Clobetasol propionate emollient formulation foam in the treatment of corticosteroid-responsive dermatoses

Topical Management of Pediatric Psoriasis: A Review of New Developments and Existing Therapies

Psoriasis is a chronic immune-mediated disorder that commonly affects adults and children. In recent years, pediatric psoriasis has increased in prevalence and the disease is often associated with various comorbidities and psychological distress. The conventional topical treatments for psoriasis, such as corticosteroids, calcineurin inhibitors, vitamin D analogs, anthralin, and coal tar, are often limited by their side effects, tolerability, and/or efficacy, particularly for use in children and on sensitive and intertriginous areas. Recently, the US Food and Drug Administration approved two new topical non-steroidal agents for treating psoriasis that target different pathogenic pathways than the conventional treatments. Roflumilast is a phosphodiesterase type 4 inhibitor approved for the treatment of plaque psoriasis in patients aged 12 years and older. Tapinarof is a novel aryl hydrocarbon receptor modulator approved for adult psoriasis and currently undergoing studies for pediatric psoriasis. Ongoing efforts are also being made to optimize conventional treatments, for instance, a new foam formulation of halobetasol propionate was recently approved for pediatric psoriasis. Clinical trials of various new drugs targeting one or multiple pathogenic pathways of psoriasis, such as Janus kinase inhibitors, different formulations of phosphodiesterase type 4 inhibitors, and aryl hydrocarbon receptor modulators have also been explored. The recent emergence of novel topical agents provides promising new options for managing pediatric psoriasis with the potential to improve clinical outcomes and quality of life. In this article, we review the mechanism of action, efficacy, and safety profile of novel topical agents and discuss their potential roles in the management of pediatric psoriasis.

Patches as Polymeric Systems for Improved Delivery of Topical Corticosteroids: Advances and Future Perspectives

Mucoadhesive polymer patches are a promising alternative for prolonged and controlled delivery of topical corticosteroids (CS) to improve their biopharmaceutical properties (mainly increasing local bioavailability and reducing systemic toxicity). The main biopharmaceutical advantages of patches compared to traditional oral dosage forms are their excellent bioadhesive properties and their increased drug residence time, modified and unidirectional drug release, improved local bioavailability and safety profile, additional pain receptor protection, and patient friendliness. This review describes the main approaches that can be used for the pharmaceutical R&D of oromucosal patches with improved physicochemical, mechanical, and pharmacological properties. The review mainly focuses on ways to increase the bioadhesion of oromucosal patches and to modify drug release, as well as ways to improve local bioavailability and safety by developing unidirectional -release poly-layer patches. Various techniques for obtaining patches and their influence on the structure and properties of the resulting dosage forms are also presented.

Update on the Management of Pediatric Psoriasis: An Italian Consensus

Introduction

Psoriasis affects children with a considerable burden in early life. Treating pediatric psoriasis is challenging also because of the lack of updated specific guidelines. With the recent approval of several biologics for pediatric psoriasis and the ongoing COVID-19 pandemic, the management of young psoriatic patients is facing major changes. A revision of treatment recommendations is therefore needed.

Methods

In September 2021, a board of six Italian dermatologists convened to update treatment recommendations. The board issued evidence- and consensus-based statements covering relevant areas of pediatric psoriasis, namely: assessment of psoriasis severity, management of children with psoriasis, and treatment of pediatric psoriasis. To reach consensus, the statements were submitted to a panel of 24 experts in a Delphi process performed entirely via videoconference. A treatment algorithm was produced.

Results

There was full consensus that psoriasis severity is determined by the extension/severity of skin lesions, site of lesions, and impact on patient quality of life. Agreement was reached on the need for a multidisciplinary approach to pediatric psoriasis and the importance of patient/parents education. The relevance of vaccinations, including COVID-19 vaccination, for psoriatic children was acknowledged by all participants. Management issues that initially failed to reach consensus included the screening for psoriasis comorbidities and early treatment with biologics to prevent them and the use of telemedicine to facilitate patient follow-up. There was full consensus that topical corticosteroids are the first choice for the treatment of mild pediatric psoriasis, while phototherapy and systemic therapy are used in children with moderate-severe psoriasis. According to the proposed treatment algorithm, biologics are the first line of systemic therapy.

Conclusions

Targeted systemic therapies are changing the treatment of moderate-severe pediatric psoriasis, while topical corticosteroids continue to be the first choice for mild disease. Children-centered research is needed to further improve the treatment of pediatric psoriasis.

A practical guide to the safety of topical medications for the pediatric population

Prescribing topical therapy for a child could be a challenging matter. This is due to the higher susceptibility of children to local and systemic side effects of topical drugs than adults. Herein, we provide clinicians with a practical guide regarding the side effects, precautions, and lower age limit of commonly prescribed topical medications for the pediatric population.

Safety of topical corticosteroids in atopic eczema: an umbrella review

OBJECTIVE

An umbrella review summarising all safety data from systematic reviews of topical corticosteroids (TCS) in adults and children with atopic eczema.

METHODS

Embase, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and the Centre of Evidence Based Dermatology map of eczema systematic reviews were searched until 7 November 2018 and Epistemonikos until 2 March 2021. Reviews were included if they assessed the safety of TCS in atopic eczema and searched >1 database using a reproducible search strategy. Review quality was assessed using version 2 of 'A MeaSurement Tool to Assess systematic Reviews' (AMSTAR 2 tool).

RESULTS

38 systematic reviews included, 34 low/critically low quality. Treatment and follow-up were usually short (2-4 weeks).

KEY FINDINGS

TCS versus emollient/vehicle: No meta-analyses identified for skin-thinning. Two 2-week randomised controlled trials (RCTs) found no significant increased risk with very potent TCS (0/196 TCS vs 0/33 vehicle in children and 6/109 TCS vs 2/50 vehicle, age unknown). Biochemical adrenal suppression (cortisol) was 3.8% (95% CI 2.4% to 5.8%) in a meta-analysis of 11 uncontrolled observational studies (any potency TCS, 522 children). Effects reversed when treatment ceased.TCS versus topical calcineurin inhibitors: Meta-analysis showed higher relative risk of skin thinning with TCS (4.86, 95% CI 1.06 to 22.28, n=4128, four RCTs, including one 5-year RCT). Eight cases in 2068 participants, 7 using potent TCS. No evidence of growth suppression.Once daily versus more frequent TCS: No meta-analyses identified. No skin-thinning in one RCT (3 weeks potent TCS, n=94) or biochemical adrenal suppression in two RCTs (up to 2 weeks very potent/moderate TCS, n=129).TCS twice/week to prevent flares ('weekend therapy') versus vehicle: No meta-analyses identified. No evidence of skin thinning in five RCTs. One RCT found biochemical adrenal suppression (2/44 children, potent TCS).

CONCLUSIONS

W e found no evidence of harm when TCS were used intermittently 'as required' to treat flares or 'weekend therapy' to prevent flares. However, long-term safety data were limited.

PROSPERO REGISTRATION NUMBER

CRD42018079409.

Evaluating calcipotriene 0.005% foam for the treatment of plaque psoriasis of the scalp and body in patients aged 12 years and older

Introduction: Topical corticosteroids are the mainstay of treatment for mild-to-moderate psoriasis in adult and adolescent patients but there can be many adverse events associated with long-term corticosteroid use. Corticosteroid-sparing alternatives include Vitamin D3 analogs, such as calcipotriene (also known as calcipotriol), which have long been used as monotherapy or combination therapy with other topical agents to treat psoriasis. Calcipotriene's mechanism of action is not fully understood but it is believed to be effective due to its anti-proliferative and anti-inflammatory properties.Areas covered: Herein, the authors review the safety and efficacy of calcipotriene 0.005% aerosol foam, as well as factors affecting patient adherence to topical therapies. The authors offer an expert opinion and future perspectives on the use of calcipotriene foam as monotherapy compared with other topical pharmacotherapies.Expert opinion: Calcipotriene 0.005% foam is a safe and effective topical treatment when used to treat plaque psoriasis in patients aged 12 years and older. Despite its safety and efficacy, it remains largely utilized as a second-line agent due to its slow clinical improvement. Slow onset of action can result in poor patient adherence.

Investigation of solute permeation across hydrogels composed of poly(methyl vinyl ether-co-maleic acid) and poly(ethylene glycol)

OBJECTIVES

Swelling kinetics and solute permeation (theophylline, vitamin B(12) and fluorescein sodium) of hydrogels composed of poly(methyl vinyl ether-co-maleic acid) (PMVE/MA) and poly(ethylene glycol) (PEG) are presented.

METHODS

The effects of PMVE/MA and PEG 10 000 content on swelling behaviour (percentage swelling, the type of diffusion and swelling rate constant) were investigated in 0.1 m phosphate buffer. Network parameters, such as average molecular weight between crosslinks (M(c)) and crosslink density, were evaluated.

KEY FINDINGS

The percentage swelling and M(c) of hydrogels increased with decrease in PMVE/MA content, where the water diffusion mechanism into the hydrogels was Class-II type. In contrast, increase in PMVE/MA content caused an increase in the crosslink density. Permeation of theophylline, vitamin B(12) and fluorescein sodium, with increasing hydrodynamic radii, was studied through the equilibrium swollen hydrogels composed of PMVE/MA and PEG. In general, the permeability and diffusion coefficients of all three solutes decreased with increase in the PMVE/MA content. In addition, permeability and diffusion coefficient values increased with decreases in the hydrodynamic radii of the solute molecules.

CONCLUSIONS

The hydrogels have shown a change in swelling behaviour, crosslink density, M(c) and solute permeation with change in PMVE/MA content, thus suggesting a potential application in controlled drug-delivery systems.