Psound Bytes™ Transcript: Episode 202

Release date: August 15, 2023

“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”

Shiva: My name is Shiva Mozaffarian and joining me today for an in-depth look at the use of topicals for psoriasis and some of the do’s and don’ts is dermatologist Dr. George Han. Dr. Han is an Associate Professor in the Department of Dermatology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health in New York. Dr. Han is active in both scientific research and clinical trials serving as Principal Investigator and International Coordinating Investigator for numerous studies exploring new therapies in psoriasis, atopic dermatitis, vitiligo and other skin diseases. He is also a member of the Medical Board of the National Psoriasis Foundation.

Dr. Han, thank you so much for being here with us today! It’s such a pleasure having you back on Psound Bytes™! In a previous episode, #83, you spoke about how to make telehealth visits successful. Today we’re here to talk about topicals with a focus on use of corticosteroids. To start our discussion, when you first see someone with psoriasis, how do you determine what medication or medications they should start with? And what factors influence your decision of what to recommend first?

Dr. Han: Well, first thanks for having me. It's always a pleasure to be on these podcasts talking about psoriasis. We have so many great options for treating psoriasis nowadays, but I think it's important to really take a look at where patients have the psoriasis coming out. Whether it's affecting their joints, how it's affecting their quality of life because a lot of times you know what I try to avoid as a dermatologist is telling a person, based on how much of the skin you have involved I think you are only eligible for these medicines because, truthfully, a lot of times patients maybe don't have a huge body surface area involved. But let's say it's their hands or it's their feet and it really gets in the way of their daily life. You think about other areas like the scalp. Scalp psoriasis even if it's only in the scalp, can be very itchy, very embarrassing and also there's a high rate of concurrence with scalp psoriasis with psoriatic arthritis. So I think it's important that we keep those things in mind when we're thinking about a global approach to our patients. When you think about the medications that we have from a topical standpoint, we of course have a lot of different options nowadays. There’s medicines ranging from the older topical steroids that we have to newer topical medicines. But of course, we also have a lot of systemic medicines ranging from pills, oral medications to biologics which are injectables. And so we have a pretty broad range of treatments that we can think about for a psoriasis patients. So we have that conversation about how it affects their quality of life, where they're getting it, what kind of effect it has on their physical health, but their mental health as well. And that really helps us guide it. The other thing I try to keep in mind is a lot of times there are places that patients have the psoriasis that are not amenable to like treatment with thick, greasy ointment. So we really have to be careful and mindful of how our patients are using the medications.

Shiva: So Dr. Han, what overall is the purpose of topicals in the treatment of psoriasis? How do they work? And in general, what forms do they come in?

Dr. Han: When we think about psoriasis in general, we have to keep in mind there’s an overactivation of certain parts of your immune system. So there's too much inflammation. Your body's kind of response that normally tries to fight off germs, bacteria, things that shouldn't be there. It's just kind of overactivated and that's why people get psoriasis. So in some way, shape or form we have to kind of suppress that overactive inflammation to get your skin back to normal. The way that topical steroids work is that they're just pretty broad immunosuppressants. That's why a lot of times people take oral steroids for certain inflammatory conditions. When you have asthma exacerbations, people often go on steroids, but from topical steroids, it just kind of locally delivers the medicine to where you need it for your psoriasis. So I think that's very helpful in thinking about in general where they come in. But there's of course a lot of nuance to it because our topical steroids can come in a lot of different forms. There's ointments, creams, foams, steroid shampoos, steroid liquids, steroids in oil formulations. So all that tries to go towards what I think patients prefer the best.  When you think about medications that go onto the scalp, sometimes the foams are better, sometimes the gels are more helpful for that area. Solutions or oils depending on hair type. Also, I think takes some trying to figure out what is best for the patient's hair type. When you think about the other topicals, ointments, creams, lotions, those are all options, foams, spray. So we have a lot of different things that we can give and we also have varying strengths of topical steroids. So one of the things we always try to keep in mind is how much you can really put on practically from how much psoriasis is on the body. So obviously, if somebody is covered with psoriasis, it's probably not so reasonable to ask people to smear themselves all over with these medicines. Because one thing that does happen is if you're applying to too large of a body surface area, you actually will absorb enough of the steroid to potentially affect you internally. So some of the things that we think about as risks of long term internal steroid use like weight gain, kind of Buffalo hump, issues with bone strength. There's a lot of things that are kind of negative with too much steroids, so I think we need to balance those two sides. You also need to think about local effects on the skin. If you overuse topical steroids, especially strong ones, you may thin out your skin. You may be prone to stretch marks, and I've seen a lot, especially in patients with a little darker skin tones, is that you'll get this like halo of skin lightening around the psoriasis lesions, which actually is not so great to have either. When you think about all the different options, we certainly have different formulations for each different context as well as different strengths of medications that are helpful depending on how thick the plaques are, how long we've been treating. So we have a lot of different options there.

Shiva: So you mentioned topical steroids. When would you choose to use a corticosteroid and how effective are they?

Dr. Han: We still, generally speaking, reach for topical steroids as first line in terms of patients with limited body surface areas with psoriasis. When you think about it at the end of the day, if we're able to get these things under control and even though psoriasis does tend to be recurrent and a long term issue, if we can keep it under wraps with topical steroids and a lot of times we work in other non-steroidal topicals like we've had medicines like topical vitamin D calcipotriene for a very long time. We have newer topical medications, I think we'll talk about later. Those are really helpful in just trying to keep the psoriasis at bay. So they are effective when they're used properly, but we have to be very careful. Like I said before, when you use a very strong topical steroid within a short of time period as two weeks or so, you can actually start getting suppression of your internal hormone axis if you're overusing topical Class 1 Super Potent steroids. So we have to use a little bit of caution, but it still is our first approach because they are very easily accessible. It's often convenient to use these medications when you need and where you need, and so those are all helpful features of the topical steroids.

Shiva: You mentioned corticosteroids come in a variety of strengths or potency which we know range from low, moderate, high and superpotent ultra high. Could you please provide some examples of each and how they differ? You alluded to factors that impact the choice of a corticosteroid earlier.

Dr. Han: So when you think about the different topical corticosteroids, we do have a broad range of topical potencies. Medicines that are safe for use on the face, for example, more sensitive area of skin where you want to avoid thinning if possible, you want to avoid stretch marks, we tend to reach for what's called non-fluorinated steroids. Most common are different forms of hydrocortisone, as well as a medicine called desonide. So those are all pretty safe to use on the face. We still try not to overuse them, but that's what we reach for. Similarly, in areas of where you have skin on skin, so we call them body folds, right? So you're underarms, your private areas. We tend to not reach for super strong medicines either because those can exacerbate the side effects. Then you have medications such as triamcinolone, which I'd imagine most people with psoriasis have at least heard of at some point. It's probably the most popular topical steroid because it's very easily accessible, and it comes in a variety of sizes because we have to keep in mind also for people who have large body surface areas of psoriasis, if we give them like a small tube and the insurance company only generally covers what we give for one month. So the tube they might be done with in a few days or a week, but then they don't have enough to treat for the whole month. So the triamcinolone comes in a one pound jar where sometimes it's helpful in helping with the treatment. Then you start to get to the higher potencies, right. Medicines like fluocinonide, desoximetasone, mometasone, those are a little stronger, so we're a bit more careful with those, but they are more efficacious. So we should start if somebody's coming in with psoriasis for the first time, we really wanna get in control, we often will start with a higher potency and maybe later on we'll start to move down to lower strengths. So those medications are helpful in that regard. And then you have the super potent medications such as clobetasol, halobetasol. Those are very, very strong medicines. Those are the strongest that we have. But we want to be a little careful with them because there were some studies we talked about earlier where after just around two weeks of use, you can affect your internal hormone access. So we want to be a little careful with those superpotent medications, but we don't want to shy away, especially on tough to treat areas like the hands, the feet, the elbows, and the knees. A lot of times giving a little bit of those superpotent steroids at the beginning can help just accelerate the response. Then we need to move down to more appropriate strengths after that point.

Shiva: So for effectiveness, what results or clearance should someone expect with use of a corticosteroid?

Dr. Han: That's a really good question because I think that's something that we kind of assume with newer medicines we have very, very specific controlled trials. But these steroids were developed a long time ago, and we don't necessarily have very good comparator data for a lot of the different medications. In general though, you should start to see results within a week or two of starting use, but that will probably continue over a couple of months depending on how thick your plaques are and how large of a body surface area you have. I would say here, you really want to use the medicines as prescribed. Meaning most of our topical corticosteroids are meant to be used twice daily and part of that is just to get the maximum efficacy. But part of that is also so that when we, as dermatologists, see you back at your follow up, we kind of know what we're seeing is on treatment and not a result of kind of not using very often. But the truth is, if you do forget, everybody forgets. That's OK, just tell us. Be honest about it. Don't be somebody who, like, maybe uses it once every couple of days and then comes in and tells us you're using it twice a day, every day. That really doesn't help. We'd rather kind of try to figure out a right treatment for you, and I think in that sense it's helpful that some of our newer medicines, the nonsteroidal ones that I alluded to earlier are meant to be used just once a day. I think that's probably a little more practical for a lot of patients but try to be consistent with the use because then we have a good picture of how well you were responding to the treatment that we're giving you. 

Shiva: It sounds like it's important to stay with the dose and frequency as prescribed. Are there any precautions to consider when using a corticosteroid? Do you have any tips you can provide our listeners who use a corticosteroid?

Dr. Han: Yeah, I think it's important not to get mixed up with where things go right, because sometimes we see this happen like people will be getting a milder topical steroid for their face and body folds, a stronger one for the rest of the body and even stronger one for the hands and feet. Maybe they're getting an antifungal cream for something else going on. So you know, people bring in these shopping bags full of tubes. Part of the challenge is, I think when you get the instructions, assuming that you have the right instructions printed on the label (a lot of times people throw out the boxes). So after a while it's kind of hard to remember what goes where. So I find it always very helpful when you're in there with your dermatologist and let's say you're being prescribed more than one medicine, let's just write down and take note of what goes where. And I think that really will help, because after a week, two weeks, a month or two, let's say things get better, but then it comes back again. Now you have to remember that conversation from a few months ago of what goes where? So I think that's where things kind of fall apart a little bit. So I think that's very important.  When you're thinking about it, please don't use it more than you ought to because what happens is that you actually saturate the steroid receptors in your skin. So you might think I'll just use it 3, 4 times a day and I'll get better faster. It doesn't really work like that. You're actually just setting yourself up to have more side effects from the medications at that point. So just be careful on that front. If you are pregnant or you're breastfeeding, please let us know because that's really important in us designing a proper regiment for you. We generally are careful with potent topical steroids, especially in early parts of pregnancy. And we do have some topical steroids that are less absorbed into the bloodstream. So sometimes it helps us really design a proper treatment regimen for you if we know exactly what else is going on in your life.

Shiva: Dr. Han, you’ve already mentioned some of the side effects of using a corticosteroid. Are there any other additional risks that our listeners should consider?

Dr. Han: Yeah, again there are a lot of things that can happen. These topical steroids are very helpful in our treatment regimen, but they are not without their risks and downsides. So what I hate seeing is patients who come in after decades of using topical steroids too much and their skin is just paper thin. They have stretch marks all over. It's very hard to come back from that. So those are the things we look out for. Skin atrophy. You can have differences in pigmentation, right? So it can go either darker or lighter depending on your skin tone and the steroid being used. The stretch marks we talked about. Other steroid effects are like steroid acne. So you can actually get a form of acne or occlusion of your hair follicles from too much use of steroids. Bruising in the areas you're using it, you might get little blood vessels that are appearing like little dilated surface blood vessels. So that's something we do often see as well in conjunction with the thin skin. So that's not really a good look either. And then you think about, especially with the stronger steroids, if you're using it too long, it's almost like taking internal steroids for too long, which is not good for a number of your organ systems especially, things like bone strength and easy fracturing. Those are things that can happen actually with overuse of topical steroids. So we wanna use them with some appropriate level of caution.

Shiva: And can corticosteroid be used in combination with other topicals, phototherapy or a systemic medication?

Dr. Han: Yeah, for sure. A lot of times especially when we're starting a treatment, we just wanna get people better quickly. So in conjunction with phototherapy, with systemics, often times we'll give a topical medicine. Sometimes we'll give a systemic medication and people don't get 100% clear, but they have just a couple of stubborn areas and so topical medicines are a good adjunctive for that. And often we do combine different topicals because as I mentioned earlier, for different body parts, we need to do different things. And there's also other topicals that we've traditionally combined with topical steroids just to try to prevent overuse of steroids. So for example, some people do give out regimens involving a vitamin D analog, a topical vitamin D called calcipotriene. And so we have different ways that we can use it. A popular one, for example, is using the calcipotriene, the topical vitamin D, during the weekday and then just using a steroid on the weekends. So there are ways we try to avoid some of those steroid side effects and design a regimen custom for our patients, but those are areas where you can be a little more creative as well.

Shiva: When would you consider switching to either another topical or a systemic medication?

Dr. Han: I think when you think about some of the situations that we face, certainly if somebody has psoriasis that's expanding, it's really affecting new areas, and they're always trying to play catch up with the topicals. That's a situation where I think it's a good time to just take a step back and then take a look and say “Hey, we're starting to have evolution of the psoriasis.” We need to ask and please talk to your provider about any joint pains you may be having, because that's important in our approach to it. If we have undiagnosed or underdiagnosed psoriatic arthritis, that's something that over time can break down the joints and cause permanent deformation. So please don't sleep on that and don't ignore it. Those are all signs that we need to switch to maybe a systemic medicine, for example. But if we're using too much topical steroid, that's another sign that we need to be doing something else and that can actually be either systemic medicine or another topical because we have new choices that are available to us now.

Shiva: I'm so glad you mentioned new choices! Let's now switch to discussion about nonsteroidal topicals. In 2022, a couple new topicals came to market. Let’s start with Tapinarof. How does Tapinarof act in comparison to a corticosteroid? What’s the mechanism of action and how effective is it?

Dr. Han: We're really excited about these new options because they really represent the first really new thing that we've had in a long time. I would be remiss not to mention that we haven't mentioned topical retinoids, that’s something that also we've used traditionally for psoriasis as well, but those can be kind of drying and irritating to the skin as well. I think that's where these new medicines really step apart because they are quite effective. We've actually in practice, been kind of impressed with how effective these are because traditionally we've thought of nonsteroidal options as a bit of a trade off in terms of efficacy or tolerability because a lot of times and some of this comes from our treatment of atopic dermatitis, as well as, some of the non-steroidal topicals in the past at least have come with stinging or burning and they're just not as effective as our steroids are. But these new medicines really have changed the conversation because they're very effective and they're very tolerable on the lesions. So they're actually like in some ways you could argue they're good for the skin. So for example, Tapinarof is an aryl hydrocarbon agonist and it's really interesting because we usually think of medicines as something to block something, right? You think of psoriasis as too much inflammation. We need to block the inflammation. What's really, I think, unique about tapinarof is that rather than blocking something, it's actually upregulating something you naturally have in your skin that seeks to maintain homeostasis or balance. So it's actually trying to achieve balance by using something that's already in your body that's meant to kind of balance things out. So how it works specifically for psoriasis is by upregulating this mechanism, while actually downregulating the IL-17/ TH17 pathway that's involved in specifically the inflammation of psoriasis. There's also evidence that this medication restores skin barrier proteins as well. So there's a lot of interest in this kind of approach to treating skin disease by really using your body's mechanisms to try to achieve balance and utilizing that to help this situation. When you think about some of the efficacy, we're kind of impressed from it, especially because when you stop tapinarof, after a while it actually seems to keep the psoriasis away for a longer period of time than a topical steroid would. So in some of the clinical studies, patients were able to maintain clearance out to months after stopping utilization of tapinarof. So I think that's a really interesting feature of it that we haven't really talked much about because we haven't had anything that does that. But we think it has to do with what's called memory T cells, which are cells that are in lesions where you have psoriasis, but they stay even after the psoriasis is treated. And if you've ever wondered about why you treat your psoriasis with a steroid and it comes back in the same spot, this is why. It's because of those memory T cells. So by blocking that you're able to maybe change the dynamic of future psoriasis as well as the psoriasis that's there. So that's really interesting. Tapinarof, the main side effect that we see in the proportion of patients is the side effect that’s called folliculitis, essentially sometimes, especially if you're using it outside of the areas of psoriasis, you'll actually start to get little red bumps around like where your hair follicles are supposed to come out. It's usually something that in the patients that have had it for me at least we either take a break or treat through it depending on how severe it is and then it goes away. It seems to be something that happens during the course of treatment, as you're kind of restoring skin barrier and there's kind of changes in those proteins. But I think it's nice that that's kind of the worst thing that we have to talk about for the medicine. It's something kind of transient and not certainly not life threatening but not so bad when it comes down to it. I do now tell my patients to be very careful about applying the cream only to where you have psoriasis lesions and not kind of just smearing it all over. I think that's important.

Shiva: So the other new nonsteroidal topical is Roflumilast. What’s the mechanism of action and how effective is Roflumilast in comparison to corticosteroids? 

Dr. Han: So when you think about roflumilast, this has been very nice to have in our arsenal because it's really well tolerated. Now the mechanism is by blocking phosphodiesterase, which is something that we're actually familiar with in psoriasis. We have an oral medication, apremilast which functions the same way. It's an oral inhibitor of phosphodiesterase and the way we think about this is phosphodiesterase is involved in our immune system and so it is upregulated in psoriasis. It does have kind of arms branching through different mechanisms that affect the inflammation of psoriasis. So by blocking it, we can really help a lot in terms of alleviating the excessive inflammation that you have with psoriasis. I think one of the nice things about Roflumilast is that it also utilizes a mechanism we think about as pretty safe. For example, we have another medicine, Crisaborole, that is a topical medicine we use for atopic dermatitis or eczema that we think of as very safe. We use it in babies down to just a few months of age, so it's a mechanism, at least that we're very familiar with and that has a long history of use in dermatology. Roflumilast, also works very well, quite effective in treating and I think where it has a little extra data is for use in sensitive areas. So I think it's really nice because it's very well tolerated, doesn't cause stinging, burning, any kind of those local skin issues, doesn't have that side effect of folliculitis or anything else to speak of at the site. So you can think of it as just very safe to use on the skin. So we have some good data and good evidence of utilization of roflumilast and in genital areas, under arms, sensitive areas. The face is a good match for it, so that's where it really has some extra utilization. But we're really glad to just have these newer options on the market for us because they really have changed how we can approach psoriasis and really to some degree have changed who's eligible for topical therapy because in the past if a patient has a little too much body surface area we might say “I don't feel so comfortable giving you steroids for so much of your body”. Here we have these newer medicines that are very well tolerated. The absorption is really very minimal, pretty much negligible. So we don't really have to think about systemic side effects either. That really addresses a need for us and also by the way, they're both once a day only. So that's actually really helpful also. 

Shiva: Yeah, it's so exciting to see new topical options at last. Are there any over-the-counter products that can be combined with either a corticosteroid or non-steroidal medication if needed? And if so, can you provide an example of what you would recommend? 

Dr. Han: Yes. So sometimes we think about psoriasis and one of the challenges, especially if you have pretty thick plaques, is the medicines we're giving may not be getting deep enough to address the inflammation that's underlying the psoriatic plaque. So if you think about it, if you have a really thick psoriasis plaque and you put on all this topical steroid or topical, one of these newer medicines, it just is sitting up there on layers of dead skin. That's not really helpful and a lot of times people are very frustrated with that, rightly so because they're not getting the results they expect. So sometimes actually having agents that will thin out those upper layers are very helpful. So in the past, traditionally we've reached for salicylic acid for this purpose and I found honestly that it's becoming a little harder to find salicylic acid products for psoriasis on the market, but you can still find them. Sometimes something like a 6% salicylic acid can be helpful in thinning out those extra layers, or you can reach for some of the creams that are for rough, thick skin. Those often will have either salicylic acid, or they might have some urea, or maybe they might have some ammonium lactate in them. Those are all things that are very helpful. So you can look for those products over-the-counter. Some of those products, for example, are CeraVe has a line of both psoriasis products and the Essay line that has some salicylic acid in it. Eucerin, for example, makes a roughness relief that has a pretty decent percentage of urea in it. So those all can help just break down those layers of dead skin so that when you put your treatments on, they're more effective. 

Shiva: Yeah, that makes sense. And are you aware of any other new topicals in development that could offer alternatives to corticosteroids?

Dr. Han: There's always a drug development in the pipeline. We're glad to see that we're finally getting some more attention to novel topicals in psoriasis. I imagine in the next couple of years we may be hearing about some more options, but this is exciting for our patients because the more choices we have, the better we can design you know custom regimens for each person because everybody's different, right? Everybody has their psoriasis manifest a little differently. Some people talk about very significant seasonal changes. I mean, there's a lot that we have to really dissect. What we're trying to figure out what the best treatment is for each person. So those are alternatives are gonna become very helpful for us.

Shiva: Yeah, I guess personalized medicine is the direction care is moving in, right? 

Dr. Han: Yes.   

Shiva: Dr. Han, thank you so much for such an enlightening discussion about use of corticosteroids and the latest topicals. Do you have any final comments you'd like to share with our listeners today?

Dr. Han: I just would, tell everybody don't accept if you're not getting the treatment that you think you deserve for your psoriasis. We have so many options right now for people. If you're not happy with the treatment you're getting, look for another option. I see this all the time. We shouldn't take it personally. I mean, I think everybody has a different approach to how they want their healthcare to be and we should be sensitive to that and really try to bring care to our patients. So from that standpoint, I would tell you there are options. Go to the NPF website. We have large networks of dermatologists who are passionate about treating psoriasis. There are now telemedicine programs that can help with treatment of psoriasis nationwide. So there's no reason to just kind of get complacent. If you find yourself smearing on all these topicals, they're not really helping. There are new things out there and so don't be shy.  You gotta be an advocate for yourself and we want to bring that care to you. Don't be afraid to ask for it. 

Shiva: Dr. Han, thank you so much for being here with us today! It’s always a pleasure having you on Psound Bytes™ and it was great having you back to discuss use of corticosteroids and the latest topicals. I look forward to seeing what the future holds for development of topicals. For our listeners, August is Psoriasis Action Month. Learn more about psoriasis and what your treatment options are by contacting our Patient Navigation Center to request the free “PsO Action Month” Kit by calling (800) 723-9166 or by emailing education@psoriasis.org.  And finally, thank you to our sponsors who provided support on behalf of this program activity through unrestricted educational grants: Bristol Myers Squibb, CeraVe, Janssen, Novartis and UCB.        

We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Google Play, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at podcast@psoriasis.org.  

This transcript has been created by a computer and edited by an NPF Volunteer.