The right dose in the right place: an overview of current prescription, instruction and application modalities for topical psoriasis treatments

miRNA-559 and MTDH as possible diagnostic markers of psoriasis: Role of PTEN/AKT/FOXO pathway in disease pathogenesis

Psoriasis is a persistent, inflammatory, autoimmune skin disorder which can be elicited by genetic and environmental factors. Several microRNAs (miRNAs) that are abnormally expressed in psoriasis have emerged as an interesting candidate in psoriasis pathogenesis. However, the expression profile and function of miRNA-559, and its direct target metadherin (MTDH), in psoriasis need to be further illuminated. This study intended to assess miRNA-559 and MTDH levels in skin and sera of psoriatic patients and to investigate their clinical significance in an attempt for developing novel distinct tools for early diagnosis of psoriasis. Moreover, this study aimed at exploring participation of miRNA-559 in regulating MTDH/PTEN/AKT pathway in psoriasis. Expression levels of miRNA-559, AKT, FOXO1 and PTEN were measured by real-time qRT-PCR, whereas MTDH and p27 levels were assessed by ELISA in lesional, non-lesional tissues and serum of 20 psoriatic patients and 20 matching controls. Correlation study was conducted between different parameters. The diagnostic performance of miRNA-559 and MTDH in psoriasis was estimated by receiver operating characteristic (ROC) curve analysis. Expression of miRNA-559 in psoriatic patients was significantly downregulated in both lesional tissues and serum as compared to controls. Conversely, MTDH protein level showed significant increase in both tissues and serum of psoriatic patients and was inversely correlated with miRNA-559 level. Meanwhile, levels of PTEN, AKT and FOXO1 were dramatically changed in psoriatic patients compared to controls. Furthermore, serum miRNA-559 and MTDH displayed comparable diagnostic accuracy in discriminating psoriatic patients from controls. Yet, miRNA-559 demonstrated superior diagnostic performance than MTDH in psoriasis diagnosis. Together, the current findings provide the first suggestion of a new mechanism by which downregulation of miRNA-559 might induce proliferation in psoriasis through modulating PTEN/AKT/FOXO1 pathway by positive regulation of MTDH. Thus, miRNA-559 and MTDH might be proposed as promising diagnostic biomarkers of psoriasis.

Patient-Centric Design of Topical Dermatological Medicines

Topical treatments are essential approaches to skin diseases but are associated with poor adherence. Topical vehicles have the primary purpose of ensuring drug effectiveness (by modulating drug stability and delivery, as well as skin properties) but have a marked impact on treatment outcomes as they influence patient satisfaction and, consequently, adherence to topical treatments. There is also a wide variety of vehicles available for topical formulations, which can complicate the decisions of clinicians regarding the most appropriate treatments for specific skin disorders. One of the possible strategies to improve topical-treatment adherence is the implementation of patient-centric drug-product design. In this process, the patient's needs (e.g., those related to motor impairment), the needs associated with the disease (according to the skin lesions' characteristics), and the patient's preferences are taken into consideration and translated into a target product profile (TPP). Herein, an overview of topical vehicles and their properties is presented, along with a discussion of the patient-centric design of topical dermatological medicines and the proposal of TPPs for some of the most common skin diseases.

Patterns of dosage regimen instructions regarding topical medicines: how is the information perceived by patients?

BACKGROUND

The communication of dosage regimen instructions by physicians is of utmost importance on treatment adherence. Few studies until now have approached the topical treatment adherence subject.

OBJECTIVE

This study aims the characterization of dosage regimen instructions given by physicians and the assessment of chronic dermatological patients' perception regarding these instructions.

METHODS

Two instruments one for physicians (PHYSDOSAGE) and one for patients (PATIENTDOSAGE) were developed and applied in a cross-sectional, descriptive and exploratory study to two independent samples composed by 91 physicians and 43 patients.

RESULTS

Most of physicians reported to provide dosage regimen instructions. When cross checking information from both studied samples, physicians and patients, it was concluded that physicians reported to provide more frequently oral and written treatment instructions, e.g. electronic prescription, than patients reported having received it. Also, physicians claimed to often provide information about the duration of treatment and the frequency of topical medicines' application, which was not acknowledged by patients.

CONCLUSIONS

Contradictory results were found between the physicians' information input and the patients' perception about dosage regimen instructions provided during the consultation. These findings could negatively influence the treatment adherence and the clinical outcomes. Thus, it is of paramount importance the implementation of strategies to improve optimal communication of dosage regimen instructions for topical medicines.

The diversity of shedder tests and a novel factor that affects DNA transfer

Since the first shedder test was formulated almost 20 years ago, a plethora of different test strategies has emerged. The amount of data generated so far is considerable. However, because of the limited reproducibility of its results, the reliability of the shedder concept is frequently questioned. This study provides a literature overview of applied shedder tests that capture the diversity of the concept. It is pointed out to what extent different classification criteria, workflows, and trace evaluation can impair the classification outcome. The robustness of shedder status was assessed by applying a promising approach established by Fonneløp et al. (Forensic Sci Int Genet 29:48-60, 21). Data provide similar results to those in recent studies but also ambiguous shedder classifications. The applied shedder test was adapted based on our own as well as the reviewed data. With novel classification parameters, promising results were achieved. This study reveals uncertainties and inconsistencies of the shedder concept. Recommendations for harmonization and transparency are proposed. Implementation of the recommendations may result in an increased impact on casework and transfer studies, including activity-level assessments. Furthermore, this study shows that moisturizers affect participants' shedder status as well as DNA transfer. The impact appears to remain relevant even 60 min post ointment application but depends greatly on the type of moisturizer applied.

Knowledge and Practices of Community Pharmacists in Topical Dermatological Treatments

The connection between pharmacists’ knowledge and practice on the provided information to patients about dermatoses and their treatment is insufficiently characterized. Furthermore, pharmacists’ contributions in counselling and in promoting adherence to topical treatment is not fully understood. This study has three main objectives. It aims to identify the knowledge and practices of pharmacists about dermatoses and their treatment, and to compare the perspective of pharmacists with that of patients regarding treatment information, with the future goal of establishing guidelines on the communication of dosage regimen instructions to dermatological patients and promotion of adherence to treatment, filling a gap. A cross-sectional, exploratory, and descriptive study was carried out. Based on experts’ prior knowledge and extensive collected literature information, two questionnaire protocols, one for pharmacists and another one for patients, were designed. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were carried out in relation to the pharmacists’ questionnaire for instrument validation. The results indicate that knowledge of pharmacists regarding dermatoses and their treatment is considered acceptable. Most of the pharmacists were reported to provide information to patients. Oppositely, patients reported not to have receive it. This is an important issue because pharmacists play a primary role in the management of several diseases. As non-adherence can be triggered by poor understanding of the dosing instructions, pharmacists’ communication practices play an important role in improving this hinderance. Results from this study identified pharmacist–patient communication gaps, so the development of guidelines to improve the transmission of clear dosage regimen instructions and knowledge about patient’s disease are of paramount importance. Training programs for continuous education of pharmacist should be implemented to solve the identified communication problems found in this study.

[Adequate prescription and application of topicals : How to calculate the right volume for the prescription of ointment needed?]

BACKGROUND

Uncertainty regarding the suitable amount of prescribed ointment and its application by patients may cause insufficient or uneconomic health care provision. To address this issue, standardized methods and experts' knowledge on the suitable amount and coherent patient's elucidation for application of topicals are needed.

OBJECTIVES

Presented are current data in routine care and scientific evidence on the prescribed amount of topical agents as well as its application by patients in dermatological care.

MATERIALS AND METHODS

A literature review was conducted via PubMed using the keywords as individual and pooled search terms: "local therapy", "topical treatment", "prescription", "amount of ointment needed", "involved area", "BSA", "finger-tip-unit", "Rule of Hand", "calculated dosage" and "rule of nines". We included original studies by manually screening title and abstract according to the relevance of the topic.

RESULTS

The search strategy identified 19 clinical trials. The fingertip unit (FTU) is the most frequently used measurement for accurate application of external agents. Appropriate prescribed amount is calculated by required topical agent per involved surface area.

CONCLUSIONS

There is still a need for clarification to which extent the optimized amount of ointment is prescribed and advice for its application in routine care is given. The FTU combined with the "Rule of Hand" is an adequate measurement for patient's guidance on self-application.

Is the Skin Absorption of Hydrocortisone Modified by the Variability in Dosing Topical Products?

Fingertip units have been proposed as a tool to standardize topical therapy with semisolid formulations. However, no studies to date have characterized the variability in dosing by patients using this concept and whether this variability ultimately affects the topical absorption of drugs. This work aimed to answer these two questions. A first study determined the dose measured, the area of spread and the area-normalized dose for a 1% hydrocortisone cream and ointment applied by members of the public using this dosing approach before and after brief counselling. Then, in vivo tape-stripping and in vitro permeation studies investigated whether the variability in the area-normalized dose altered the skin absorption of hydrocortisone. Participants applied greater doses and spread them over larger areas after a short counselling intervention leading to smaller area-normalized doses. In vivo hydrocortisone uptake by the stratum corneum was significantly greater for the higher normalized dose and the differences were further supported by the in vitro permeation studies. However, these differences were relatively small and not proportional to the increase in normalized dose. This work shows that, following brief advice, patients and carers can apply consistent and sufficient doses of corticosteroids whilst minimizing risks and variability in hydrocortisone absorption.

Treatment of Mild to Moderate Plaque Psoriasis with Calcitriol Ointment Applied with or without a Dosing Device

Results of topical treatments can be influenced by several factors, including accurate dosing based on the affected skin area. The aim of this open-labelled multicenter study is to evaluate if correct dosing of calcitriol ointment has an impact on the clinical response of plaque psoriasis. For this purpose, patients with plaque psoriasis eligible to be treated with calcitriol ointment were randomized to treatment with a ‘standardized dose’ method, using a dosing device (N. 100), or treatment without the device (N. 101), for 12 weeks. Regardless of the use of the dosing device, calcitriol ointment caused a significant reduction of both the severity of signs and symptoms and the extent of body surface area affected after both 4 weeks and 12 weeks. Clinical response was not significantly different between the two groups. Local adverse events occurred in 12 subjects (of whom five treated with the device) and were mild and transient in most cases.

Methodologies for medication adherence evaluation: Focus on psoriasis topical treatment

Adherence to topical treatment has been less studied in comparison with systemic therapeutic regimens and is poorly understood. High-quality research on this area is essential to outline a strategy to increase medication adherence and clinical outcomes. For a more comprehensive understanding of this issue, a systematic review of the methodologies for topical treatment adherence evaluation in psoriasis was undertaken. Twenty one studies were selected from the literature which used six different adherence methodologies. Merely three studies used multiple adherence measurement methods. The most used method was questionnaire (44%) which was also associated with higher variability of the adherence results. One possible explanation is the lack of a validated questionnaire designed specifically for the evaluation of adherence to topical treatment. Only one method (medication weight) takes into consideration the applied dose. However, the estimation of the expected weight is complex, which renders this method, as used presently, less effective. The use of a dosing device could improve its accuracy and be helpful to clearly instruct the patients about the correct dose. As there is no single method that allows an accurate and complete assessment of adherence it is recommended to use a combination of methods, including self-report and medicines' weight measurements.

Are we giving patients enough information on how to use topical treatments? Analysis of 767 prescriptions in psoriasis

BACKGROUND

Unclear instructions probably contribute to the suboptimal efficacy and adherence to topical agents in psoriasis.

OBJECTIVES

To analyse the quality of prescriptions for topical therapy in psoriasis and to determine factors associated with high-quality prescription writing.

METHODS

We made a systematic analysis of 767 topical prescriptions written by dermatologists and general practitioners (GPs). The following parameters were recorded: writing mode (electronic vs. hand written), indication of formulation, frequency of administration, duration of treatment, indication of areas to be treated, and indication of amount of product to be used. We considered prescriptions of high quality to be those including at least four of the five prospectively defined quality parameters.

RESULTS

Only 35·7% of prescriptions fulfilled the definition of a high-quality prescription. Quality of prescription writing was significantly influenced by two factors: electronic writing [odds ratio (OR) 3·04, 95% confidence interval (CI) 2·2-4·21; P < 10(-4) ] and specialty of the prescriber, dermatologists writing higher quality prescriptions compared with GPs (OR 1·61, 95% CI 1·54-2·14; P < 10(-4) ).

CONCLUSIONS

Almost two-thirds of topical prescriptions are not adequately written and do not include the required information to help patients manage their topical treatment in psoriasis correctly. The quality of topical prescriptions could be improved by making the use of electronic prescriptions widespread and by the development of aids for easy evaluation of the right amount of topical treatment to be applied according to body surface area involved.

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the American Academy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients' needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

Management of psoriasis

Psoriasis is common, affecting about 2-3% of the population, and has major effects on patients' quality of life. Psoriasis varies in its manifestations and in how patients perceive the condition. Successful treatment involves addressing the clinical, psychological, and social aspects of the disease. Treatment options include topical agents, phototherapy and systemic treatment. Topical treatments are only practical for a fairly limited area of involvement. Phototherapy is practical for larger areas of involvement, but office phototherapy treatments are inconvenient. Traditional systemic medications are limited by side effects. New biologic agents that target specific components of the immune system are the most recent addition to our list of medications and provide higher efficacy with an improved safety profile, albeit at a higher cost.

How much of a topical agent should be prescribed for children of different sizes?

BACKGROUND

Compared with guidelines for the quantity of topical corticosteroids to apply in adults, standards for the use of topical corticosteroids in children are not well described.

OBJECTIVE

To devise simple-to-use guidelines for topical corticosteroid quantities needed in infants, children, pre-teens, and adults.

METHODS

We determined body surface area (BSA) using mean heights and weights in order to calculate the appropriate quantities of medication to be prescribed.

RESULTS

As a rough estimate, infants require one-fifth of adult doses, children two-fifths of adult doses, and adolescents two-thirds of adult doses. However, the assessment of BSA may vary considerably between clinicians. Patients may also vary in how thickly they apply topical medication.

CONCLUSIONS

A simple guideline for how much topical corticosteroid to prescribe may facilitate the treatment of young children with skin disease.