The following is an excerpt from our latest Pearls in Psoriasis podcast hosted by Lawrence Green, MD. This episode highlights the experience and insight of Mark Lebwohl, MD, on the evolution of topical therapies and clinical trials for psoriasis.
Dr Green: What do you think about the future beyond nonsteroidals? Do you think there’s another path for topical treatment for psoriasis?
Dr Lebwohl: Janus kinase (Jak) inhibitors are taking off in atopic dermatitis, and they are being studied topically for atopic dermatitis. They’re also being studied for vitiligo and for alopecia areata, where they’re not quite as effective yet, but there’s no question that they will work for psoriasis. Tofacitinib was brought to the FDA for approval for psoriasis orally. It did not get approval for psoriasis, because there were a lot of agents out there that are even more effective and safer at the time, but newer Jak inhibitors are coming out. Certainly, in a cream, I think anyone would consider them to be very safe. I’m sure they will be used topically as well.
Dr Green: That’s so interesting. Again, I mentioned how the topical landscape is really changing. I wanted to ask you one question, because everyone I’m sure wants to hear from you as someone we all respect for treatment of psoriasis. Let’s forward 10 years to 2030. How do you think the landscape will be different, and will we be doing things different? How do you think we’re going to approach the psoriasis patient?
Dr Lebwohl: Again, in terms of localized disease, I don’t think we’re going to be treating them systemically. I think we will be treating them with better and better topicals. I think excimer laser, which we use a lot for psoriasis now, has a major place. We didn’t talk about lasers.
There are also some home [phototherapy] handheld units. Clarify Medical has this little narrowband UV-B box that you hold while you watch [television], keep it in place for 6 minutes, and it works pretty well.
I think we’re going to have things that are patient-friendly that can be done at home, [such as] better lasers that reduce the number of treatments for patients. I think we’ll have better and better topicals in that space.
Dr Green: We’re going to wrap up, but[…]do you have any clinical pearls for treating psoriasis you’d like to share with us, something you’ve learned over the years that is a good trick?
Dr Lebwohl: I have many clinical pearls. A lot of them, of course, apply to biologic therapies and oral therapies. I will say, in the realm of topical therapies, I also have many. There are some ingredients that enhance penetration and efficacy, as well as side effects, of topical psoriasis therapy. Salicylic acid is one of those agents. A couple of cautions about it. Don’t use it on the entire body surface, because it gets absorbed and has side effects. Secondly, if you have a pharmacist compound it for you, call them up and make sure they know what they’re doing. Years ago, when we were using a lot of compounded salicylic acid preparations, we actually called the pharmacy after I went to an [American Academy of Dermatology] meeting, and I heard a statistic. Sure enough, half the pharmacists we were using were using aspirin instead of salicylic acid, acetylsalicylic acid, which to the best of my knowledge doesn’t do anything for psoriasis as opposed to salicylic acid. But salicylic acid does make many topical therapies penetrate more. Be careful what you combine things with, though, because for example, salicylic acid on contact immediately inactivates 100% of calcipotriene.
I would leave you with that pearl. It’s a great ingredient, but be careful when you mix things to make sure that you know what [those ingredients are] doing.
