Frontline Forum Part 1: Topical Therapy for Corticosteroid-Responsive Dermatoses

Read part 2 here.

Read part 3 here.

“I think through the art of combination therapy, we can get our patients’ [symptoms] under good control,” said Linda Stein Gold, MD, during the Dermatology Times Frontline Forum custom video series “Enhancing Patient Outcomes: Topical Therapy for Corticosteroid-Responsive Dermatoses.”

Recent approvals of multiple new topical therapies for psoriasis and atopic dermatitis (AD) have greatly enhanced the therapeutic armamentarium, and treatment for these common inflammatory skin diseases has become both an art and a science. However, the downside of so many available options is potential confusion for clinicians, who must weigh the pros and cons of each to fit patient symptoms, lifestyles, and condition severity. Because each agent has its own unique merits, the idea that older topical therapies are obsolete may not be true. In practice, the variations in clinical challenges faced by the clinician are vast. Given this, a topical agent thought to be outdated or ineffective may turn out to be the best agent for a particular patient.

Although psoriasis and AD are caused by dysregulation in different parts of the immune system (psoriasis affects the Th1 signaling cascade while AD affects the Th2 cascade), they are both very responsive to topical corticosteroid therapy. Both diseases have seen recent approval for new oral and systemic therapies, including JAK inhibitors and biologic therapies. Although safe and effective, these medications are often expensive and may be difficult to obtain quickly, requiring complicated prior authorizations and specialty pharmacy coordination. Furthermore, some of these medications have black box warnings and systemic adverse effects that are not well tolerated by patients. Therefore, topical therapy still represents a robust and important option in the therapeutic armamentarium for psoriasis and AD. This is especially true given that most cases of AD and psoriasis disease are localized and do not require systemic therapy.

To help make sense of the options, Stein Gold, moderator James Del Rosso, DO, and other panelists discussed the treatment of corticosteroid-responsive dermatoses with both topical steroid and nonsteroidal therapy, strategies for real world clinical cases, and treatment pearls for the busy, practicing dermatologist.

A “Mounting Mutiny” Against Topicals

Del Rosso asked the panelists about their thoughts on the current state of topical corticosteroid use in dermatology for psoriasis and AD. Of particular concern is their well-known adverse events and negative connotations (eg, illegal steroid use by athletes) that may sway patient opinion. Although there are many new nonsteroidal options, corticosteroids still remain an important and effective option, he said.

Nevertheless, topical corticosteroids are critical for getting flares of disease under control, Stein Gold said. Panelist Jayme Heim, MSN, FNP-BC, agreed, adding that corticosteroids remain a critical part of standard of care. Unfortunately, misinformation from social media channels such as TikTok is creating confusion and fostering fear regarding medications such as topical corticosteroids, added TJ Chao, MPAS, PA-C.

Patient education is of the utmost importance for this very reason, the panelists noted. “We need to educate our patients,” Darren West, MPAS, PA-C, said. West discusses the drugs with his patients, and he has seen success even with those who said they did not want to go “anywhere near a steroid.” West said he tells patients, “Look, we’ve been writing these medications for many, many years. There’s always a right way to do it and a wrong way to do it.”

He added, “There’s always a risk involved with any medication you prescribe. It doesn’t matter what it is, and there’s always going to be somebody that has a side effect. But if you do it responsibly, which I think we mentioned earlier, if we do it the right way and we do it the way we prescribe it, you’re not going to have a problem.”

Sometimes patients are concerned about using a topical corticosteroid every day, and patient education can also help here, the panelists agreed. Psoriasis and AD are chronic diseases that wax and wane by the way of disease flares, and there is an important role for both topical steroids and topical non-steroids for maintenance and acute flares, Stein Gold said. “[We need to explain that] this is a rescue; this is going to be used periodically from time to time,” she said.

Heim said patient education should include how to appropriately use the medications for flares and an explanation of why certain high-potency topical corticosteroids are inappropriate for certain areas of the body. She educates patients about the 7 categories of topical steroids, based on strength, and the reasoning for their use.

Stein Gold added, “I think when you explain in layman’s terms exactly what’s going on, what am I watching for, what you are watching for, what are our expectations, I think most people feel comfortable.”

The Importance of Vehicles in Topical Therapy

Del Rosso asked the panelists about the importance of vehicles in topical therapy, and West was quick to jump in. He noted that the vehicle is nearly as important as the active ingredient in any topical therapy compound because the vehicle is responsible for drug delivery into the skin.

“I think it makes a really big difference in our newer products today,” West said. Traditionally, ointments were considered stronger than creams, and lotions were considered weak (along with solutions). For example, mometasone ointment is considered a category 2 topical steroid, whereas mometasone cream is considered category 4. With the introduction of newer excipients, such as spray lotion, this paradigm needs to be reexamined, he added.

“I consider topical therapy to be the marriage of the active ingredient and the vehicle,” Stein Gold said. Her pearl for clinicians: Pay close attention to the vehicle when studying and selecting a particular topical therapy. Novel vehicles allow these medications to improve skin barrier function upon delivery. They are used once daily, as opposed to twice-daily use, and come in a more cosmetically elegant formulation, she said.

Although traditional ointments are very effective, patients often complain about its greasy nature and are worried about it staining or soiling clothes. This is especially concerning for social settings.

In addition, Chao added that older male patients do not like ointments because they want something that is absorbed quickly.

Traditional vehicles such as propylene glycol, ethanol, and their associated fragrances and preservatives lead to issues such as damage to the epidermal barrier, stinging/burning sensations upon application, and allergic contact dermatitis.

However, Heim said that ointments may still be very beneficial in certain cases, such as for patients with AD with many excoriations and erosions on the skin from scratching and for patients with psoriasis with thick, heavy plaques. Therefore, clinicians need to pay close attention to the vehicle, which is very important for patient satisfaction and treatment adherence, she said.