General practice recommendations for the topical treatment of psoriasis: a modified-Delphi approach

Psoriasis: an overview

This article discusses psoriasis with a brief overview of the various types. It considers the symptoms, aetiology and treatment options and hopes to give nurses and non-medical prescribers more confidence in recognising and treating this disease.

Mapping the psoriasis research landscape: A comprehensive bibliometric analysis from 2012-2023

An extensive investigation explores the complex terrain of psoriasis, a persistent inflammatory dermatological disorder that impacts between 1% and 3% of the worldwide populace. Acknowledging the intricate interplay between environmental, genetic, and immunological influences on the etiology of psoriasis, the study utilizes sophisticated bibliometric techniques to investigate patterns, gaps in knowledge, and emergent trends within the field. The study utilizes advanced bibliometric techniques to analyze patterns, gaps in knowledge, and emerging trends in the field while acknowledging the intricate interplay between environmental, genetic, and immune-related influences on the etiology of psoriasis. An examination of 18,765 documents from December 2012 to December 2023 was conducted using machine learning techniques and the Scopus database. The explanation for conducting analysis is rooted in its capacity to provide significant perspectives on the dynamic progression of psoriasis research. The study facilitates the identification of significant subject areas, exposes patterns in publication trends, emphasizes influential authors and journals, and outlines the worldwide contributions to the field. The study demonstrates a steady and progressive increase in publications, with significant contributions from the Journal of the American Academy of Dermatology, the British Journal of Dermatology, and the Journal of the European Academy of Dermatology and Venereology. Prominent scholars in research output, such as the United States, China, and Germany, as well as authors including Feldman, Wu, Griffiths, Puig, and Reich K., are identified. Biochemistry, genetics, and molecular biology come to the forefront as esteemed fields that make substantial contributions to the study of psoriasis alongside medicine. This research highlights the interdisciplinary aspects of psoriasis by uncovering knowledge hubs and international collaborations between authors and organizations. The findings highlight the global reach of research on psoriasis and the importance of international cooperation.

Topical Treatment for the Management of Mild-to-Moderate Psoriasis: A Critical Appraisal of the Current Literature

Several comprehensive and updated guidelines are available on the management of psoriasis with systemic treatments. However, there is a lack of updates in recommendations and guidelines on topical treatments, particularly regarding the latest evidence and developments in treatment formulations. Consequently, a comprehensive literature review on this topic, considering the continuous evolution of knowledge and evaluation of the relevance of the available literature evidence, represents a current need to improve the topical management of psoriasis. This study critically appraises the available literature on all topical treatments of psoriasis from the past 20 years to address some relevant issues, such as the vehicle associated with the highest effectiveness, the best vehicle for improving patient adherence, and the best strategy in terms of efficacy and safety for long-term treatment. The greater effectiveness of the foam formulation was demonstrated for calcipotriene/betamethasone dipropionate (Cal/BD) administration compared with the gel and ointment. Without a direct comparison, matching-adjusted indirect comparison analyses support the superiority of the foam versus the cream overall. In addition, the reduced treatment period required by the Cal/BD foam (4 weeks) may favor this formulation over cream (8 weeks). The literature evidence, supported by a broad clinical experience, reported high rates of acceptability and adherence for the foam vehicle. A growing consensus is shared among dermatologists sustaining the proactive approach as the best option for the long-term topical treatment of psoriasis in adults. The Cal/BD foam is the only treatment for which the approved label allows biweekly maintenance use (proactive management), thus representing the first option for long-term topical treatment.

Prospective Observational Evaluation of Fixed Combination Calcipotriol/Betamethasone Aerosol Foam (Enstilar®) in the Management of Psoriasis with Scalp Involvement in Everyday Clinical Practice (the CAPITIS Study)

BACKGROUND AND AIM

Clinical trials have demonstrated the efficacy of fixed-dose combination calcipotriol/betamethasone (Cal/BD) aerosol foam for the treatment of patients with scalp psoriasis. However, data on the real-world effectiveness of Cal/BD aerosol foam in this subgroup of patients are lacking. Therefore, this study investigated the effectiveness and tolerability of 4 weeks' treatment with Cal/BD aerosol foam in patients with scalp psoriasis in everyday clinical practice.

METHODS

This prospective, non-interventional multicenter study involved 217 adults with scalp psoriasis who were treated with Cal/BD aerosol foam for 4 weeks. Primary endpoints included the proportion of patients with <10% of the scalp area affected (Scalp-BSA) plus a Scalp-PGA of "mild" after 4 weeks, as well as the proportion of patients with an absolute PSSI ≤2 points after 4 weeks. Secondary endpoints included patient reported changes in erythema, itching, flaking, and thickness at baseline, 3 days, 1 week, 2 weeks, and 4 weeks.

RESULTS

After 4 weeks, 53.4% of patients treated with Cal/BD aerosol foam had achieved a Scalp-BSA of <10% and a mild Scalp-PGA. Furthermore, 47.6% of patients achieved a PSSI ≤2. Improvements in pruritus and other symptoms (induration, erythema, and scaling) were seen already within 3 days. The proportion of patients who reported that scalp psoriasis had no influence on their quality of life (Dermatology Quality of Life Index 0/1 points) increased from 3.2% at baseline to 47.9% at study end. Patient satisfaction with treatment was high (Treatment Satisfaction Questionnaire-9 scores of 74.5 ± 27.1 for effectiveness, 72.0 ± 25.2 for ease of use, and 77.8 ± 24.2 for general satisfaction). Overall, 97.4% of HCPs assessed the tolerability of Cal/BD aerosol foam as good/very good with no new safety concerns.

CONCLUSION

This study demonstrated the effectiveness, rapid onset of action, good tolerability, and good safety profile of the Cal/BD aerosol foam in patients with scalp psoriasis treated in a real-world setting.

The role of topical therapies along the psoriasis patient journey: An overview from the Symposium 'Tailoring topical psoriasis treatments to patients' needs and expectations' of the 30th EADV Congress 2021

This article summarizes a presentation titled 'The role of topical therapies along the psoriasis patient journey' held at the Satellite Symposium of the 30^th European Academy of Dermatology and Venereology Congress. During this session, the role of topical treatments in the management of psoriasis was presented, with a particular focus on the current unmet needs and data gaps. Psoriasis plays a significant role in a patient's daily life, impacting them not only physically but also psychologically and socially. The disease burden increases with duration and severity. Topical therapies are the keystone of the management of psoriasis. About 70%-80% of patients present a mild-to-moderate form of psoriasis that can be successfully treated with topical agents. According to a German recommendation, patients with mild psoriasis should initiate a topical therapy in combination with skin care products. In the real-life setting, the calcipotriol/betamethasone dipropionate (CAL/BDP) fixed combination was the most prescribed topical treatment for beyond-mild patients in Germany, Spain and the United Kingdom. Healthcare professionals also often or very often prescribed topicals as an alternative to non-biologic systemics in certain situations, such as patient preference (51%), contraindication (50%) and to limit side effects (26%). Adjunctive topical therapy to patients using systemic therapy is used to optimize treatment outcomes and improving the quality of life for patients. Topical treatments can be also effective in severe forms of psoriasis. However, there are still some gaps and unmet needs on topical therapy. Ineffectiveness, patient dissatisfaction and adherence are the largest barriers to treatment success. Main strengths of topical treatments include the availability of various topical ingredients and galenics, the adaptability to different anatomical areas and the possible combination with phototherapy and systemics. Moreover, patients in specific situations can benefit from switching to topical treatments (e.g. pregnancy or surgery).

Long-term proactive management of psoriasis with calcipotriol and betamethasone dipropionate foam: an Italian consensus through a combined nominal group technique and Delphi approach

BACKGROUND

Although long-term management of psoriasis is paramount, this approach is challenging in clinical practice. In the recent PSO-LONG trial, a fixed-dose combination of betamethasone dipropionate (BD) and calcipotriol (Cal) foam applied twice a week on non-consecutive days for 52 weeks (proactive treatment) reduced the risk of relapse. However, the role of Cal/BD foam in the long-term management of psoriasis needs further clarifications. The ProActive Management (PAM) program, a nationwide Italian project, aims at reaching a consensus on the role of proactive management of psoriasis.

METHODS

A steering committee generated some statements through the nominal group technique (NGT). The statements were voted by an expert panel in an adapted Delphi voting process.

RESULTS

Eighteen statements were proposed, and the majority of them (14/18) reached a consensus during the Delphi voting. The need to provide long-term proactive topical treatment to reduce the risk of relapse for the treatment of challenging diseases sites or in patients where phototherapy or systemic therapies are contraindicated/ineffective was widely recognized. A consensus was reached about the possibility to associate the proactive treatment with systemic and biological therapies, without the need for dose intensification, thus favoring a prolonged remission. Moreover, the proactive treatment was recognized as more effective than weekend therapy in increasing time free from relapses. Approaches to improve adherence, on the other hand, need further investigation.

CONCLUSIONS

The inclusion in guidelines of a proactive strategy among the effective treatment options will be a fundamental step in the evolution of a mild-moderate psoriasis therapeutic approach.

Comorbidity in Adult Psoriasis: Considerations for the Clinician

Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.

Short Term and Long-Term Efficacy of Calcipotriene/ Betamethasone Dipropionate Foam Combination

Psoriasis is a well-known chronic disease characterized by the development of erythematous, indurated, scaly, pruritic plaques on the skin with cycles of remission and symptom flare-ups. The management of patients with chronic plaque psoriasis has been more challenging since the Covid-19 pandemic as health care professionals have had to adapt to remote consultations for some patients, and patients have had to adapt to the changing health landscape. The rapid resolution of psoriasis symptoms especially those with a substantial impact on quality of life can improve patient satisfaction and adherence, making it an important factor in successful treatment. Cal/BD foam contributes to improved patient adherence and treatment outcome through its rapid action and superior efficacy versus Cal or BD monotherapy, Cal/BD ointment and gel and clobetasol cream in the short-term flare treatment of psoriasis. Moreover, the benefits of proactive long-term management of psoriasis compared to reactive management and its favourable safety profile are higher efficacy and a better health-related quality of life. Cal/BD foam should be considered an effective topical treatment for short-term flare treatment and long-term control of adult psoriatic patients.

Patient Preference for Biologic Treatments of Psoriasis in the Chinese Setting

OBJECTIVE

Assessments of patients' preferences can support in clinical decision-making regarding biologic therapies for psoriasis. Our objective was to investigate patient preference for biologic treatments in patients with psoriasis in China.

METHODS

From October 2020 to January 2021, psoriasis patients were recruited for a survey that included demographic and disease-related questions, as well as a discrete choice experiment to measure their preferences for biologic therapy. A discrete-choice experiment was used in which respondents selected psoriasis treatments based on benefits (ie, early onset of efficacy, long-term efficacy, sustained efficacy) and treatment costs. We analyzed choice data using conditional logit model.

RESULTS

This study included 236 patients with moderate-to-severe psoriasis. The relative importance of the cost of biologic treatments, probability of keeping PASI100 at 5 years, probability of achieving PASI100 at 3 months and time to achieve PASI50 after initiation the biologic treatment were 0.593, 0.137, 0.185 and 0.085. Over 50% of patients regarded the cost of biologic treatments as the most important attribute. High-income and low-income subgroups had higher preference weight in probability of achieving PASI100 at 3-month and monthly cost.

CONCLUSION

The cost of biologic treatments was found as the most important attribute for Chinese patients with psoriasis. Among efficacy attributes, the probability of achieving PASI100 at 3 months showed most sensitive. These results may be helpful to understand patient preference for biologic treatments used for psoriasis in China.

Efficacy and Safety of Different Formulations of Calcipotriol/Betamethasone Dipropionate in Psoriasis: Gel, Foam, and Ointment

Preparations containing calcipotriol combined with betamethasone dipropionate (in the forms of ointment, gel, and foam) are available for the topical treatment of psoriasis. This review summarizes the differences in the efficacy and safety of these formulations, as well as the preferences of patients with various forms of psoriasis (plaque, scalp, and nail psoriasis). It has been documented that foams provide higher bioavailability, resulting in increased efficacy in plaque psoriasis compared to ointments and gels. Gels or foams are preferred by patients for their different practical qualities (e.g., gels for “easy application”, and foams for “immediate relief”). The available data indicate that ointments may be the most effective formulation in nail psoriasis, and gels are preferred by patients with scalp psoriasis because of their cosmetic features. Treatment with a foam formulation is associated with a lower number of medical appointments compared to treatment with an ointment and with a lower probability of developing indications for systemic treatment. The safety profiles of foams, ointments, and gels are comparable, with the most common adverse effect being pruritus at the application site (in 5.8% of the patients). A long-term proactive maintenance therapy markedly reduces the number of relapses and is likely to close the gap between topical and systemic treatment in psoriasis.

Long-term maintenance treatment of psoriasis: the role of calcipotriol/betamethasone dipropionate aerosol foam in clinical practice

Most patients with psoriasis present with localized mild-to-moderate disease. In this case, the application of topical treatments in the first-line setting is recommended in most cases.Among different topical options, the fixed-dose combination of betamethasone dipropionate (BD) and vitamin D analogue (Cal) aerosol foam (Enstilar®, Leo Pharma) is approved as first-line topical therapy for the treatment of psoriasis in USA and the EU, due to its high efficacy and its favorable administration scheme.The PSO-LONG was the first trial to report on the long-term efficacy and safety of the Cal/DB foam treatment for the proactive management of psoriasis and now, the indications of Cal/BD foam included its use in the psoriasis maintenance treatment. However, the precise role of this treatment and the potential therapeutic schemes in the long-term management of psoriasis need further clarification.This Position Paper, authored by a group of Italian Expert Dermatologists, critically discusses the long-term management of psoriasis with Cal/BD foam in clinical practice. In particular, the biological rationale in the proactive treatment with Cal/BD foam and current evidence regarding this therapeutic approach are presented, along with its application also in patients with moderate-to-severe disease, difficult-to-treat lesions, or within combination regimens. In addition, strategies to improve adherence to long-term treatment of psoriasis are discussed.