A Top-Down Approach: Talking Topical Therapies With Neal Bhatia, MD

When evaluating treatment options for patients with psoriasis, rosacea, or eczema, clinicians should employ a top-down approach and remember to consider topical therapies. Neal Bhatia, MD, director of clinical dermatology at Therapeutics Clinical Research in San Diego, California, discusses this and more in his Winter Clinical Miami presentation.

This transcript has been edited for clarity and length.

Dermatology Times: Your talk at Winter Clinical Miami focuses on topical therapies. Can you share the major takeaways from that presentation?

Bhatia: My biggest challenge to the audience is to remind them not to forget topical therapies and working from top down for conditions like psoriasis, rosacea, some of the nuts and bolts of eczema. We forget, with all the new innovations of systemic therapies like biologics and JAK inhibitors, fundamentals of topicals, including steroids, but also the new non-steroid alternatives and focal itch treatments that we have…We want to really take the patient's experience into account; not just the vehicle, not just the active ingredients, the frequency and the timing, but really the patient experience of when do they want to put things on, what time of day. But also, for psoriasis, especially thinking about breakthrough. Thinking about rosacea patients with concomitant seborrheic dermatitis, for example. And then, of course, the eczema patients, very simple nuts and bolts, but these are just fundamentals that make dermatologists who we are.

Dermatology Times: Looking ahead at the year, are there any FDA approvals or agents in the pipeline that you are anticipating?

Bhatia: The year has been pretty exciting. Even last year, coming out of the pandemic with the approvals…Definitely the JAK inhibitors that came out in January for atopic dermatitis. Obviously we have some new treatments for alopecia areata, some new indications for drugs like [dupilumab].

For some others that are coming out…obviously lebrikizumab and tralokinumab will round out the atopic biologics, but we really have some good things coming for vitiligo and alopecia areata like I mentioned, conditions that really needed treatments. Just the outcomes that we've seen for safety…We really have to get past the phobias of black box warnings and the phobias ‘these are not our drugs’ when they are our drugs, and we don't want to lose these patients. I think that those FDA approvals should translate to ‘expand your horizons and don't be afraid.’

Dermatology Times: There’s a poster being presented at the meeting on patient-reported outcomes from a study of tirbanibulin for patients with actinic keratosis. You were an investigator in the trial. Can you share some of the takeaways from that?

Bhatia: The outcome is based on the patient experience of local skin reactions, but also the cosmetic outcomes that come from treatment. You've had a lot of patients with less erythema, less crusting, and less dermal effects, more superficial effects from the turnover of AKs [actinic keratoses], mainly because the mechanism of action lends itself to apoptosis of the atypical keratinocytes and not necrosis like we've seen with 5-FU [topical 5-fluorouracil] and ingenol mebutate. The PROAK study was meant to look at the patient experience [and] the clinical outcomes 2 months after treatment. How does your skin feel? How does it look? Does it still look sallow? Do you still feel like you have a lot of essence of photodamage?

Looking at the core of treating, not just photodamage, but the essence of photoaging that goes with it—not to make it a cosmetic drug by any means—but by treating the process that makes photodamage turn into AKs, you can slow that down, but also slow down some of the elements of atypical skin by clearing up some of the damaged area. The PROAK study was meant to look at long-term outcomes. It should tell us how often should we use a course, for example. Down the road we'll learn about ‘can we use it with other adjuncts like liquid nitrogen and [photodynamic therapy]?’ But for the most part, right now, we're learning about the patient experience of how well they'll feel, not just for their AKs being treated, but how well they'll do overall with the outcomes of their skin.