In their session on the third day of Fall Clinical 2022, “Plaque Psoriasis: Itching for New Topical Options,” Neal Bhatia, MD, and April W. Armstrong, MD, MPH, reviewed key data for emerging topical therapies to manage plaque psoriasis.

Drs Bhatia and Armstrong began the session with an overview of the nonhistaminergic itch pathway. Direct activation of skin sensory neurons is mediated by the cytokines IL-4, IL-13, IL-31, and TSLP. IL-4, IL-13, and IL-31 are pruritogenic cytokines that signal through JAK1. IL-4R and IL-31R also signal via JAKs, share the IL-4Rα subunit, and are expressed on histamine-independent C-fibers. IL-31 is predominantly expressed by Th2 cells, with IL-31Rα primarily found on C-fibers. Itch is the most burdensome symptom of psoriasis.

They pointed out that 80% of patients with psoriasis have scalp psoriasis, which is often associated with itch. Itching, flaking, and plaque visibility on the scalp can cause social embarrassment and adversely impact quality of life. Treatment of scalp psoriasis is difficult because the hair may limit efficacy of creams and ointments and reduce treatment adherence. Roflumilast is a selective and highly potent phosphodiesterase-4 inhibitor being investigated as a once-daily, nonsteroidal, topical treatment for various dermatologic conditions. Roflumilast foam is uniquely formulated as an emollient, water-based, moisturizing foam that can be used on the scalp or body. Roflumilast cream met the primary and secondary endpoints and was well-tolerated in a phase 2b, randomized, double-blind, vehicle-controlled trial in adults with psoriasis.

The current landscape of topical therapies for psoriasis includes:

• Topical corticosteroids
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus)
• Vitamin D analogues (calcipotriene, calcitriol)
• Keratolytics (tazarotene, salicylic acid)
• Combination therapies with advances in vehicle
• Corticosteroid + vitamin D analogue
• Corticosteroid + keratolytic
• Topical PDE4 inhibitor
• Tapinarof

Lastly, Drs Bhatia and Armstrong discussed how to determine who is the appropriate patient for topical psoriasis treatment. Limited body surface area and incomplete control with systemic medications are indications.

Reference

Bhatia N, Armstrong AW. Plaque psoriasis: itching for new topical options. Presented at: Fall Clinical Dermatology Conference 2022; October 20–23, 2022; Las Vegas, NV.