7338. Uponregistering and successfully completing the posttest witha score of 70% or better and the activity evaluation, yourcertificate will be made immediately available. Processingcredit requests online will reduce the amount of paper usedby nearly 100,000 sheets per year.The estimated time to complete the activity is 75 minutes.MEDIAPrinted monograph.DISCLOSURE OF UNLABELED USEThis educational activity may contain discussion of publishedand/or investigational uses of agents that are not indicatedby the US Food and Drug Administration. PostgraduateInstitute for Medicine; Millennium CME Institute, Inc; andGalderma Laboratories, LP, do not recommend the use ofany agent outside of the labeled indications.The opinions expressed in the educational activity arethose of the faculty and do not necessarily represent theviews of PIM; Millennium CME Institute, Inc; and GaldermaLaboratories, LP. Please refer to the official prescribinginformation for each product for discussion of approvedindications, contraindications, and warnings.DISCLAIMERParticipants have an implied responsibility to use thenewly acquired information to enhance patient outcomesand their own professional development. The informationpresented in this activity is not meant to serve as aguideline for patient management. Any procedures,medications, or other courses of diagnosis or treatmentdiscussed or suggested in this activity should not beused by clinicians without evaluation of their patient’sconditions and possible contraindications on dangersin use, review of any applicable manufacturer’s productinformation, and comparison with recommendations ofother authorities.PHYSICIAN CMEAccreditation StatementThis activity has been planned and implemented in accordancewith the Essential Areas and Policies of the AccreditationCouncil for Continuing Medical Education (ACCME) throughthe joint sponsorship of Postgraduate Institute for Medicine (PIM)and Millennium CME Institute, Inc. Postgraduate Institute forMedicine is accredited by the ACCME to provide continuingmedical education for physicians.Credit DesignationPostgraduate Institute for Medicine designates this educationalactivity for a maximum of 1.25 AMA PRA Category 1 Credit(s).Physicians should only claim credit commensurate with theextent of their participation in the activity.NURSING CONTINUING EDUCATIONAccreditation StatementPostgraduate Institute for Medicine is accredited as aprovider of continuing nursing education by the AmericanNurses Credentialing Center’s Commission on Accreditation.Credit DesignationThis educational activity for 1.25 contact hours is providedby Postgraduate Institute for Medicine.4 CUTIS ® www.cutis.com

Optimizing Topical Therapies for TreatingPsoriasis: A Consensus ConferenceJoshua A. Zeichner, MD; Mark G. Lebwohl, MD; Alan Menter, MD; Jerry Bagel, MD; James Q. Del Rosso, DO;Boni E. Elewski, MD; Steven R. Feldman, MD, PhD; Leon H. Kircik, MD; John Koo, MD; Linda Stein Gold, MD;Emil Tanghetti, MD; for the Psoriasis Process of Care Consensus PanelIn 2010, an expert committee of physicians andresearchers in the field of dermatology workingtogether as the Psoriasis Process of Care ConsensusPanel developed consensus guidelines for thetreatment of psoriasis. As much as possible, theguidelines were evidence based but also includedthe extensive clinical experience of the dermatologists.Psoriasis is a lifelong disease that requireslong-term treatment and 80% of psoriasis patientshave mild to moderate disease. Topical therapiesplay an important role in the treatment of psoriasis,especially in patients with mild to moderate disease.Patients usually start with monotherapy; however,in more severe cases (.10% body surfacearea [BSA], severely impaired quality of life [QOL],or recalcitrant psoriatic lesions), multiple treatmentmodalities may be used as part of combination,sequential, or rotational therapeutic regimens. Maintreatment options include topical steroids, systemictherapies, topical vitamin D treatments such as vitaminD 3 ointment, retinoids, phototherapy, and biologictherapies. Other topical therapies include thefollowing steroid-sparing agents: coal tar, anthralin,calcineurin inhibitors, keratolytics, and emollients.Therapeutic considerations also should focus onadherence, improving QOL, and promoting a goodpatient-physician relationship.Cutis. 2010;86(suppl 3):5-31.Drs. Zeichner, Lebwohl, and Kircik are from The Mount Sinai MedicalCenter, New York, New York. Dr. Menter is from Baylor ResearchInstitute, Dallas, Texas. Dr. Bagel is from Columbia University Collegeof Physicians and Surgeons, New York. Dr. Del Rosso is fromValley Hospital Medical Center, Las Vegas, Nevada. Dr. Elewski isfrom the University of Alabama School of Medicine, Birmingham.Dr. Feldman is from Wake Forest University School of Medicine,Winston-Salem, North Carolina. Dr. Kircik also is from IndianaUniversity School of Medicine, Indianapolis. Dr. Koo is from theUniversity of California at San Francisco School of Medicine.Dr. Stein Gold is from Henry Ford Health System, Detroit, Michigan.Dr. Tanghetti is from Sacramento, California.Dr. Zeichner is an advisory board member for Promius Pharma.Dr. Lebwohl is a consultant for and has received honoraria fromAbbott Laboratories; Allostera Pharma Inc; Amgen Inc; AstellasPharma Inc; Biosynexus Incorporated; Cambridge Pharma;Can-Fite BioPharma; Celgene Corporation; Centocor Ortho BiotechInc; DermaGenoma, Inc; DermiPsor Ltd; Ethicon, Inc; HelixBioMedix, Inc; Novartis Pharmaceuticals Corporation; Pfizer Inc;and Stiefel, a GSK company. He also has lectured for and hasreceived honoraria from Ranbaxy Laboratories Ltd. Dr. Menter isan advisory board member, consultant, investigator, and speakerfor, and has received grants and honoraria from Abbott Laboratories;Amgen Inc; Astellas Pharma Inc; Centocor Ortho Biotech Inc; andGenentech, Inc. He also is an advisory board member, consultant,investigator, and speaker for, and has received honoraria fromWarner Chilcott and Wyeth Pharmaceuticals, and is an investigatorfor and has received grants from Allergan, Inc; AsubioPharmaceuticals, Inc; Celgene Corporation; DUSA Pharmaceuticals,Inc; Novartis Pharmaceuticals Corporation; Novo Nordisk; PfizerInc; Promius Pharma; and Syntrix Biosystems, Inc. Dr. Menteralso is a consultant and investigator for and has received grantsfrom Eli Lilly and Company; is an advisory board member, consultant,and speaker for and has received honoraria from GaldermaLaboratories, LP; and is a consultant and investigator for and hasreceived grants and honoraria from Stiefel, a GSK company.Dr. Bagel is a consultant and speaker for Abbott Laboratories;Amgen Inc; Centocor Ortho Biotech Inc; Galderma Laboratories,LP; LEO Pharma; The NeoStrata Company, Inc; and Stiefel, a GSKcompany. Dr. Del Rosso is a consultant and speaker for CoriaLaboratories, Ltd; Galderma Laboratories, LP; Intendis, Inc;Medicis Pharmaceutical Corporation; Ranbaxy Laboratories Ltd;and Stiefel, a GSK company. Dr. Elewski is an advisory boardmember and consultant for Centocor Ortho Biotech Inc; GaldermaLaboratories, LP; and Intendis, Inc. She also is a consultant forNovartis Pharmaceuticals Corporation and has received researchgrants from Abbott Laboratories; Amgen Inc; Centocor OrthoBiotech Inc; Galderma Laboratories, LP; Intendis, Inc; NovartisPharmaceuticals Corporation; and Novo Nordisk. Dr. Feldman isa consultant and speaker for and has received grant support fromAbbott Laboratories; Amgen Inc; Astellas Pharma Inc; Bristol-Myers Squibb Company; Centocor Ortho Biotech Inc; GaldermaLaboratories, LP; PharmaDerm; Stiefel, a GSK company; andWarner Chilcott. He also has received grant support fromHoffmann-La Roche Ltd; Ortho-McNeil-Janssen Pharmaceuticals,Inc; and sanofi-aventis. Dr. Feldman also is a consultant for, hasreceived research support from, and has stock options withPhotoMedex, Inc; is a consultant for and has received grantWWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 5

Optimizing Topical Therapies for Psoriasissupport from Coria Laboratories, Ltd, and Valeant PharmaceuticalsInternational; is a speaker for and has received grant support from3M Pharmaceuticals; is a consultant and speaker for and hasreceived research support from Novartis PharmaceuticalsCorporation; is a consultant for and has received grant supportfrom Peplin Inc; has received royalties from Informa and XlibrisCorporation; and is a majority stockholder for Medical QualityEnhancement Corporation. He also is a consultant for CaremarkLLC; Kikaku America International; Medscape; Merck & Co, Inc; andSuncare Research Laboratories, LLC. Dr. Kircik reports the followingrelationships: investigator and speaker for 3M Pharmaceuticals;speaker for Abbott Laboratories; advisory board member, consultant,investigator, and speaker for Allergan, Inc; consultant,investigator, and speaker for Amgen Inc; speaker for AssosPharmaceuticals; investigator and speaker for Astellas Pharma Inc;investigator for Asubio Pharmaceuticals, Inc; investigator for BayerHealthCare; advisory board member for Biogen Idec; investigatorfor Biolife; investigator for Breckinridge Pharmaceutical, Inc; investigatorfor Centocor Ortho Biotech Inc; advisory board memberand consultant for Colbar Life Science, Ltd; consultant, investigator,and speaker for CollaGenex Pharmaceuticals Inc; investigatorfor Combinatrix; advisory board member, consultant, investigator,and speaker for Connetics Corporation; investigator for CoriaLaboratories, Ltd; speaker for Dermik Laboratories; investigator forDow Pharmaceutical Sciences, Inc; investigator for DUSAPharmaceuticals, Inc; speaker for Embil Pharmaceutical CorporationLtd; advisory board member for EOS Pharmaceutical Corporation;advisory board member and investigator for Ferndale Laboratories,Inc; advisory board member, consultant, investigator, and speakerfor Galderma Laboratories, LP; advisory board member, consultant,investigator, and speaker for Genentech, Inc; investigatorfor GlaxoSmithKline; investigator for Healthpoint, Ltd; speaker forInovail; advisory board member, consultant, and investigator forIntendis, Inc; advisory board member, consultant, investigator,speaker, and stockholder for Johnson & Johnson; consultant forLaboratory Skin Care, Inc; consultant, investigator, and speakerfor LEO Pharma; consultant for Medical International Technologies;investigator for Medicis Pharmaceutical Corporation; speakerfor Merck Serono; consultant for Merz Pharma; advisory boardmember and investigator for NanoBio Corporation; consultantand investigator for Novartis Pharmaceuticals Corporation; investigatorfor Nucryst Pharmaceuticals Corporation; investigator forObagi Medical Products, Inc; investigator and speaker for OnsetTherapeutics; advisory board member, consultant, investigator,and speaker for Ortho Dermatologics; investigator and speaker forPharmaDerm; investigator for Pfizer Inc; advisory board member,consultant, and investigator for Promius Pharma; investigator forQLT Inc; investigator for Quatrix; investigator for Sanofi PasteurBiologics Co; advisory board member, consultant, investigator, andspeaker for SkinMedica, Inc; advisory board member, consultant,investigator, and speaker for Stiefel, a GSK company; investigatorfor Tolerrx, Inc; speaker for Triax Pharmaceuticals, LLC; consultant,investigator, and speaker for UCB; speaker for ValeantPharmaceuticals International; advisory board member, investigator,and speaker for Warner Chilcott; and consultant for ZAGE.Dr. Koo is an advisory board member, investigator, and speaker forAbbott Laboratories; Amgen Inc; Astellas Pharma Inc; GaldermaLaboratories, LP; and LEO Pharma. He also is an advisory boardmember and investigator for PhotoMedex, Inc; an investigator forTeikoku Pharma USA; and a speaker for Centocor Ortho BiotechInc. Dr. Stein Gold is an advisory board member and researcherfor Galderma Laboratories, LP, and Stiefel, a GSK company, andis a speaker for Coria Laboratories, Ltd. Dr. Tanghetti is a consultantfor Allergan, Inc; DUSA Pharmaceuticals, Inc; GaldermaLaboratories, LP; Obagi Medical Products, Inc; and Stiefel, aGSK company.Effective use of topical therapies for psoriasis isan art learned from experience. While thereis a limited number of classes of medicationsavailable, there is an increasing number of formulations.Choosing the right vehicle for the right bodypart is crucial in treating patients with psoriasis.Regimens must be customized to accommodateindividual patient preferences, and there is no onecorrect formula to treat individual patients withpsoriasis. To provide guidance, a panel of psoriasisexperts gathered to create a road map that can beused in everyday practice, representing differentviewpoints based on available data as well as extensiveclinical experience. This article is designedto give useful tips and help guide dermatologiststhrough the practical challenges of treating psoriasispatients with topical medications as part of bothinitial and maintenance therapiesDefining Severity of PsoriasisCreating a working definition of mild, moderate,and severe psoriasis is a difficult task; there wasno consensus among the members of the PsoriasisProcess of Care Consensus Panel (hereafter, thepanel). However, it was acknowledged that topicaltherapy is an integral part of the therapeutic regimen,regardless of the severity of disease. In clinicalpractice, diagnosing psoriasis severity takes intoaccount both subjective and objective measures.Dermatologists must take into account the percentagebody surface area (BSA) involved; location,severity, and number of individual lesions; andresponse to topical therapies, as well as the physicaland psychosocial effects of the disease on thepatient (Table 1).Table 1.Determinants of Psoriasis Severity• Body surface area (%) involved• Location of individual lesions• Severity and number of individual lesions• Response to topical therapies• Associated physical disability, including psoriaticarthritis• Psychosocial side effects/quality-of-life issues6 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisFigure 1. Approximate representation of 1% of apatient’s body surface area.Psoriasis severity traditionally has been definedby the percentage of BSA involved: mild psoriasisgenerally is defined as BSA involvement of 3% orless, moderate disease involves 5% to 10% BSA,and severe psoriasis is disease that affects greaterthan 10% BSA. 1 Most clinical trials evaluating thetreatment of severe psoriasis define severe diseaseas greater than 10% BSA. 2 In addition, documentationof greater than 10% BSA is required bymany insurance plans for patients to qualify toreceive some systemic medications, such as a biologicagent. Although this definition of severe psoriasisdoes not take into account issues of quality oflife (QOL), BSA determination is important in thepractical management of patients with psoriasis.The method to determine percentage of BSAmust be clarified to avoid variation from one dermatologistto another. There was consensus amongmembers of the panel that the area of a patient’sfull palm including the fingers and thumb tuckedtogether is an approximate representation of 1%of the patient’s BSA (Figure 1). It is important torecognize that the area of the dermatologist’s palmdoes not necessarily correlate with the patient.The total percentage of BSA affected by psoriasis isthe sum of the individual areas of psoriasis includingthe head and neck, trunk, axillae, groin, andupper and lower extremities.The ability to adequately treat patients withtopical agents alone or the need to use systemicmedications may be another defining factorfor psoriasis severity. For some members of thepanel, only patients with involvement of less than10% BSA are candidates for topical agents aloneand, for that reason, their disease should be consideredmild. The opposing view, also represented onthe panel, is that the BSA percentage should notbe used to determine if topical agents can be usedalone. In some cases, even a patient with greaterthan 10% BSA involvement may be adequatelytreated with only topical medicines, provided thatthe patient adheres to the suggested topical regimen.Conversely, patients with less than 3% BSAmay have resistant or disabling disease requiringsystemic treatment. Regardless of the viewpoint,dermatologists should take patient preferences andtime available for therapy into consideration whenevaluating therapeutic options.Psoriasis may be characterized as severe dependingon the degree of resulting physical disabilityindependent of BSA. 3 In some locations, psoriasiscan interfere with everyday functioning, even ifonly a small percentage of BSA is affected. Forexample, scalp disease has a substantial impact onthe QOL of patients. Patients frequently experiencepruritus, and thick scale may cover the scalpand extend visibly beyond the hair margin. Inaddition, the presence of hair makes this area achallenge to treat effectively; overall, patients aredissatisfied with current treatments. 4,5 Palmoplantardisease may lead to notable problems with dailyactivities, such as use of the hands and ambulation.Although collectively representing only 4% to 5%of the total BSA, substantial involvement of thepalms and soles has to be considered severe disease,frequently requiring the use of systemic therapies.6 Intertriginous (flexural) diseases includingthe genitalia frequently lead to severe symptomsbecause of secondary maceration and candidiasis,despite limited areas of skin involvement. 7,8Patients with concomitant psoriatic arthritis mayhave severe disease regardless of degree of skindisease, and unlike psoriasis of the skin, psoriaticarthritis may be degenerative and irreversible. 9Psoriasis has a remarkable impact on patientQOL that may be affected by disease severity. Forsome patients, even a single plaque of psoriasis onthe elbow may be devastating, while others mayhave more extensive involvement and be unconcerned.In general, psoriasis has negative effectson the psychological and social dimensions ofpatients’ lives. 10 Several tools have been developedto help evaluate QOL in patients with psoriasis.The Koo-Menter Psoriasis Instrument (KMPI)is designed to include not only the psychosocialaspects of the disease but also its other effects onlife such as occupation (Figures 2 and 3). 11 TheKMPI includes both a patient self-assessment anda physician assessment. In the KMPI, scores forpart 1 range from 0 to 120, with higher scoressignifying greater impairment of a patient’s QOL.WWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 7

Optimizing Topical Therapies for PsoriasisFigure 2. Koo-Menter Psoriasis Instrument patient self-assessment.8 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisFigure 3. Koo-Menter Psoriasis Instrument physician assessment. BSA indicates body surface area;IP, interphalangeal; MCP, phalangeal; MT, metatarsal.WWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 9

Optimizing Topical Therapies for PsoriasisFigure 4. Dermatology LifeQuality Index (DLQI). TheDLQI is ©AY Finlay, GKKhan April 1992 www.dermatology.org.uk. TheDLQI can be used for routineclinical purpose withoutseeking permission andwithout charge. For all otheruses, please contactdermqol@cardiff.ac.uk.Further information:www.dermatology.org.uk. 121. Over the last week, how itchy, sore, painful,or stinging has your skin been?Very muchA lotA littleNot at all2. Over the last week, how embarrassed or selfconscioushave you been because of your skin?Very muchA lotA littleNot at all3. Over the last week, how much has your skininterfered with you going shopping or lookingafter your home or garden?Very muchA lotA littleNot at allNot relevant4. Over the last week, how much has your skininfluenced the clothes you chose to wear?Very muchA lotA littleNot at allNot relevant5. Over the last week, how much has yourskin affected any social or leisure activities?Very muchA lotA littleNot at allNot relevant6. Over the last week, how much has yourskin made it difficult for you to do any sport?Very muchA lotA littleNot at allNot relevant7. Over the last week, has your skin preventedyou from working or studying?YesNoNot relevant8. Over the last week, how much has your skincreated problems with your partner or any ofyour close friends or relatives?A lotA littleNot at all9. Over the last week, how much has your skincaused any sexual difficulties?Very muchA lotA littleNot at allNot relevant10. Over the last week, how much of a problemhas the treatment for your skin been, forexample by making your home messy ortaking up your time?Very muchA lotA littleNot at allNot relevantThe Dermatology Life Quality Index (DLQI),commonly used in clinical trials, is another tool thatcan evaluate the impact of skin diseases on patientQOL. This 10-item questionnaire assesses both skindiseases and treatment (Figure 4). Most questions arescored on a 4-point Likert scale (05not at all/notrelevant; 15a little; 25a lot; 35very much). Thetotal score ranges from 0 to 30, with higher scoressignifying greater impairment of a patient’s QOL. 12Assessing QOL in patients with psoriasis is ofutmost importance. Although many dermatologistsmay not incorporate the entire KMPI or DLQI intotheir practice, they may adopt specific questionsas they see fit. The DLQI is one important factorincluded in the rule of tens for current severepsoriasis: BSA involved greater than 10%, psoriasisarea and severity index score greater than 10, orDLQI score greater than 10. 2Establishing a Relationship With the PatientAt the patient’s first visit to the office, the dermatologistmust set the groundwork for a long-termrelationship, which includes not only evaluatingthe patient’s skin and QOL but also educating him/her on the skin condition itself and on what toexpect both short term and long term. Patients mayhave seen many other dermatologists in the pastand be frustrated with prior treatments. Much ofthis frustration may result from a lack of educationon the chronic nature of the disease or the properways to use medications. Expectations for treatmentsPanel Tips: Patient EducationGive patients written handoutsEngage office staff to be available to answerquestions and educate patientsDemonstrate how to apply topical agentsand how much to applyEncourage patients to join support groups,including the National Psoriasis Foundation10 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisTable 2.Comorbid ConditionsComorbid ConditionPrevalence/CommentsPsoriatic arthritis Affects ≈30% of patients 13Anxiety and depression 24% prevalence 14Obesity Associated with more severe psoriasis; 49% prevalence 15Diabetes mellitus 10%−12% prevalence 16Hypertension 32% prevalence with mild psoriasis; 40.3% with severe psoriasis 17Dyslipidemia Risk ratio is ≈2-fold that of individuals without psoriasis 18Crohn disease Risk ratio is 1.5- to 2.9-fold that of individuals without psoriasis 19CVDPsoriasis may be a risk factor for developing atherosclerosis and myocardialinfarction; however, other studies do not detect a connectionIt is clear, however, that patients with psoriasis have a higher riskfor many of the comorbidities associated with CVD and screeningis warranted 20Abbreviation: CVD, cardiovascular disease.must be defined, taking into consideration differencesin patient preferences and cultural backgrounds.With an open conversation on treatmentoptions, the patient can become an active participantin developing the treatment regimen, whichmay improve adherence to therapy.Patients ideally should be fully examined fromhead to toe at the initial office visit. When questioningpatients about their psoriasis, they may not fullydiscuss their disease. Due to insecurity or naïveté,patients often do not disclose involvement of thescalp, genital area, or intertriginous skin. Thus toperform a complete and proper physical examination,the patient should be undressed and in a hospitalgown. Discovery of psoriasis in the interglutealskin, for example, will give the dermatologist acomplete understanding of the extent of the diseaseprocess, leading to a full and sensitive discussion ofQOL issues and treatment options, even in patientstoo embarrassed to bring up the topic themselves.Psoriasis is a systemic inflammatory condition.All patients should be evaluated for the presenceof comorbidities (Table 2), including the metabolicPanel Tips: Establishing a GoodDermatologist-Patient RelationshipSpeak to patients in a way that showsempathy:“I am sure you find this very frustrating.”Ask questions that patients will see asinsightful to their condition:“Do you wear long sleeves to cover yourvisible psoriasis?”“Can you wear a black blouse or jacket?”“How much itching do you have?”“Do you lose sleep because of your psoriasis?”“How much does your disease affect yourrelationships with other people?”“Are your sexual experiences affected byyour psoriasis?”WWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 11

Optimizing Topical Therapies for PsoriasisTable 3.Preferred Vehicles for Different Anatomic LocationsAnatomic LocationScalpMale chest/hair-bearing locationsIntertriginous areasKnees/elbowsExtensive skin involvementFacePalms/solesVehiclesShampoo, foam, gel, solution, sprayFoam, gel, sprayCream, ointment, lotionCream, ointment, lotion, spray, foamSpray, foamCream, lotionOintment, cream, lotionsyndrome X, coronary artery disease, psoriaticarthritis, obesity, and diabetes mellitus. 21 In addition,the incidence of depression is increased inpatients with psoriasis. 22 Psoriasis patients maypresent to the dermatologist before other cliniciansbecause of visible skin lesions; therefore, the dermatologistserves an important role in identifyingpotentially unrecognized comorbid conditions andshould refer patients to the appropriate specialists.Psoriasis is a chronic disease that requires longtermtreatment. The schedule for follow-up visitsvaried among the experts on the panel. Accordingto one panel member, “You may see a personat baseline, then 1 month later, and then every3 months. If a patient has problems with adheringto medication, which typically would be apatient with scalp psoriasis who has seen anotherdermatologist and has failed multiple treatments,I’d bring that patient back to the office in 3 days.”Another panel member noted that there is ashortage of medical dermatologists and “We can’tdictate how to factor that into visit frequency.There is no single right frequency of visits for allpatients.” The consensus included frequent earlyfollow-up appointments when possible to evaluateinitial response and adherence to application ofmedicines. After initial control has been obtained,long-term office visits should be less frequent andshould be used to reinforce maintenance therapyand readjust regimens to treat psoriasis flares. Thefrequency of office visits must be tailored to theneeds of the individual patient.Topical Vehicles in the 21st CenturyIn the 21st century, dermatologists have options foragents to prescribe to their patients and vehicles toselect. Choosing the appropriate vehicle dependson several factors, including the application site(Table 3) and patient preferences. Advances indrug formulations have put old drugs into newvehicles with increased efficacy, lower risks for sideeffects, and greater patient cosmetic acceptability.New vehicles allow for improved delivery of thedrug from vehicle into the skin, designed to havespecific release characteristics and rates of absorptionthrough the stratum corneum.The US Food and Drug Administration recognizes8 different topical formulations consisting ofcreams; gels; lotions; ointments; pastes; solutions;suspensions; and others, which encompasses variousfoams, sprays and aerosols, powders, and patches.Technical definitions of the various formulationsdepend on the chemical makeup of the vehicle andthe process by which the vehicle is created. If theproduct is pourable, then it is broadly categorizedas a liquid (eg, lotion, solution) or as a semisolid(eg, cream, ointment). If it is not pourable, it is anonliquid nonsemisolid formulation or other (eg,foam, spray). 23 Regardless of classification, theconsensus of the panel was to prescribe the vehiclethat is most acceptable to each individual patient.New formulations have improved patient adherenceto therapy. Gels, for example, historically havebeen alcohol based and caused drying, stinging,and irritation of the skin. They have been replaced12 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for Psoriasisby newer hydrogels and nonaqueous gels that canbe used more widely while minimizing cutaneousside effects. New foam and spray vehicles havebeen developed with various penetration enhancersthat temporarily disrupt the skin barrier toimprove absorption of the drug across the stratumcorneum. Penetration enhancers include detergentsand emulsifiers, which vary from vehicle tovehicle. 14 A new formulation of clobetasol propionatespray 0.05% contains isopropyl myristate thatpartially dissolves lipids in the stratum corneum toallow for rapid penetration of clobetasol. Ethanolbasedfoam vehicles dissolve on the skin, leaving asupersaturated solution on the skin that, in combinationwith propylene glycol, drives penetration ofthe drug. 24 With newer technology, occlusion of amedication is used less frequently.Generics Versus BrandsAll classes of topical medications have genericpreparations to decrease cost, regardless of clinicalclass. 25 However, according to the panel,caution is warranted when using generics.According to one panel member, “When youuse a generic, you don’t know which vehicleyou are going to get.” Another panel memberwas concerned that “there may be different mixcharacteristics, especially if you’re remixing.”It should be noted, however, that many patientsare successfully treated with generic therapies.Panel Tips: Generic MedicationsBe aware that there is a 20%–25% marginof potency, either up or down, that canaffect outcomesTo better anticipate response, know whichvehicle is being usedIf potency is underestimated, the patientmay develop cutaneous adverse eventsKnowing How Much Topical MedicationIs EnoughIn addition to choosing the appropriate topicalagent, the dermatologist must understand howmuch of the medicine will be necessary. Not givingpatients an adequate amount of medicationwill prevent them from treating all affected areasfor the appropriate period, which will undoubtedlyFigure 5. A fingertip unit, which measures approximately500 mg and should be enough cream or ointment tocover approximately 1% body surface area for 1 daywith twice daily application. Reprinted from Menter et al;American Academy of Dermatology. 26 ©2009, with permissionfrom the American Academy of Dermatology.lead to treatment failure. The percentage of BSAinvolved varies greatly among patients, as does theamount of medication that is required. The differencesin the amount of medication can be large,ranging from approximately 15 g/wk for twice dailytreatment of the elbows and knees to 400 g/wkfor twice daily treatment of the entire BSA of anaverage-sized adult.In the previous section, guidelines were providedto calculate a patient’s percentage of BSAaffected by psoriasis, which is important to masterso that appropriate amounts of topical medicationsmay be dispensed. It is estimated that 0.55 g/d ofa cream or ointment is needed to cover 1% BSAfor an average-sized adult with a twice daily application.This amount, known as a fingertip unit,can be easily demonstrated to patients; it is theamount of medicine needed to cover a thin filmover the volar surface of the first phalanx of theindex finger (Figure 5). One fingertip unit measuresapproximately 500 mg and should be enough creamor ointment to cover approximately 1% BSA for1 day with twice daily application. 26Dermatologists need to ensure that patientsreceive enough medication to treat their psoriasisper month and per medication co-payment.Patients will commonly pay the same co-paymentfor a topical medication regardless of the size of thetube. In addition, the dermatologist may need toprovide documentation of the amount of medicationrequired to treat a particular BSA percentageto obtain approval for coverage by the insuranceWWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 13

Optimizing Topical Therapies for Psoriasisplan. Given 0.55 g per 1% BSA twice daily application,it is estimated that 55 g of cream or ointmentare required for a total body treatment twice daily.Practically, this means that the dermatologist mustwrite a prescription for a 60-g tube of medicineper day. Although most patients will not be coveringthemselves from head to toe in medication, apatient with psoriasis of both the elbows and kneeshas approximately 4% BSA involved. The patientwill require 66 g of cream or ointment per monthfor twice daily application. Although a single tubeof medicine will be sufficient for a patient withthis severity of disease, those patients with moreextensive involvement will require more than1 tube of medicine. A detailed summary of theamount of medicine required monthly (Table 4)and the amount required to treat each body part(Table 5) are provided.Selecting a Treatment RegimenTopical therapies play an important role in thetreatment of all patients with psoriasis, regardlessof disease severity. Selecting the appropriate treatmentregimen for patients is an art that is learned,the panel concluded. Clinicians must weigh factorssuch as the extent of disease, patient preferences,QOL issues, time available for application oftopical agents, and patient finances. Most dermatologistsmake decisions on treatment optionsbased on personal experiences, published clinicaltrials, pharmaceutical company promotionalmaterials, and peer recommendations. While mostpublished studies evaluate topical treatments foronly 12 weeks, psoriasis in the real world requireslifelong treatment. The goal of treatment is toobtain an initial clearance, maintain an extendedremission, and treat flares as necessary.Psoriasis may be difficult to treat using monotherapy.27 According to a 2003 consensus statementfrom the American Academy of Dermatology, thegoal of psoriasis treatment is to produce a durableimprovement while minimizing adverse events (AEs). 28Multiple treatment modalities may be usedtogether, and combination, sequential, and rotationalregimens have been developed. The goalof these treatment strategies is to maximize efficacywhile minimizing the risk for side effects. 28Recently, the updated consensus statement fromthe American Academy of Dermatology notedthat approximately 80% of patients affected withpsoriasis have mild to moderate disease and mostof these patients can be treated with topicalagents. 26 However, the use of topical agents aloneor in combination can be challenging in patientswith extensive disease. In these cases, combinationTable 4.Amount of MedicineRequired Monthly aBSA InvolvedAmount of Medicine5% BSA 82.5 g/mo (twice daily)10% BSA 165.0 g/mo (twice daily)15% BSA 247.5 g/mo (twice daily)25% BSA 412.5 g/mo (twice daily)Abbreviation: BSA, body surface area.a0.55 g • % BSA • 30 days5gram prescribed per month.therapy with topical and systemic agents maybe beneficial. 26Combination therapy is the concomitant use of2 or more agents with synergistic or complementarymechanisms of action. By combining morethan one agent, each may be used at a lower dose,thereby reducing the potential for toxicity. Withsequential therapy, a strong but potentially moretoxic agent is used to induce clearance, and then itis replaced with a less toxic agent for maintenance. 26An example of a sequential regimen that has beenevaluated is the initial use of potent topical steroidswith topical vitamin D 3 treatment followedby topical vitamin D 3 treatment as monotherapy. 29Sequential therapy maximizes efficacy while minimizingAEs and provides both rapid clearance andlong-term remission. 30 With rotational therapy,an agent is used for a specified period and then isswitched to an alternative. By rotating medicines,dermatologists can both limit the long-term toxicitiesof the medications and prevent resistance toindividual medications. 26Maintenance TherapyGiven the chronic nature of psoriasis, long-termmanagement options are important. Long-term useof topical corticosteroids is limited by risks for cutaneousatrophy and hypothalamic-pituitary-adrenal(HPA) axis effects. 31 Vitamin D topical treatments,such as calcitriol ointment, permit safe, effective,long-term management of psoriasis. 32A long-term study evaluated the safety, tolerability,and efficacy of calcitriol ointment 3 µg/gtwice daily in patients with chronic plaque psoriasis. 3214 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisTable 5.Amount of Medicine Needed Per Area a Amount of Amount ofAmount of Medicine MedicineNo. Fingertip Medicine Needed NeededUnits Needed Needed Per Week Per MonthPer Per Day (7 Days; (30 Days;Body Part BSA, % Application (Twice Daily) Twice Daily) Twice Daily)Scalp 6 3.0 3.3 g 23.1 g 99.0 gBoth elbows 2 1.0 1.1 g 7.7 g 33.0 gBoth knees 2 1.0 1.1 g 7.7 g 33.0 gBoth palms 2 1.0 1.1 g 7.7 g 33.0 gBoth soles 3 1.5 1.65 g 11.6 g 49.5 gFace and neck 5 2.5 2.75 g 19.3 g 82.5 gTrunk (anterior) 16 8.0 8.8 g 61.6 g 264.0 gTrunk (posterior) 16 8.0 8.8 g 61.6 g 264.0 gEntire leg 16 8.0 8.8 g 61.6 g 264.0 g(including foot)Genitals 1 0.5 0.55 g 3.9 g 16.5 gButtocks 8 4.0 4.4 g 30.8 g 132.0 gAbbreviation: BSA, body surface area.aCalculations based on 0.55 g per 1% BSA twice daily.Reprinted from Menter et al; American Academy of Dermatology. 26 ©2009, with permission from the American Academyof Dermatology.The evaluation included 253 patients over atreatment period that extended up to 78 weeks.At end point, 40.1% of the participants showeddefinite or considerable improvement. Therewere no serious AEs or deaths, or any clinicallyrelevant effects on calcium and phosphoroushomeostasis or renal function. Fifteenpercent of participants experienced a transientskin irritation, 2.8% withdrew because oflocal intolerance, and 0.4% withdrew becauseof hypercalcemia. 32In a 52-week, open-label, multicenter study,324 participants with mild to moderate chronicplaque psoriasis were treated with calcitriolointment 3 µg/g twice daily. 33 Adverse events(including abnormal laboratory test results) werereported in 40.1% of participants; however, only13.9% of the AEs were considered study related.Eight participants (2.5%) withdrew because of AEs;AEs for 4 of these participants (1.2%) were consideredtreatment related, including irritant dermatitis,pruritus, kidney pain, and urine abnormality(1 participant each). 33In this study, the psoriasis global severity score(05clear; 1=minimal; 25mild; 35moderate;45severe; 55very severe) was assessed at eachvisit. 33 At any given point during the study,42.6% of participants received a rating ofWWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 15

Optimizing Topical Therapies for Psoriasis0 or 1 (clear or minimal psoriasis); the percentagerose to 47.1% during the last treatment period. Whenparticipants were asked to rate their improvementon a 7-point scale (55clear to 215worse), 52.6%of participants reported marked improvement atweek 26. By week 52, the percentage had risento 63.8%. 33Another 52-week study evaluated the longtermsafety and efficacy of a vitamin D topicaltreatment in participants with scalp psoriasis. 34 Inthis randomized study, combination therapy withcalcipotriol 50 µg/g plus betamethasone dipropionate0.5 mg/g (n5429) was compared withcalcipotriol 50 µg/g monotherapy (n5440) in869 participants with moderate to severe scalp psoriasis.Overall, 92.3% of combination therapy participantswere well-controlled compared with 80.0%of monotherapy participants (P,.001). Regardingsafety and tolerability, 17.2% of participants inthe combination group experienced adverse drugreactions compared with 29.5% of participants inthe monotherapy group (P,.001). The main AEswere pruritus and erythema. Although the withdrawalrate was 21.4% in the combination groupover the 52-week period, treatment generally waswell-tolerated. 34A 52-week, randomized, double-blind studycompared the efficacy of 3 different calcipotriolcontainingmaintenance regimens in 634 participants:group 1 (the 2-compound group)(n5212),participants treated daily with calcipotriol 50 µg/gand betamethasone dipropionate 0.5 mg/g;group 2 (n5213), participants treated over a52-week period with an alternating regimen thatincluded the 2-compound product for 4 weeks, followedby calcipotriol monotherapy for 4 weeks;group 3 (n5209), participants treated for 4 weeks withthe 2-compound product, followed by calcipotriolmonotherapy for 48 weeks. 35 Based on investigatorassessments, 35.8% of participants in group 1 had a100% satisfactory response compared with 27.7%of participants in group 2 and 24.4% of participantsin group 3. The median values for the percentageof satisfactory responses in groups 1, 2, and 3 were84%, 75%, and 70%, respectively. There did notappear to be a significant difference in the outcomesbetween the 3 treatment groups. Based onavailable evidence, it appears that various vitamin Dtopical treatment–based regimens are safe andeffective as maintenance therapy in patients withpsoriasis. In current clinical practice, combinationregimens that include topical vitamin D have animportant therapeutic role in maintaining longtermsafe control while addressing the chronicnature of psoriasis. 35Panel Tips: Use of Multiple AgentsKeep the regimen simpleLimit the number of topical agentsprescribed. Choose appropriate vehiclesand medications that can be used on multiplebody partsConsider combination treatments, especiallyin resistant areas such as the palmsand solesKnow which topical agents should not becombined (eg, vitamin D topical therapyis inactivated by the acid pH in topicalagents such as ammonium lactateor salicylic acid). If you are unsure aboutcombining medications, separate theirapplications in the morning and eveningKnown Compatible DrugsCalcipotriene ointment and topical halobetasol 36Calcitriol ointment and clobetasolpropionate 0.05% (spray and lotion) 29,37Calcipotriene ointment and tazarotene gel 38Topical halobetasol and ammonium lactatelotion 12%Calcipotriene ointment and topicalsteroids in foam vehicles 38Tazarotene gel and topical steroids 39Maintaining Patient AdherenceTopical therapies are both safe and effective forpsoriasis in clinical trials. However, patients inclinical trials are in a structured environment withfrequent evaluations and medication logs to maintainadherence to the designated regimen. Psoriasispatients in clinical practice commonly report thatapplying messy topical medications is one of themost negative aspects of the disease. 40 A notableproportion of psoriasis patients do not use topicalmedications as directed. Lack of adherence maylead to poor outcomes and treatment failures. Onepotential outcome is decreasing response to treatmentover time, so-called tachyphylaxis. Tachyphylaxismay be caused by poor adherence ratherthan loss of steroid receptor function. 41In line with other treating dermatologists,panel members expressed frustration over16 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for Psoriasisadherence challenges. One panel member suggestedthat it becomes clear that a patient is nonadherentif a biologic agent is having no effect onhis/her psoriasis or if a very potent topical agentsuch as clobetasol is not working at all. Anothermember of the panel suggested having a patientcome back within 3 days if he/she clearly demonstratedthe need to be convinced of the importanceof adherence.Improving patient adherence to topical regimensis a challenge faced by all dermatologists.Several factors contribute to lack of patient adherenceto treatment regimens, including patient perceptionsthat medications are not efficacious or areunsafe. In addition, patients may find prescribedregimens too complex to follow. Medication costsand personal preferences for specific medicationvehicles also play a role. 25Treatment of Scalp PsoriasisScalp psoriasis affects an estimated 50% to 80% ofpsoriasis patients and is a challenge to treat. 42 Itmay manifest as localized areas of superficial scalesor as thick warty plaques covering the entire scalp.In some cases, it may be visible and extend beyondthe hairline to the face, neck, and ears. Additionally,patients frequently complain of markedpruritus. 5 Scalp psoriasis has a negative impact onQOL and interferes with psychosocial functioning.6,43 There may be concern that the presenceof hair on the scalp along with the thick scaleof psoriatic plaques reduces the absorption oftopical medications; however, a healthy scalp haspenetration characteristics similar to the axilla,and diseased skin is expected to have even lessbarrier function. Nevertheless, the hair-bearingscalp often responds poorly to topical treatment,most likely because of poor adherence due to thedifficulty of applying medications to the scalp.In addition, many topical medications interferewith daily hair grooming and are not cosmeticallyacceptable to patients. 5 Thus patientsfrequently are dissatisfied with current treatmentsdue to inconvenience of usage andperceived ineffectiveness. 4A recent consensus statement from the NationalPsoriasis Foundation gave recommendations for thetreatment of scalp psoriasis. 5 First-line therapy is theuse of short-term topical corticosteroids followedby intermittent maintenance therapy. Alternatively,topical retinoids, vitamin D topical therapy,and salicylic acid preparations may be tried. Combinationtherapy also is recommended. 5 Althoughtopical agents are the most frequently used therapiesfor scalp psoriasis, selection of the appropriatePanel Tips: Ways to MaintainPatient AdherenceInteract with patientsProvide written instructionsMake a deal with the patient (eg, “If you usethis strong topical medication to start yourregimen, we can use another less intensemedication to maintain your good resultsonce your symptoms improve”)Set realistic expectationsOn follow-up visits, before assuming amedicine did not work, ask questions aboutits usage (eg, “Did you have the chance tofill your prescription?” or “Did you have thechance to use your medicine?”)Limit the number of refills on a medicationto ensure that the patient does not use itfor too longConfirm adherence and results at follow-upoffice visits. You may give differentpatients varying numbers of refills, takinginto account economic considerations aswell as the body part being treatedFor severe psoriasis (.10% BSA), it maynot be feasible to treat the entire body. Inthese cases, first focus on areas of highimportance to the patient, which likely willbe areas most commonly exposedPanel Tips: Medication-Related Advice toImprove AdherencePrescribe once daily medication applicationwhenever possibleMake sure the patient can afford a medicinebefore prescribing itTailor the treatment to the patient’spreferenceAvoid a treatment the patient did not like inthe pastSelect a vehicle that matches the patient’spreferences and is appropriate for the anatomiclocationProvide appropriate handoutsWWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 17

Optimizing Topical Therapies for PsoriasisPanel Tips: Treatment of Scalp PsoriasisGeneral AdviceEducate the patient: the medication is forthe scalp, not the hair, and shampoosmust lather for variable periods beforebeing rinsedChoose the vehicle the patient is mostwilling to useGive written instructions. Set realisticexpectations. Keep the regimen simple(eg, once daily therapy), if possibleTell the patient not to scratch, pick, orharshly shampoo the scalpExplain that medications must be usedevery day until the psoriasis isadequately controlledReduce the burden of treatment by havingthe patient use the medication twice dailyfor only 3 daysHave the patient’s friend or relative applythe medication to ensure it gets appliedand gets on the scalpTell the patient that if the medication causessymptoms of burning, “it is a sign themedication is working” (ie, the medicationhas been applied to the scalp)Panel Tips: Medication-RelatedAdvice for PsoriasisTreat scalp pruritus with antihistaminesAsk the patient for his/her preference ofvehicles; remember to offer spray, solution,or foam vehicle optionsTopical corticosteroid sprays with nozzlesare especially appropriate for coifed hairstylesrequiring a lot of hair sprayConsider an oil-based medication forpatients who have a cultural preferencefor using oils in the scalp forhair maintenanceAvoid polypharmacy. Use same medi-cines for the scalp as for other areas ofthe bodyPanel Tips: Treating Patients Who FailedPrior Therapies(Note: Panel tips represent divergent viewpointsfrom different individuals.)Three days of potent topical agents canwork, even when treatment has failed inthe past. Try the same medicine in a differentvehicleIf all else fails, apply liquor carbonisdetergens 10%–20% in a lotion or otherointment and a keratolytic such as ammoniumlactate or lactic acid 10% to thescalp in the morning. Cover with a showercap. At the end of the day, wash off gentlywithout scrubbing the scalp. Repeat theprocess 3–4 times for a weekHave the patient come to the office for3 days and apply the medication inthe officeHeat olive oil and apply it to the scalp undershower cap occlusionApply a steroid ointment to the scalpovernight under shower cap occlusion.Wash the ointment out gently with dishwashingdetergentBefore bed, apply baking soda to the scalp, then wet the area. Wash out the mix in themorning with a coal tar shampoovehicle is of utmost importance. For example, creamand ointment vehicles are messy and difficult toapply through the hair to reach the scalp. 4,44,45 Newervehicles such as shampoos, sprays, and foams aremore appropriate for use on the scalp. The bestvehicle is generally the one the patient prefersto use.If patients fail topical therapies, systemic agentsmay need to be added, though one panel membersuggested that measures to improve adherenceshould be used instead. Dermatologists mustthen evaluate what is considered scalp psoriasisrefractory to treatment. The consensus of thepanel defines scalp psoriasis refractory to topicaltreatment as failure of clearance after 4 weeks ofadherence to an adequate topical regimen alongwith a negative impact on QOL. An example of an18 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for Psoriasisadequate topical regimen is the use of fluocinoloneacetonide topical oil 0.01% at night with occlusionand clobetasol propionate 0.05% shampoo orspray in conjunction with a salicylic acid or coaltar shampoo in the morning. Alternatively, usinga combination product of vitamin D 3 and a steroidfrequently is helpful. Pending response and adherenceto this regimen, a short course of systemictherapy may need to be considered.Treatment of Palmoplantar PsoriasisWhile the palms and soles collectively representless than 5% BSA, palmoplantar psoriasissubstantially affects QOL. Patients often experiencephysical difficulty and discomfort from dailyactivities. Therefore, patients with palmoplantardisease may be considered to have severe diseasedespite the small percentage of BSA involved.Moreover, palmoplantar psoriasis often is resistantto potent topical treatments. Recalcitrant palmarand plantar disease may require systemic therapies(eg, acitretin, methotrexate, cyclosporine), phototherapy,or biologic agents. 6The choice of vehicle is critical. Encouragepatients to use an ointment of their choice. Afterapplying the ointment, they must cover the treatedarea with wet cotton gloves for the hands or wetcotton socks for the feet and then occlude withplastic for 2 hours. This regimen needs to berepeated 2 to 3 times weekly. Also, encourage thepatient not to debride but to use a skin-softeningagent (emollient) of their choice, such as salicylicacid, urea cream, or a steroid ointment; the vehicleis vital in palmoplantar psoriasis treatment. Also,instruct the patient to regularly use a barrier handcream during the day.Treatment of Nail PsoriasisUp to 80% of psoriasis patients may have nailinvolvement, which commonly is overlooked byhealthcare providers. 46,47 Nail psoriasis may manifestas either changes in the nail plate or the nailbed. Nail pitting commonly is observed in the nailplate, and discoloration or splinter hemorrhagesmay be seen in the nail bed. 46 Options for the treatmentof nail psoriasis are limited. Various topicalregimens have been used, but no therapy hasemerged as the clear first-line treatment, as notableimprovement seldom is obtained. Topical, intralesional,and systemic therapies have been usedindividually and in combination for nail disease.Topical steroids often are used as first-line treatmentof nail psoriasis, but their efficacy is limitedby their inability to penetrate deeply into the nailmatrix. Nonetheless, topical steroids, especiallyPanel Tips: Treatment ofPalmoplantar PsoriasisSoak hyperkeratotic fissured hands and feetwithout debriding. Apply the ointment ofchoice, then cover the area with wet cottongloves or socks and occlude airtightwith plastic for 2 hours. Remove and applythe emollient of choice (eg, salicylic acid,urea cream). Repeat this procedure3–4 times the first week, then twice perweek for the following weeks. On the offdays, use emollients onlySoak the palms and soles in crude coaltar, then apply salicylic acid lotionfollowed by clobetasol ointment (with orwithout occlusion)Use a topical steroid cream during the dayand an ointment at nightUse tazarotene at night in combinationwith topical steroids by day. Be cautiousto avoid contact with the dorsal aspects ofthe hands and feetTry a 3-step approach: (1) use a combinationof topical agents, including vitamin D,tazarotene, and a class 1 topical steroid;(2) if this fails, add phototherapy or psoralenplus UVA (PUVA); (3) if this fails, addcyclosporine to decrease inflammationConsider compounding salicylic acid witha topical steroid. Salicylic acid enhancesefficacy; however, it also may increaseside effects of steroidsointments, can be effective in reducing psoriaticchanges in the periungual region, resulting inreduced secondary matrix inflammation and ridging.In patients with onycholysis, one approachthat improves access to the diseased area is trimmingthe nail to the cleavage by making asymmetricsnips on both sides of the nail until they meetin the middle, allowing for direct application of thesteroid preparation. 48In addition, treatment with tazarotene gel 0.1%is moderately effective in markedly reducingWWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 19

Optimizing Topical Therapies for Psoriasisonycholysis in nonoccluded nails and in reducingpitting in occluded nails with overallgood tolerability. 49Triamcinolone acetonide 2.5 to 10 mg/mL canbe injected directly into the psoriatic digit using aPanel Tips: Treatment of Nail PsoriasisGeneral AdviceNail psoriasis is frequently a marker forpsoriatic arthritisMedication-Related AdviceDo not be afraid to give cortisoneinjections for severe nail psoriasis.Nail plate disease (eg, pitting) requiresdelivery of corticosteroids to the nailmatrix, as injection to the nail fold doesnot work. Nail bed disease (eg, subungualhyperkeratosis) requires injections all theway around the nail through the lateralnail foldsTry a potent topical corticosteroid, avitamin D analogue, or a fixed-dosecombination of calcipotriene 0.005%–betamethasone dipropionate 0.064%ointment twice daily for 12 weeksCheck a fungal culture to ensure there is noconcurrent fungal infection. If the cultureis positive, treat the fungal infection withan agent such as oral terbinafine becausetinea unguium may induce psoriasis by aKöbner phenomenonReduce pain with the use of topicalanesthetics or ethyl chloride spray priorto injections. Also consider dilutingtriamcinolone in lidocaine for injectionChange needles frequently to avoid dullingof the needle, which causes excess painThe experts suggest using either a5-mg/mL dilution of triamcinolone withinjections of 0.1 mL per nail, or a10-mg/mL dilution of triamcinolone withinjections of 0.05 mL per nailfine gauge needle. However, injections directly intothe nail bed or deep nail fold are painful and usuallyrequire anesthesia. Pain management optionsinclude a ring block or injection of lidocaine at theinjection site. Injecting too frequently can lead todigital atrophy; however, at weaker concentrations,injections can be administered over approximately3 months. Higher concentrations of triamcinoloneacetonide (10 mg/mL) are more effective for thetreatment of nail ridging and subungual hyperkeratosisrather than pitting or onycholysis. 48One member of the panel reported not administeringinjections for nail psoriasis at all becauseof the pain to the patients. However, other panelmembers suggested that the pain is manageable.Certain systemic therapies are effective, includingacitretin, methotrexate, and cyclosporine. 50Tumor necrosis factor a inhibitory agents (eg,adalimumab, etanercept, infliximab) are effectiveat improving nail psoriasis when used in patientswith moderate to severe psoriasis.Treatment of Intertriginous PsoriasisIntertriginous psoriasis affects the body’s skinfolds, including the axillary, inguinal, inframammary,intergluteal, and abdominal folds, as wellas the genital areas. “We can’t just talk of intertriginouspsoriasis as one disease,” one of the panelmembers noted.According to estimates, 4% to 6% of patientswith psoriasis have intertriginous involvement. 51However, it is likely to be an underestimation, especiallyin the obese psoriatic population. Patientscommonly complain of irritation, which is exacerbatedby friction and perspiration in these areas.These areas have thin skin and relative occlusion,which limit the use of many medicines. Topicalsteroids, for example, should be applied cautiouslybecause of a higher risk for cutaneous AEs (eg,atrophy, striae, telangiectasia) compared to otherparts of the body. 8 According to consensus statementsof the National Psoriasis Foundation andAmerican Academy of Dermatology, the recommendedtreatment is low-potency to midpotencytopical steroids for no longer than 2 to 4 weeks. Inaddition, topical vitamin D (especially calcitriol)and calcineurin inhibitors are efficacious and canbe safely used for longer periods of time. 8Treatment of Psoriasis in Pediatric PatientsPsoriasis in childhood is common. It is estimatedthat psoriasis represents 4% of skin conditionsin North American children younger than16 years. 52 The same topical medications used inadults with psoriasis have been tried in pediatric20 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisPanel Tips: Treatment ofIntertriginous PsoriasisLifestyle and General AdviceIf the genitals are affected, patients shouldapply lubricants during sexual activityMedication-Related AdviceIf areas are lichenified, patients may needto use higher-potency steroids for ashort time (ie, 7–10 days), despite theintertriginous locationIf there is suspicion for a superimposedfungal infection, add a topical antifungalproduct. Fungal infections, especiallycandidiasis, frequently exacerbateintertriginous psoriasisPanel Tips: Tolerability Issues forMedicines in Intertriginous AreasIf calcipotriene causes irritation, try calcitriolPrescribe a high-potency steroid for a shortperiod (eg, ,1 week), then switch to a lesspotent steroid or another agentIf there is concern about prescribing ahigh-potency steroid for an intertriginousarea, remember it is not how strong buthow long the medicine is usedTry a regimen with a steroid for 1–2 weeks,then switch to weekends only, usingcalcitriol on weekdaysTopical calcineurin inhibitors may causeself-limited irritation. If tacrolimusointment cannot be tolerated, trypimecrolimus creamMake sure patients understand the blackbox warning associated with topicalcalcineurin inhibitors and document thediscussion in their medical recordAvoid tazarotene use in the genital area andother intertriginous areasPanel Tips: Treatment of Psoriasis inPediatric PatientsGeneral AdviceAvoid potent topical steroids in neonatesWhen treating pediatric patients withpsoriasis, consider the way pediatricatopic dermatitis patients are treatedUse appropriate emollients daily for1–2 weeksPanel Tips: Medication-Related Advice forPediatric PatientsSome panel members believe thatmometasone furoate ointment 0.1% hasa high benefit-risk ratio with virtually nosystemic absorptionTry a vitamin D topical treatment incombination with a topical steroid with animproved benefit-risk ratio (eg, mometasone,fluticasone)In extreme circumstances, superpotenttopical steroids may be used for shortperiods (1–2 weeks, maximum)Consider the use of coal tar with or withoutlight therapyIf treating a pediatric patient with photo-therapy, have the guardian (who should bewell-protected from the UV light) go intothe treatment room with the childIf treating with a topical steroid, intermit-tently step-down the strength to avoid arebound effectTry maintenance therapy with vitamin Dtopical therapy and phototherapyReduce the topical steroid dose proportion-ately to body sizeSystemic (eg, methotrexate, cyclosporine)or biologic agents may be required forrecalcitrant widespread psoriasis causingmajor QOL issues 53WWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 21

Optimizing Topical Therapies for Psoriasispatients. However, there is greater concern forHPA axis suppression in infants and childrenbecause of a higher ratio of total skin surface areato body mass compared to adults. 7 There are fewevidence-based guidelines for the treatment ofpsoriasis in pediatric patients. A recent systematicreview of the literature recommends first-linetreatment with a vitamin D therapy with or withouta topical steroid and second-line treatmentwith anthralin. 54In reviewing topical steroid use in pediatricpatients with psoriasis among the experts on thepanel, many were concerned with the potentialside effects of long-term use. Thus it may be prudentto reduce topical steroids to applications inaccordance with the reduced size of the child. Asone member of the panel commented:When clobetasol propionate came out in1973 in the United Kingdom, within a yearthere was HPA axis suppression in childrenbecause clobetasol was never studied in thispopulation. All of us who use potent orsuperpotent topical steroids for a week or10 days or 2 weeks to clear intractable psoriasisin the pediatric population need to becareful. We need to give specific instructionsregarding how much, how long, and whatto use.One panel member stated that he would not useclobetasol in children younger than 6 years. Eventhen, he would focus on the arms, legs, hands, orfeet rather than the face or trunk.Treatment of Psoriasis in Older PatientsMany older patients have already used a substantialnumber of prior therapies, including topical agents,phototherapy, and systemic and biologic agents.Older patients have thin atrophic skin comparedto their younger counterparts. Although all topicalmedications may be used for older patients, theymay not be able to apply them as regularly becauseof potential concurrent health problems. A headto-toeskin examination also is important in olderpatients, and one of the panel members noted,“Many of these patients have treated their psoriasisfor many years with phototherapy or PUVAtherapy and lots of sun exposure, and they have anincreased risk for skin cancer or even melanoma.I don’t simply focus on the psoriasis. I also do acomplete skin examination looking for skin cancersand melanoma in these patients.”Panel Tips: Treatment of Psoriasis inOlder PatientsGeneral AdviceGive older patients regular total bodyskin checks. These patients may be at anincreased risk for developing skin cancersor melanoma because of a long history ofphototherapy and/or PUVA therapyPanel Tips: Medication-Related Advice forOlder PatientsUse topical steroids with caution in olderpatients with thin skin, as it may increasethe risk for atrophy and purpuraUse vehicles that patients find easy to use.Some patients may prefer easy-to-spreadvehicles including foams, sprays, and lotionsIt may be appropriate to use a cream-basedvehicle to lubricate the scalp, which maybe drier compared to younger patientsUse ammonium lactate lotion as part of theregimen because it may prevent furtherthinning of the skinConsider using topical tazarotene in patientswith thin skin to help reverse atrophyUse nonsteroidal medications when possibleTreatment of Psoriasis in Patients WithSkin of ColorPatients with dark skin (Fitzpatrick skintypes IV–VI) tend to heal with marked postinflammatoryhyperpigmentation. These skin changesmay cause substantial psychosocial distress andmust be addressed as much as their preceding psoriaticplaques. Postinflammatory hyperpigmentationmay last for months to years, so measures must betaken to prevent psoriasis flares that will exacerbateexisting pigmentation.Treatment of Psoriasis in Pregnant PatientsPsoriasis runs a variable course during pregnancy.While approximately 60% of patients improve,others may experience worsening of their disease.Although topical steroids are the mainstayof topical treatment of psoriasis, there is22 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisPanel Tips: Treatment of Psoriasis inPatients With Skin of ColorConsider using an ointment vehicle, asmany patients prefer it and use ointmentsas part of their cultural practicesCareful use of tazarotene may helpimprove postinflammatory hyperpigmentation.However, tazarotene can be irritating.If any irritation occurs, tazarotenemust be discontinued to avoid furtherdarkening of the skin from postinflammatoryhyperpigmentationlimited information available on their efficacy andsafety during pregnancy. However, a report of apotential association between first-trimester topicalsteroid use and orofacial clefts in neonates hasbeen reported. 55 The experts on the panel agreedthat pregnant patients should be treated with asmuch nonmedicine as possible. For severe disease,UVB phototherapy would be first-line treatment.However, the panel felt that topical steroids,vitamin D topical treatments, and coal tar likelyPanel Tips: Treatment of Psoriasis inPregnant PatientsTreat patients with as few agents as possiblePhototherapy and emollients should beused as first-line treatment in pregnancyFirst-trimester spontaneous abortion in theUnited States is 15%–20%For more information on treating pregnancyduring psoriasis, refer to the Organizationof Teratology Information Specialists registryat www.otispregnancy.orgIf it is necessary to treat a patient with anagent with any theoretical risk to the fetus,share the decision making with the patientIn the postpartum period, topical agentsmay be used, except around the nipple ifthe patient is breastfeedingTable 6.Pregnancy Safety Categoriesof Medications aMedicationTopical steroids (most)Vitamin D topical therapiesCoal tarAnthralinBiologic agentsTopical calcineurin inhibitorsSalicylic acidTazaroteneAmmonium lactateSafety CategoryaRisks to the fetus are categorized from A (safest) toX (known danger).pose little risk; most experts would use them inpregnant patients, if necessary, in individual circumstances.Table 6 outlines the pregnancy safetycategories of various treatments.Use of Topical SteroidsTopical steroids are the most commonly prescribedmedicines for psoriasis. They range in strengthacross 7 classes based on their ability to inducevasoconstriction. Additionally, they are dividedinto 4 different groups according to their chemicalcomposition. Corticosteroids bind to cell receptorswhose downstream effects include an alteration ofcytokine expression as well as inhibition of T cellproliferation and down-regulation of antimicrobialpeptides. 56 Long-term use of topical steroids is limitedby cutaneous side effects, including skin atrophy,telangiectasia, striae, and acne. Additionally,HPA axis suppression may occur with the overuse ofpotent topical corticosteroids. 56 The potential sideeffects have led to the development of combination,sequential, and rotational regimens using morethan one medication. 28 Many questions still remainunanswered and the experts on the panel haddiffering opinions.CCCCBCCXBWWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 23

Optimizing Topical Therapies for PsoriasisPanel Tips: Using Topical SteroidsPrimary Treatment ConsiderationsDon’t give up on using a topical steroid. Ifone preparation or vehicle does not work,try anotherPatients can occasionally develop sensitivityto topical steroids; perform a patch test ifyou suspect sensitivityInitiate treatment with a superpotent steroidsuch as clobetasol propionate or halobetasolpropionate. The induction periodshould include twice daily application for2 weeks. If the condition does not clear,continue twice daily for 4 weeks. Thereafter,reduce usage to 1–2 times weeklywhile introducing a nonsteroidal (eg, vitaminD 3 ) preparationCutaneous atrophy may reverse but striaedo not. Anecdotally, most striae develop inpatients aged 8–30 years, especially whentopical steroids are used in intertriginousareas. Avoid the use of corticosteroids onthe abdomen in younger patients, particularlywomen prior to pregnancyThe maximum dosage of most potent ste-roids is 50 g/wk; check package insertTable 7.Maximum Doses of Vitamin D–Containing TreatmentsMedicineCalcitriol ointment 3 μg/gAllowed TotalDose Per Week200 gPanel Tips: Combination Topical TherapyConcurrent use of salicylic acid with topicalsteroids enhances efficacy as well as toxicityAmmonium lactate and tazarotene may beused with topical steroids to decreasesteroid atrophyPrescribe a vitamin D topical therapy incombination with a topical steroid. 57 Eitheruse the vitamin D topical therapy from thebeginning with the topical steroid or startthe vitamin D therapy after the 2–4-weekinduction period, making sure it is compatiblewith the prescribed topical steroid (eg,halobetasol in combination with calcipotriene).Otherwise, apply one topical agentin the morning and the other in the eveningConsider a fixed-dose combination product.It has advantages over monotherapy witha similar application regimenMake sure the topical steroids are compat-ible with any second agent being usedMaintenance Therapy StrategiesAfter an initial induction phase of2–4 weeks, use topical steroids lessfrequently (ie, 1–2 days per week)Prescribe topical steroids to areas that havecleared (histologically, there may be evidenceof inflammation despite clinicalclearance, which is a justification forcontinued therapy)Prescribe topical steroids only as neededIn the event of a psoriasis flare, go back toan initial induction regimenUse steroid-sparing agents (especiallyvitamin D topical therapy) topically alone,and in combination with tazarotene, coaltar, anthralin, and emollientsCalciotriene cream 0.005%Calcipotriene 0.005%–betamethasone dipropionate0.064% ointment100 g100 gUse of Vitamin D Topical TreatmentsVitamin D topical agents have emerged as first-linetherapy for psoriasis. Vitamin D topical treatmentsbind to vitamin D receptors in the skin, leadingto differential expression of genes relating to24 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisPanel Tips: Using Vitamin DTopical TreatmentsGeneral AdviceSome panel members agree that patients cantake up to 50,000 IU/mo of vitamin D orallywhen using a vitamin D topical therapyStart a vitamin D topical therapy concur-rently with topical steroids, otherwiseimprovement will be slowCalcitriol is less irritating than calcipotriene 58Vitamin D topical therapy can be used asmonotherapy for the face and intertriginousareasVitamin D topical therapies have demon-strated long-term safety and efficacy up to52 weeks without a clinically significanteffect on calcium homeostasis 33Combination Therapy With Vitamin D TopicalTreatments and Other AgentsKnow which agents are compatible withvitamin D topical therapies. They are inactivatedby many agents that haveacidic pH, including hydrocortisone valerate,ammonium lactate, salicylic acid, and phototherapy.A medication vehicle may matterfor compatibility. If compatibility is uncertain,separate the applications by time of dayThe combination of a vitamin D topicaltherapy with a topical steroid is superior tomonotherapy with a steroid aloneThere is no information yet to determine ifmixing a vitamin D topical therapy withanother topical agent will dilute the agentsor enhance their absorptionAccording to panel members, the vehiclemakes a difference in efficacy for calcipotriene;ointment is more effective thancream. The combination of a single agentcontaining calcipotriene and betamethasonedipropionate once daily is safe andeffective in patients with mild, moderate,or severe psoriasis 35cellular differentiation, which ultimately results indecreased inflammation, inhibition of keratinocyteproliferation, and improved cellular differentiation.59 The main side effect of vitamin D topicaltreatments is local skin irritation and pruritus. 58,60Vitamin D topical therapies have been used effectivelyas monotherapy or in conjunction with otheragents. Maximum doses of vitamin D–containingtreatments are highlighted in Table 7.Use of Topical RetinoidsTopical retinoids have effects on epidermal differentiation.Tazarotene is a third-generation topicalretinoid that is approved for the treatment ofplaque psoriasis. After binding to cellular retinoidreceptors, tazarotene has been shown to decreasekeratinocyte proliferation, inhibit inflammatorymediators, and normalize cellular differentiation. 56The use of tazarotene is limited by substantial localirritation, especially perilesional irritation. It mayhelp reduce the incidence of steroid-induced cutaneousatrophy. Tazarotene currently is availablein cream and gel formulations, both in 0.05% and0.1% concentrations. Currently, there is no limiton the maximum dose used on the skin, and thedrug is pregnancy category X. 61Panel Tips: Use of TazaroteneConsider combination use of tazarotene andmometasone furoate cream 0.1%, whichhas greater efficacy than tazarotenegel 0.1% alone. 39 The combination alsohas resulted in longer remissions thanusing mometasone alone 62Tazarotene has been used in combination withvitamin D topical therapy with efficacy almostequal to clobetasol propionate ointment 38Tazarotene helps prevent steroid atrophy 63Tazarotene cream is more efficacious andless irritating than the gel formulation 54Consider using cream on the trunk but gelon the scalpDo not use tazarotene in body foldsbecause of irritationSome success has been shown with theuse of short-contact tazarotene gel 0.1%WWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 25

Optimizing Topical Therapies for PsoriasisPanel Tips: Use of Coal TarGeneral AdviceWhile exonerated by the US Food and DrugAdministration, the state of Californiawarns that coal tar is a carcinogenAvoid coal tar in patients with blonde or coloredhair because of stainingAdministration and Application-RelatedConsiderationsCoal tar is commercially available in newformulations, such as a foam, which havelittle staining of the skin and lack the odorof prior formulationsCoal tar can be used effectively in combi-nation with phototherapy. 64 Removecoal tar before initializing the light treatment,otherwise patients can develop “tarsmarts” (delayed erythema and skin pain)Coal tar has been especially helpfulin shampoosConsider compounding liquor carbonisdetergens with betamethasone in hydrophilicointment to use at nightCoal tar may work well in combination withsalicylic acidPanel Tips: Use of AnthralinCommercially available as Zithranol-RR ® ,Psoriatec ® , or Drithro-cream ®Consider use in a short-contact regimen toavoid staining of household itemsUse of triethanolamine prevents irritationAnthralin powder can be compounded in3%, 5%, or 10% formulationsDo not use with white towels because of therisk for stainingAcidic soaps, such as SAStid ® (containingsalicylic acid) and Salises, can helpremove anthralin stainsBasic soaps, such as Ivory ® and Dove ® , canmake stains worsePanel Tips: Use of TopicalCalcineurin InhibitorsMay be used as monotherapy for psoriasison the face or intertriginous areasDiscuss with patients the black box warningthat these medications carryDiscuss with patients the risk for self-limitedskin burning associated with these agentsTacrolimus ointment may be more effectivebut may cause slightly more irritation thanpimecrolimus creamPanel Tips: Use of Keratolyticsand EmollientsBe aware of potential incompatibilityissues with other medicines (eg, acidic pHmay inactivate a vitamin D topical therapy)Emollients such as ammonium lactate mayprevent steroid atrophyConsider seasonal use of emollients only asmaintenance treatmentUse of Other Topical AgentsIn addition to topical steroids, vitamin D topicaltherapy, and retinoids, several other topical therapiesare available to treat psoriasis, such as coaltar, anthralin, calcineurin inhibitors, keratolytics,and emollients. These medicines have been usedas monotherapy but are more commonly combinedwith other treatments. These steroid-sparing agentsshould not be forgotten in determining a regimenfor patients. However, they must be carefully prescribed,as some may inactivate other medicationsif used together.Combination Use of Topical Agentsand PhototherapyDespite new and emerging drugs for psoriasis,UV light (ie, narrowband UVB, broadbandUVB, PUVA) is still an essential part of psoriasistreatment. Patients undergoing phototherapytraditionally have marked BSA involvement(eg, .5%). Phototherapy also may be useful inpatients with more localized disease, particularlywith use of focused narrowband laser or nonlaserUVB phototherapy. Phototherapy is both26 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for PsoriasisPanel Tips: PhototherapyGeneral AdviceA topical medication should not be usedwithin 2 hours prior to phototherapy unlessthere is certainty it will not be inactivatedby light. Otherwise, apply the medicineafter phototherapyTopical PUVA therapy is useful for psoriasisaffecting the palms and solesApply emollients before phototherapy butonly those agents that do not block light(eg, petrolatum, mineral oil, Theraplex ® ).Mineral oil enhances penetration of lightthrough psoriatic plaquesTo avoid phototoxicity, use photosensitizingmedicines (including antibiotics) subsequentto phototherapy sessionsFailure of topical PUVA therapy does notmean that oral PUVA therapy also will fail(and vice versa)For treatment with topical PUVA therapy,dissolve 1 tablet (10 mg) of methoxsalen in2 L of waterFor treatment with bath PUVA therapy,dissolve 5 tablets (50 mg) of methoxsalenin a bathtub half filled with water, which willmake patients extremely photosensitive andshould be used with appropriate cautionHave patients use wristbands after soakingin oxsoralen to prevent burns on the wristsin areas that may not consistently soakPUVA therapy penetrates deeper into theskin and may be especially helpful for thickpsoriasis plaquesCombination Therapy (Phototherapy)Apply a topical steroid to an area that isresistant to treatment with phototherapyConsider using tazarotene in combinationwith UVB therapy to enhance the efficacyof phototherapy 65Vitamin D topical therapies can help reducethe frequency of phototherapy needed totreat psoriasis 66For patients receiving tazarotene, decreasethe phototherapy dose by one-thirdor one-half. It takes approximatelyone week for tazarotene to thin thestratum corneum and make the skinmore photosensitiveFor resistant cases, use an inductiontherapy with a vitamin D topical therapy(with or without a topical steroid) in combinationwith phototherapyFor patients with erythrodermic psoriasis,first cool down the skin with dilute topicalsteroids and wet compresses; then treatcarefully with phototherapyConsider priming patients with topicalagents for 2 weeks prior to phototherapy,which may help decrease the number ofphototherapy sessions neededTable 8.What to Avoid Before Phototherapy• Avoid calcipotriene before UVAefficacious and safe without the potential sideeffects of systemic immunosuppressive therapies;it has been used effectively as monotherapy orin combination with systemic and topical agents(Table 8). 26A member of the panel suggested that thesafety profile of phototherapy may be appropriatefor certain pregnant women. He noted, “Weprefer not to treat pregnant patients, but if we have• Avoid calcitriol for at least 3–6 hours beforeUVA and UVB• Avoid applying too much of an emollient, asit physically blocks light; a thin application ofpetrolatum or mineral oil would be best priorto phototherapyWWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 27

Optimizing Topical Therapies for Psoriasisto, narrowband and broadband phototherapy aresafe options.”The Use of Topical Agents WithSystemic AgentsTraditional systemic medications and biologicagents are effective at treating moderate to severepsoriasis, but patients may not be totally clear allof the time. Systemic agents often have a slowonset of action. Topical agents easily can be used asadjunctive therapy until the systemic agent startsto show efficacy. Moreover, some patients willhave resistant plaques that do not resolve with asystemic or biologic medication, and topical agentscan complement a systemic medication on theseareas. When psoriasis flares occur, it is not necessaryto abandon the systemic agent. Regardless ofthe cause of the flare, patients can be maintainedon a systemic agent while the flare is treated byaddition of a topical medicine. Adjunctive therapywith a clobetasol propionate spray 0.05% wasevaluated as add-on therapy in patients receivingother medications (including topical or systemicagents), resulting in improvement of disease severity.67 There are many questions about combiningtopical and systemic medications that may beanswered through personal experience and futureclinical trials.ConclusionAlthough the experience of having psoriasis issubjective and differs from patient to patient,there are guidelines for determining the levelof severity. Mild psoriasis generally is defined asBSA involvement of 3% or less. Moderate diseaseinvolves 5% to 10% BSA. Severe psoriasisis disease that affects greater than 10% BSA.Dermatologists must take into consideration thepercentage of BSA involved; location, severity,and number of individual lesions; response totopical therapies; associated physical disability,including psoriatic arthritis; and psychosocial andQOL issues.Existing guidelines provide a framework forcategorizing patients as well as the severity andtype of psoriasis. Nonetheless, psoriasis manifestsin various ways. Psoriasis is a systemic inflammatorycondition that gives rise to increasedrisk for comorbidities, including the metabolicsyndrome X, depression, hypertension,and dyslipidemia.In psoriasis therapy, the goal of treatment isdurable improvement with minimal AEs. Thereare numerous therapies available for patients withpsoriasis, including topical steroids, vitamin D 3treatments, retinoids, and other topical agents, aswell as phototherapy and systemic and biologicagents. The topical agents can be delivered inmany different vehicles. Although the choicesare broad, problems of adherence can underminetreatment success. The use of vehicle is importantin bolstering adherence rates and, when possible,vehicles should be chosen based on the preferenceof the patient. In addition, it generally helps tohave the first follow-up appointment soon after thebaseline visit.Guidelines differ based on the populationinvolved. Special care is warranted in children, olderpatients, and pregnant women. Overall, therapeuticoptions allow dermatologists to use a varietyof well-researched approaches to treatPanel Tips: Using Topical Agents WithSystemic AgentsUse a topical agent with a systemic agentwhen beginning therapy to give patients aquicker responseAdd topical agents to recalcitrant areas andhelp improve responseAdd topical agents to treat flares ofpsoriasis while continuing the systemic orbiologic agentTopical agents may be particularly usefulfor psoriasis plaques on the lower extremitiesand scalp that may be less responsiveto systemic and biologic agents than otherbody partsContinue using a topical agent whiletapering a systemic agent and switchingto another systemic agentUse topical agents while waiting forinsurance coverage approval for asystemic agentConsider using a vitamin D topical therapyin combination with an oral retinoid, 68cyclosporine, 69 or methotrexate 70Fixed-dose calcipotriene 0.005%–betamethasone dipropionate 0.064% ointmentplus etanercept may be more beneficialthan etanercept alone for some patients28 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for Psoriasistheir patients with the goal of improvingoverall health and QOL. Topical therapy isimportant in the treatment of mild to severepsoriasis and can be used safely and effectively asmaintenance therapy.References1. Menter A, Griffiths CE. Current and future managementof psoriasis. Lancet. 2007;370:272-284.2. Feldman SR. A quantitative definition of severe psoriasisfor use in clinical trials. J Dermatolog Treat. 2004;15:27-29.3. Stern RS, Nijsten T, Feldman SR, et al. Psoriasis iscommon, carries a substantial burden even when notextensive, and is associated with widespread treatmentdissatisfaction. J Investig Dermatol Symp Proc. 2004;9:136-139.4. Dubertret L, Mrowietz U, Ranki A, et al; EUROPSOPatient Survey Group. European patient perspectives onthe impact of psoriasis: the EUROSPO patient membershipsurvey. Br J Dermatol. 2006;155:729-736.5. Chan CS, Van Voorhees AS, Lebwohl MG, et al. Treatmentof severe scalp psoriasis: from the Medical Board ofthe National Psoriasis Foundation. J Am Acad Dermatol.2009;60:962-971.6. Kragballe KD. Management of difficult to treat locationsof psoriasis. scalp, face, flexures, palm/soles and nails. CurrProbl Dermatol. 2009;38:160-171.7. Voorhees AV, Feldman SR, Koo JYM, et al. The Psoriasisand Psoriatic Arthritis Pocket Guide. Portland, OR: NationalPsoriasis Foundation; 2009.8. Kalb RE, Bagel J, Korman NJ, et al; National PsoriasisFoundation. Treatment of intertriginous psoriasis: from theMedical Board of the National Psoriasis Foundation. J AmAcad Dermatol. 2009;60:120-124.9. Sege-Peterson KWR. Psoriatic arthritis. In: Freedberg IM,Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatologyin General Medicine. New York, NY: McGraw-Hill Inc;1999:522-533.10. Rapp SR, Feldman SR, Exum ML, et al. Psoriasis causes asmuch disability as other major medical diseases. J Am AcadDermatol. 1999;41:401-407.11. Koo J, Menter A. The Koo-Menter Instrument for identificationof psoriasis patients requiring systemic therapy.Psoriasis Forum. 2003;9:6-9.12. Finlay AY, Khan GK. Dermatology Life Quality Index(DLQI)—a simple practical measure for routine clinicaluse. Clin Exp Dermatol. 1994;19:210-216.13. Kaltwasser JP, Nash P, Gladman D, et al; Treatment ofPsoriatic Arthritis Study Group. Efficacy and safetyof leflunomide in the treatment of psoriatic arthritisand psoriasis: a multinational, double-blind, randomized,placebo-controlled clinical trial. Arthritis Rheum.2004;50:1939-1950.14. Gupta MA, Gupta AK. Psoriasis and sex: a study ofmoderately to severely affected patients. Int J Dermatol.1997;36:259-262.15. Langley R, Krueger GG, Reich K, et al. High prevalenceand under-diagnosis of cardiovascular risk factorsamong psoriasis patients in a clinical trial population.Poster presented at: 83rd Annual Meeting of theCanadian Dermatology Association; June 27-July 2, 2008;Montreal, Quebec.16. Gulliver W, Tomi Z. Comorbidities associated with psoriasisin the Newfoundland and Labrador founder population.J Am Acad Dermatol. 2007;56(suppl 2):AB63.17. Al-Mutairi N, Al-Farag S, Al-Mutairi A, et al. Comorbiditiesassociated with psoriasis: an experience from theMiddle East. J Dermatol. 2010;37:146-155.18. Mrowietz U, Elder JT, Barker J. The importance of diseaseassociations and concomitant therapy for the long-termmanagement of psoriasis patients. Arch Dermatol Res.2006;298:309-319.19. Persson PG, Leijonmarck CE, Bernell O, et al. Riskindicators for inflammatory bowel disease. Int J Epidemiol.1993;22:268-272.20. Kimball AB, Gladman D, Gelfand JM, et al; NationalPsoriasis Foundation. National Psoriasis Foundation clinicalconsensus on psoriasis comorbidities and recommendationsfor screening. J Am Acad Dermatol. 2008;58:1031-1042.21. Gottlieb AB, Chao C, Dann F. Psoriasis comorbidities.J Dermatolog Treat. 2008;19:5-21.22. van Voorhees AS, Fried R. Depression and quality of lifein psoriasis. Postgrad Med. 2009;121:154-161.23. Buhse L, Kolinski R, Westenberger B, et al. Topical drugclassification. Int J Pharm. 2005;295:101-112.24. Tamarkin D, Friedman D, Shemer A. Emollient foamin topical drug delivery. Expert Opin Drug Deliv. 2006;3:799-807.25. Wu JJ, Weinstein GD. General guidelines for administrationof topical agents in the treatment of mild-to-moderatepsoriasis. In: Koo JYM, Lebwohl MG, Lee CS, eds. Mild toModerate Psoriasis. New York, NY: Informa Healthcare;2006:11-21.26. Menter A, Korman NJ, Elmets CA, et al; AmericanAcademy of Dermatology. Guidelines of care for themanagement of psoriasis and psoriatic arthritis. Section 3.Guidelines of care for the management and treatmentof psoriasis with topical therapies. J Am Acad Dermatol.2009;60:643-659.27. Lebwohl M, Menter A, Koo J, et al. Combination therapyto treat moderate to severe psoriasis. J Am Acad Dermatol.2004;50:416-430.28. Callen JP, Krueger GG, Lebwohl M, et al; AAD. AADconsensus statement on psoriasis therapies. J Am AcadDermatol. 2003;49:897-899.WWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 29

Optimizing Topical Therapies for Psoriasis29. Lahfa M, Mrowietz U, Koenig M, et al. Calcitriol ointmentand clobetasol propionate cream: a new regimenfor the treatment of plaque psoriasis. Eur J Dermatol.2003;13:261-265.30. Koo JY. New developments in topical sequential therapyfor psoriasis. Skin Therapy Lett. 2005;10:1-4.31. Callen J, Chamlin S, Eichenfeld LF, et al. A systematicreview of the safety of topical therapies for atopic dermatitis.Br J Dermatol. 2007;156:203-221.32. Langner A, Ashton P, Van De Kerkhof PC, et al. A longtermmulticentre assessment of the safety and tolerabilityof calcitriol ointment in the treatment of chronic plaquepsoriasis. Br J Dermatol. 1996;135:385-389.33. Lebwohl M, Ortonne J-P, Andres P, et al. Calcitriol ointment3 μg/g is safe and effective over 52 weeks for thetreatment of mild to moderate plaque psoriasis. Cutis.2009;83:205-212.34. Luger TA, Cambazard F, Larsen FG, et al. A study of thesafety and efficacy of calcipotriol and betamethasonedipropionate scale formulation in the long-term managementof scalp psoriasis. Dermatology. 2008;217:321-328.35. Kragballe K, Austad J, Barnes L, et al. Efficacy resultsof a 52-week, randomised, double-blind, safety studyof a calcipotriol/betamethasone dipropionate twocompoundproduct (Daivobet/Dovobet/Taclonex) in thetreatment of psoriasis vulgaris. Dermatology. 2006;213:319-326.36. Lebwohl M. Vitamin D and topical therapy. Cutis.2002;70(suppl 5):5-8.37. Data on file. Lausanne, Switzerland: Galderma; 2010.38. Bowman PH, Maloney JE, Koo JY. Combination of calcipotriene(Dovonex) ointment and tazarotene (Tazorac)gel versus clobetasol ointment in the treatment of plaquepsoriasis: a pilot study. J Am Acad Dermatol. 2002;46:907-913.39. Lebwohl MG, Breneman DL, Goffe BS, et al.Tazarotene 0.1% gel plus corticosteroid cream in thetreatment of plaque psoriasis. J Am Acad Dermatol. 1998;39(4, pt 1):590-596.40. Rapp SR, Exum ML, Reboussin DM, et al. The physical,psychological and social impact of psoriasis. J HealthPsychol. 1997;2:525-537.41. Feldman SR, Horn EJ, Balkrishnan R, et al;International Psoriasis Council. Psoriasis: improvingadherence to topical therapy. J Am Acad Dermatol.2008;59:1009-1016.42. Wozel G. Psoriasis treatment in difficult locations: scalp,nails, and intertriginous areas. Clin Dermatol. 2008;26:448-459.43. Tan J, Thomas R, Wang B, et al; CalePso Study Team.Short-contact clobetasol propionate shampoo 0.05%improves quality of life in patients with scalp psoriasis.Cutis. 2009;83:157-164.44. Papp K, Berth-Jones K, Kragballe K, et al. Scalppsoriasis: a review of current topical treatment options.J Eur Acad Dermatol Venereol. 2007;21:1151-1160.45. Feldman SR, Housman TS. Patients’ vehicle preferencefor corticosteroid treatments of scalp psoriasis. Am J ClinDermatol. 2003;4:221-224.46. Jiaravuthisan MM, Sasseville D, Vender RB, et al. Psoriasisof the nail: anatomy, pathology, clinical presentation,and a review of the literature on therapy. J Am AcadDermatol. 2007;57:1-27.47. Samman PD, Fenton D, eds. The Nails in Disease. 5th ed.London, England: Butterworth-Heinemann Ltd; 1994.48. de Berker D. Management of psoriatic nail disease. SeminCutan Med Surg. 2009;28:39-43.49. Scher RK, Stiller M, Zhu YI. Tazarotene 0.1% gel inthe treatment of fingernail psoriasis: a double-blind,randomized, vehicle-controlled study. Cutis. 2001;68:355-358.50. Tosti A, Ricotti C, Romanelli P, et al. Evaluation ofthe efficacy of acitretin therapy for nail psoriasis. ArchDermatol. 2009;145:269-271.51. Kerkhof PCM. Clinical features. In: Kerkhof PCM, ed.Textbook of Psoriasis. Oxford, England: Blackwell ScienceLtd; 1999:3-29.52. Beylot C, Puissant A, Bioulac P, et al. Particularclinical features of psoriasis in infants and children.Acta Derm Venereol Suppl (Stockh). 1979;87:95-97.53. Paller AS, Siegfried EC, Langley G, et al; EtanerceptPediatric Psoriasis Study Group. Etanercept treatment forchildren and adolescents with plaque psoriasis. N Engl JMed. 2008;358:241-251.54. de Jager ME, de Jong EM, van de Kerkhof PC, et al.Efficacy and safety of treatments for childhood psoriasis:a systematic literature review. J Am Acad Dermatol.2010;62:1013-1030.55. Chi CC, Wang SH, Kirtschig G, et al. Systemic reviewof the safety of topical corticosteroids in pregnancy. J AmAcad Dermatol. 2010;62:694-705.56. Kamili QU, Menter A. Topical treatment of psoriasis.Curr Prob Dermatol. 2009;38:37-58.57. Lebwohl M, Ali S. Treatment of psoriasis. part 1. topicaltherapy and phototherapy. J Am Acad Dermatol.2001;45:487-498.58. Ortonne J, Humbert P, Nicolas JF, et al. Intra-individualcomparison of the cutaneous safety and efficacy of calcitriol3 microg g(-1) ointment and calcipotriol 50 microg g(-1)ointment on chronic plaque psoriasis localized in facial,hairline, retroauricular or flexural areas. Br J Dermatol.2003;148:326-333.59. Lehmann B. Role of vitamin D 3 pathway in healthyand diseased skin—facts, contradictions and hypotheses.Exp Dermatol. 2009;18:97-108.30 CUTIS ® WWW.CUTIS.COM

Optimizing Topical Therapies for Psoriasis60. Sigmon JR, Yentzer BA, Feldman SR. Calcitriol ointment:a review of a topical vitamin D analog for psoriasis.J Dermatol Treat. 2009;20:208-212.61. Tazorac [package insert]. Irvine, CA: Allergan; 2008.62. Koo JY, Martin D. Investigator-masked comparison oftazarotene gel q.d. plus mometasone furoate cream q.d.vs mometasone furoate cream b.i.d. in the treatment ofplaque psoriasis. Int J Dermatol. 2001;40:210-212.63. Jones SM, Armas JB, Cohen MG, et al. Psoriatic arthritis:outcome of disease subsets and relationship of joint diseaseto the nail and skin disease. Br J Rheumatol. 1994;33:834-839.64. Paghdal KV, Schwartz RA. Topical tar: back to the future.J Am Acad Dermatol. 2009;61:294-302.65. Koo JY, Lowe NJ, Lew-Kaya DA, et al. Tazaroteneplus UVB phototherapy in the treatment ofpsoriasis. J Am Acad Dermatol. 2000;43(5, pt 1):821-828.66. Ramsay CA, Schwartz BE, Lowson D, et al. Calcipotriolcream combined with twice weekly broad-band UVBphototherapy: a safe, effective and UVB-sparing antipsoriaticcombination treatment. The CanadianCalcipotriol and UVB Study Group. Dermatology. 2000;200:17-24.67. Lebwohl M, Colon LE. The evolving role of topical treatmentsin adjunctive therapy for moderate to severe plaquepsoriasis. Cutis. 2007;80(suppl 5):29-40.68. van de Kerkhof PC, Cambazard F, Hutchinson PE,et al. The effect of the addition of calcipotriol ointment(50 micrograms/g) to acitretin therapy in psoriasis.Br J Dermatol. 1998;138:84-89.69. Grossman RM, Thivolet J, Claudy A, et al. A novel therapeuticapproach to psoriasis with combination calcipotriolointment and very low-dose cyclosporine: results of amulticenter placebo-controlled study. J Am Acad Dermatol.1994;31:68-74.70. Koo JY, Nguyen KD. Treating psoriasis patients: a topicaltherapy update. Skin & Aging. 2002;10. http://www.skinandaging.com/article/395. Published March 2, 2002.Accessed June 9, 2010.WWW.CUTIS.COM VOLUME 86, SEPTEMBER 2010 31

CME PosttestOptimizing Topical Therapies for Treating Psoriasis: A Consensus ConferenceWhich of the following factors determinesWhich of the following statements1. the severity of psoriasis? 5. about generic topical medications for□ a. quality-of-life/psychosocial side effectspsoriasis is not true?□ b. response to topical therapies□ a. for many of the branded topical□ c. severity of individual lesionsmedications, there are no□ d. a and b onlygenerics available□ e. a, b, and c□ b. generic topical medications aregenerally cheaper than brand-nametopical medicationsWhat percentage body surface area (BSA)□ c. high-potency generic corticosteroid2. is affected with severe psoriasis?products are not available□ a. 1%–3% BSA□ d. the margin of potency differs betweengeneric and branded psoriasis medications□ b. 5%–7% BSA□ e. all of the above are false□ c. .10% BSA□ d. purely subjective and depends on how thepatient feels about itHow much topical medication is needed for□ e. none of the above6. 1 application to 1% BSA for the averagesizedadult?Which of the following conditions is□ a. 0.55 g3. associated with an increased prevalence□ b. 1.10 gand/or risk in patients with psoriasis?□ c. 82.5 g□ a. anorexia□ d. none of the above□ b. diabetes mellitus□ c. obesityWhen would it make sense to use a□ d. a and b7. systemic therapy?□ e. b and c□ a. in neonates□ b. in severe palmoplantar psoriasisWhich of the following situations might□ c. when topical therapies fail4. suggest that a patient with psoriasis has□ d. all of the aboveproblems with adherence?□ e. b and c□ a. clobetasol is having notreatment effect□ b. he/she has failed multiple treatments□ c. he/she has not required a refill despite1-year follow-up□ d. the medication regimen islosing effectiveness□ e. all of the above32 CUTIS ®INSTRUCTIONS: Postgraduate Institute for Medicine supports “green” CME by offering your request for credit online. If you wish to receiveacknowledgment for completing this activity, please complete the posttest and evaluation at www.cmeuniversity.com. On the navigation menu,click on Find Post-test/Evaluation by Course and search by course ID 7338. Upon registering and successfully completing the posttest witha score of 70% or better and the activity evaluation, your certificate will be made immediately available. Processing credit requests online willreduce the amount of paper used by nearly 100,000 sheets per year.TEST VALID THROUGH AUGUST 31, 2011.WWW.CUTIS.COM

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