Topical therapy in psoriasis: an important partner in combination therapy

The therapeutic efficacy of a systemic agent can not only be enhanced by dose escalation but also by combination with topical treatment. Choosing the right vehicle is especially important in scalp psoriasis.

In many patients, psoriasis shows a relapsing course with remissions and exacerbations and is sometimes refractory to treatment. In case of systemic treatment, escalating dosage, shortening injection intervals, or switching therapy is not the only way to enhance therapeutic efficacy. As Prof. Peter van de Kerkhof (Radboud University Medical Centre, the Netherlands) pointed out in his lecture, adding topical therapy to systemic agents might be a smart way to improve efficacy without safety concerns [1]. Today, combination therapies have shown improved efficacy compared with monotherapy with systemic agents [2]. Until today, topical corticosteroids play a key role in the treatment of psoriasis, especially for localised disease, due to their anti-inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects.

Topical corticosteroid therapy in combination with etanercept has shown improved efficacy without any increased safety concerns. Another recommended topical combination is calcipotriol plus betamethasone dipropionate. Together with adalimumab, this combination showed superior efficacy compared with adalimumab monotherapy at 4 weeks. Moreover, patients treated with conventional disease-modifying drugs may benefit from the addition of topical agents. By adding calcipotriol to methotrexate, a lower cumulative dose of the latter could be observed, and there was an increased time to relapse after its discontinuation. Another study showed that the clinical response was enhanced by adding calcipotriol plus betamethasone dipropionate ointment to low-dose cyclosporin. Topical calcipotriol treatment has also been shown to improve the efficacy of acitretin.

Taken together, topical corticosteroids in psoriasis are still strong options in the management of the disease. Of note, the optimal vehicle choice is often the one the patient is most likely to use [2]. For example, the scalp can successfully be treated with solutions, foam, or spray, whereas creams are preferred for glabrous skin. In every case, patient preference should be considered when selecting the most appropriate vehicle.

1. van de Kerkhof P. Corticosteroids in the topical treatment of psoriasis. B15_1, SPIN 2022 Congress, 06–08 July, Paris, France.
2. Elmets CA, et al. J Am Acad Dermatol. 2021;84:432-70.

 

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Posted on 26 August 2022