Plaque Psoriasis: Adherence and Long-Term Management

Emil A. Tanghetti, MD, is a board-certified dermatologist currently located at the Center for Dermatology and Laser Surgery in Sacramento, CA. He is a fellow in the American Academy of Dermatology (AAD) and the American Society for Laser Medicine and Surgery. His particular expertise focuses on laser surgery, psoriasis, actinic keratosis, photoaging, and acne vulgaris. His research has been published in Lasers in Surgery and Medicine, Journal of Dermatologic Surgery, Journal of Cosmetic and Laser Therapy, and Cutis. Dr Tanghetti met with The Dermatologist to offer insights into his recent June 2021 study, “Optimized Formulation For Topical Application of a Fixed Combination Halobetasol/Tazarotene Lotion Using Polymeric Emulsion Technology”.

Could you briefly discuss the mechanisms of action for the fixed combination of HP 0.01%/TAZ 0.045% lotion formulation utilizing innovative polymeric emulsion technology?
The mechanisms of these 2 agents together are, in essence, different, the same, and complementary all at the same time. The retinoid tazarotene is the only topical agent of this class that has been proved to be effective in the treatment of psoriasis, acne, and photodamage.

The steroid, halobetasol, is a strong and effective agent to treat psoriasis. Together with the retinoid these products help mitigate irritation and enhance the efficacy of each of the agents. In clinical practice it has been difficult to use these agents separately because of laying, compliance and irritation issues. There are many studies that have shown this combination is effective and tolerable. The only problem was getting our patients to use them correctly. This agent corrects this problem. Another benefit of these two products together is that the topical retinoid appears to prevent steroid atrophy. This product does appear to significantly improve the tolerability of tazarotene because of the combination of moisturizers, humectants, and topical steroids with this unique retinoid.

The idea with this polymeric technology is it allows us to combine these 2 products together. They're in little separate cells in this emulsion. This emulsion keeps them separated and, when they hit the skin, it dissolves the polymeric emulsion, and they all mix on the surface of the skin. If they were sitting in a tube this way, they wouldn't be compatible, and they would actually degradant each other.

The one thing I just want to make sure is we understand that this polymeric emulsion allows us to deliver the active ingredients, but also moisturizers with it as well, so that we get great efficacy and great clearance by using all these things concurrently once a day. This polymeric emulsion technology allows us to give them concurrently. It's that concurrent use that makes it easy-to-use for our patients.

Based on the June 2021 study, what types of patients may be good candidates for HP 0.01%/TAZ 0.045% lotion formulation by polymeric emulsion technology?
Based on the study, we used it in patients with plaque psoriasis, including those mild to moderate. Those were all candidates, and we used them in different areas. We did not study the scalp in the clinical trials. However, in my clinical practice, I have used it safely and effectively in my patients with excellent results.  

In the clinical trial this product was used up to 8 weeks with excellent results and sustained remission of plaques after the drug was discontinued. In my clinical practice, I generally treat the patient to clearance which can sometimes occur within 3 to 4 weeks. At that time I either stop the product or taper it to 2 to 3 times a week.

What we found is that it cleared problems better than anything I've used topically in my practice over many, many years. The clearances were quite dramatic and impressive, and they were long lived. We did not see them bounce right back after the treatment. They worked very well concurrently.

Based on your findings, how can HP/TAZ lotion improve adherence and long-term management of psoriasis?
Adherence is important in the sense that, if you had to use these things at 2 different times of the day, adherence dramatically drops off. When you can use them together, and you can use them together once a day, it really makes for better adherence.

It allows people to do things very easily. Again, when you can make it easy, adherence is always better. We treated reoccurrence, which sometimes could be several months.

In my practice, some of my patients use it two to three times a week to keep it away or use it as soon as they see a plaque return. They do things differently than the study, but both ways work.

The study noted that, “Most subjects responded favorably to questions on the physical attributes of the vehicle lotion.” What does this say about the durability of HP/TAZ and its impact on patient QoL?
When you use a product, you've got to make sure that patients like the consistency and the feel of it. A lot of products are very greasy with some of the other combination Vitamin D steroids being greasy, and hard to use. They stain clothes and you cannot put them in the scalp.

This product, when you put it on the skin, goes on very nicely. It's not greasy, but still moisturizing. There’re moisturizers in this product that improved its efficacy, but also its tolerability because patients with psoriasis have impaired barrier function.

This is very spreadable and moves easily. On-label, it was used on the body. Off-label, in my practice over the last number of years, I've used it in the scalp as well. I find that it can be put on at night, shampooed out in the morning, and everything works out well.

Again, this is off-label in the scalp, but I use it on all body surface areas, except the face or groin area or sensitive areas such as the underarms or inside the ears.

Regarding plaque psoriasis and HP/TAZ lotion, what key takeaways do you want to share with other dermatologists?
I think, with any of these products, what you want to do is spend a little time showing the patient how to use them, but we've got to make sure that the lesions are generally just on the plaques. The normal skin doesn't use it.

Sometimes, if you use it on a normal skin especially, it's going to be a little irritating. You want to use it generally just on the plaques. The thicker plaques work the best. We want to treat to clearance.

Now, while this is approved for 8 weeks, I generally tell my patients, "We want to treat until you're cleared. When you're cleared, we want to back down and stop then just use moisturizers." Again, use this product on the plaque, use it to achieve clearance, and if we get a little irritation, lay off for a day or 2. Moisturize, and then go back to it again.

I think these all are what we did in the clinical trial and achieved good success with them.   

Reference
Tanghetti EA, Stein Gold L, Del Rosso JQ, et al. Optimized formulation for topical application of a fixed combination halobetasol/tazarotene lotion using polymeric emulsion technology. J Dermatol Treat. 2021; doi:10.1080/09546634.2019.1668907