Beyond monotherapy: a systematic review on creative strategies in topical therapy of psoriasis

A Review of Topical Tapinarof for the Treatment of Plaque Psoriasis

OBJECTIVE

This article reviews the efficacy and safety of 1% tapinarof cream for plaque psoriasis.

DATA SOURCES

A literature search was conducted from August 2022 to February 2023. The terms tapinarof, VTAMA, benvitimod, GSK2894512, DMVT-505, and WBI-1001 were queried in PubMed. ClinicalTrials.gov was searched to identify ongoing or unpublished studies.

STUDY SELECTION AND DATA EXTRACTION

All clinical trials written in English and relevant to pharmacology, efficacy, and safety were included.

DATA SYNTHESIS

In two 12-week phase III clinical trials, disease severity assessed by a Physician's Global Assessment (PGA) score of clear or almost clear and a 2-point PGA improvement was 35.4% and 40.2% at week 12 in the 2 trials, respectively. In the 40-week, open-label extension trial, the efficacy and safety results were similar: 40.9% of patients achieved a PGA of 0 at least once during the trial, and 58.2% of patients with PGA ≥ 2 achieved PGA 0/1 at least once.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS

Tapinarof is a topical aryl hydrocarbon receptor agonist and a first-in-class, potentially promising treatment for plaque psoriasis recently approved by the U.S. Food and Drug Administration.

CONCLUSION

Compared with placebo, tapinarof may be an effective and safe topical treatment for mild to severe plaque psoriasis. Head-to-head trials to compare the efficacy and adverse effect profile of tapinarof to other topical treatments are still needed, as are investigation in patients with recent or current use of phototherapy or biologic or nonbiologic systemics. Cost and adherence to treatment may be barriers for treatment efficacy.

Statistically Optimized Tacrolimus and Thymoquinone Co-Loaded Nanostructured Lipid Carriers Gel for Improved Topical Treatment of Psoriasis

The aim of this investigation was to develop and analyze a tacrolimus and thymoquinone co-loaded nanostructured lipid carriers (TAC-THQ-NLCs)-based nanogel as a new combinatorial approach for the treatment of psoriasis. The NLCs were formulated by an emulsification-solvent-evaporation technique using glyceryl monostearate, Capryol 90 (oil), and a mixture of Tween 80 and Span 20 as a solid lipid, liquid lipid, and surfactant, respectively. Their combination was optimized using a three-factor and three-level Box-Behnken design (3³-BBD). The optimized TAC-THQ-NLCs were observed to be smooth and spherical with a particle size of 144.95 ± 2.80 nm, a polydispersity index of 0.160 ± 0.021, a zeta potential of -29.47 ± 1.9 mV, and an entrapment efficiency of >70% for both drugs. DSC and PXRD studies demonstrated the amorphous state of TAC and THQ in the lipid matrix of the NLCs. An FTIR analysis demonstrated the excellent compatibility of the drugs with the excipients without interactions. The TAC-THQ-NLC-based nanogel (abbreviated as TAC-THQ-NG) exhibited a good texture profile and good spreadability. The in vitro release study demonstrated a sustained drug release for 24 h from the TAC-THQ-NG that followed the Korsmeyer-Peppas kinetic model with a Fickian diffusion mechanism. Moreover, the TAC-THQ-NG revealed significantly higher dose-dependent toxicity against an HaCaT cell line compared to a TAC-THQ suspension gel (abbreviated as TAC-THQ-SG). Furthermore, the developed formulations demonstrated antioxidant activity comparable to free THQ. Confocal microscopy revealed improved permeation depth of the dye-loaded nanogel in the skin compared to the suspension gel. Based on these findings, it was concluded that TAC-THQ-NG is a promising combinatorial treatment approach for psoriasis.

Signaling pathways and targets of natural products in psoriasis treatment

Aim: Psoriasis is a common chronic inflammatory skin disorder, which has adverse effects on patients’ quality of life. Natural products exhibit significant therapeutic capacities with small side effects and might be preferable alternative treatments for patients with psoriasis. This study summarizes the signaling pathways with the potential targets of natural products and their efficacy for psoriasis treatment. Methods: The literature for this article was acquired from PubMed and Web of Science, from January 2010 to December 2020. The keywords for searching included “psoriasis” and “natural product”, “herbal medicine”, “herbal therapy”, “medicinal plant”, “medicinal herb” or “pharmaceutical plant”. Results: Herbal extracts, natural compounds, and herbal prescriptions could regulate the signaling pathways to alleviate psoriasis symptoms, such as T helper 17 (Th17) differentiation, Janus kinase (JAK)/signal transducer and activator of transcription (STAT), nuclear factor-kappa B (NF-κB), mitogen‑activated protein kinase (MAPK), phosphatidylinositol 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR), and other signaling pathways, which are involved in the inflammatory response and keratinocyte hyperproliferation. The anti-psoriatic effect of natural products in clinical trials was summarized. Conclusions: Natural products exerted the anti-psoriatic effect by targeting multiple signaling pathways, providing evidence for the investigation of novel drugs. Further experimental research should be performed to screen and characterize the therapeutic targets of natural products for application in psoriasis treatment.

Beyond-Mild Psoriasis: A Consensus Statement on Calcipotriol and Betamethasone Dipropionate Foam for the Topical Treatment of Adult Patients

Introduction

There are clear treatment options for mild psoriasis where topical therapies are the mainstay, and for severe psoriasis where systemic therapy (biologic or non-biologic) is necessary. However, there is less clarity in the ‘grey zone’ of patients in the moderate or so-called ‘beyond-mild’ segment. There are frequent delays to the initiation, discontinuation, switching and dose change in treatment, and many patients fail to continue treatment because of concerns about safety or lack of efficacy. Treatment with topical therapies, such as calcipotriol and betamethasone dipropionate (Cal/BD) combinations, may be suitable for these patients.

Method

These consensus recommendations on the use of topical therapies including Cal/BD foam for beyond-mild psoriasis originated from a modified Delphi process of European clinical experts. In the process, the experts iteratively refined a series of draft statements, which had to receive ≥ 80% approval to be incorporated into the consensus.

Results

The experts identified three main themes: Cal/BD foam as monotherapy, as an add-on to non-biologic systemic therapies and as an add-on to systemic biologics. The consensus emphasises disease factors and patient preference in treatment choice, summarises the evidence base for Cal/BD foam monotherapy for flare treatment as well as long-term management, and identifies the potential for improved treatment outcomes, such as reduced time to onset of action and reduced systemic dose to minimise side effects for add-on Cal/BD therapy to non-biologic systemics. The recommendations regarding add-on Cal/BD foam to biologics are similar to those for non-biologic systemic therapies, but also include suggestions for patients on biologics who are late responders. As clinical choices of Cal/BD combination vary, we have here often used ‘Cal/BD’ without reference to any particular formulation.

Conclusions

These recommendations aim to give practical guidance to those treating patients with beyond-mild psoriasis, to support patients’ use of topical preparations and to optimise treatment outcomes.

Potential herbal constituents for psoriasis treatment as protective and effective therapy

Psoriasis is a multifactorial and chronic skin disorder. It is a recurrent disease that requires incessant therapy. Psoriasis treatment includes topical and systemic routes using synthetic drugs that lead to severe unwanted adverse effects. Herbal therapy is widely used for thousands of years in countries like China and India. The use of herbal therapy in the developed region enhanced to a great extent and showed better efficacy towards psoriasis alone or as adjuvant to synthetic therapy. Herbal medicines have gained great attention in the treatment of psoriasis due to their lesser side effects compared to synthetic drugs. In this review, the various plant sources which have been found effective in psoriasis and can be used to develop novel therapeutics have been discussed. The mechanisms by which the phytoconstituents elicit anti-psoriatic activity and various research studies that have proven the effectiveness of these natural products have also been compiled in this review.

Suicidal risks with psoriasis and atopic dermatitis: Systematic review and meta-analysis

OBJECTIVE

Evidence of increased suicidal risk in association with psoriasis is growing, but findings concerning atopic dermatitis are inconsistent.

METHODS

We systematically reviewed reports of suicidal ideation, attempts, or suicides among subjects diagnosed with psoriasis or atopic dermatitis compared to healthy controls or persons with other illnesses. Reported rates of suicidal ideation and behavior were compared among the groups, using meta-analyses to compare suicidal rates with dermatologic patients versus controls, as well as between dermatological diagnoses.

RESULTS

Mean rates of suicidal ideation with psoriasis were 1.60-fold (13.9%/8.67%) above controls, and with atopic dermatitis, 1.84-fold higher (16.8%/9.12%); meta-analyses found similar differences: psoriasis (OR = 1.97 [CI: 1.26-3.08]; p = 0.003) and atopic dermatitis (OR = 2.62 [1.32-5.19]; p = 0.006). For suicidal acts, with psoriasis, mean rates versus controls were 2.51-fold higher (3.34%/1.33%), and 2.81-fold higher (5.03%/1.79%) with atopic dermatitis; meta-analyses found significantly more suicidal acts with psoriasis (OR = 1.42 [1.05-1.92]; p = 0.02) and a similar tendency with atopic dermatitis (OR = 1.53 [0.96-2.45]; p = 0.08).

CONCLUSIONS

The study findings support emerging evidence of increased risk of suicidal ideation and behavior with psoriasis and extend it to increased risk of suicidal ideation and a trend toward increased suicidal acts with atopic dermatitis.

Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the United States population. This guideline addresses important clinical questions that arise in psoriasis management and care and provides recommendations based on the available evidence. The treatment of psoriasis with topical agents and with alternative medicine will be reviewed, emphasizing treatment recommendations and the role of dermatologists in monitoring and educating patients regarding benefits as well as risks that may be associated. This guideline will also address the severity assessment methods of psoriasis in adults.

Phase 2, randomized dose-finding study of tapinarof (GSK2894512 cream) for the treatment of plaque psoriasis

BACKGROUND

There is a significant need for novel, safe, and efficacious topical treatments for psoriasis.

OBJECTIVE

We assessed the safety and efficacy of tapinarof in a new cream formulation at 2 concentrations and with 2 application frequencies in adults with psoriasis.

METHODS

Double-blind, vehicle-controlled, randomized, 6-arm trial (1:1:1:1:1:1) in adults, with psoriasis with body surface involvement ≥1% and ≤15% and Physician Global Assessment (PGA) score ≥2 at baseline. Primary endpoint included PGA of 0 or 1 at week 12 and a 2-grade improvement from baseline. Additional analyses included assessment of ≥75% improvement of Psoriasis Area and Severity Index and mean percent change in Psoriasis Area and Severity Index and body surface area involvement.

RESULTS

Treatment success defined by PGA 0 or 1 and a 2-grade improvement at week 12 was statistically significantly higher (at a .05 significance level) in the tapinarof groups (65% [1% twice daily], 56% [1% once daily], 46% [0.5% twice daily], and 36% [0.5% once daily]) than in the vehicle groups (11% [twice daily] and 5% [once daily]) and was maintained for 4 weeks posttreatment. Treatment-emergent adverse events were more frequent in patients treated with tapinarof (85/152, 56%) than vehicle (19/75, 25%) and mild-to-moderate in intensity. Severe treatment-emergent adverse events were reported in all tapinarof groups except the 0.5% once daily group.

LIMITATIONS

Large confirmation trials are needed.

CONCLUSIONS

Tapinarof cream is efficacious and well tolerated in adult patients with psoriasis.

Development of microemulsions of suitable viscosity for cyclosporine skin delivery

Psoriasis is a widespread chronic disease affecting 2-4% of the population in Western countries. Its mild-to-moderate form, representing approximately 80% of the total cases, is treated by topical application, with corticosteroid being the standard treatment. However, in case of psoriasis, no single treatment works for every patient and optimizing topical therapy is a key aspect. A possible alternative is represented by cyclosporine, an immunosuppressant cyclic peptide administered orally in the treatment of the severe form. Its topical application could avoid the problems related to systemic immunosuppression, but the unfavourable physico-chemical properties (MW: 1202 Da; LogP ≈ 3) hinder its permeation across the stratum corneum. The aim of the paper was the preparation, characterization and ex-vivo evaluation of cyclosporine loaded microemulsions using oleic acid as oil phase, either Tween^®80 or a soluble derivative of vitamin E (TPGS) as surfactants and either Transcutol^®, propylene glycol or 1,3 propanediol as co-surfactants. The issue of formulation viscosity was also addressed 1) by evaluating the thickening of Tween^®80-based microemulsions by direct addition of different rheological modifiers, 2) by building pseudo-ternary phase diagrams using TPGS, to identify the water/oil/surfactants proportions resulting in viscous self-gelifying systems. Nine formulations (five Tween^®80-based and four TPGS-based) were selected, characterized in terms of droplets size (low viscosity systems) or rheological properties (high viscosity systems), loaded with 6 mg/g cyclosporine and applied ex-vivo on porcine skin for 22 h. A relevant skin accumulation was obtained either with a low-viscosity Tween^®80-based microemulsion (9.78 ± 3.86 µg/cm²), or with a high viscosity TPGS-based microemulsion (18.3 ± 5.69 µg/cm²), with an increase of about 3 and 6 times respectively for comparison with a control cyclosporine solution in propylene glycol. The role of water content, surfactant, co-surfactant and viscosity was also addressed and discussed. The kinetic of skin uptake from the best performing formulation was finally evaluated, highlighting a relatively quick skin uptake and the achievement, after 2 h of contact, of potentially therapeutic cyclosporine skin concentrations.