National report — The treatment of psoriasis is a complicated process in which the dermatologist has to be "a little bit of an artist," according
to Steven Feldman, M.D.
In addition to being able to categorize the disease for treatment purposes and being familiar with available treatment options,
the dermatologist must be mindful of the patient's psychological state, says a panel of experts at a "Meet the Psoriasis Experts" discussion sponsored by Galderma at the 66th Annual Meeting of the American Academy of Dermatology.
Tailor to individual
Dr. Lebwohl
|
In discussing treatment options, Dr. Feldman emphasized the importance of tailoring treatment to the individual patient.
Many patients are noncompliant with their regimen owing to dissatisfaction with the type of vehicle used for delivery of topical
medications, which will be used to some degree in all patients with psoriasis regardless of disease severity. Therefore, choosing
the appropriate vehicle is of utmost importance, Dr. Feldman says. He is professor, department of dermatology, pathology and
public health services, and director, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem,
N.C.
Dr. Feldman
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"The three most important factors in the treatment of localized psoriasis are compliance, compliance and compliance," he says.
About 40 percent of patients report being noncompliant with their medications. Adherence studies show that compliance drops
dramatically over the first three to four days and then declines steadily afterward.
Dr. Bikowski
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Most of the traditional creams and ointments are messy, difficult to apply, and therefore unappealing to the patient, contributing
to poor compliance, says Joseph Bikowski, M.D., in private practice at the Bikowski Skin Care Center in Sewickley, Pa.
Treatment 'bothers'
Indeed, focus groups have identified 17 bothersome aspects of psoriasis, many of which are related to treatment, Dr. Feldman
says.
"One third are related to the treatments we've been using traditionally," he says. "These are unpleasant odors, stains on
clothing or furniture, time lost from work, medication side effects, and the monetary cost of treatment."
Lotions add to topical choices
With all of the buzz lately centered around the biologics for the treatment of psoriasis, newer forms of topical treatments
are often overlooked, yet 80 to 85 percent of patients with psoriasis have localized disease that is treatable with topical
therapy.
Dr. Bikowski
|
"A lot of interesting things are going on for these 80 to 85 percent," Dr. Feldman says.
Newer vehicles such as lotions and foams are cosmetically more acceptable than the traditional topicals, Dr. Bikowski says.
The lotions have been at least as effective as the creams in clearing lesions in patients with moderate to severe psoriasis.
The data show that newer formulations can provide high initial efficacy without occlusion, which is a departure from the traditional
perspective of the role of vehicles.
In a comparison of clobetasol propionate 0.05 percent lotion (Clobex Lotion, Galderma), which has a propylene glycol vehicle
to enhance penetration of the active ingredient, and clobetasol cream 0.05 percent (Temovate Cream, Glaxo-Wellcome) in patients
with moderate to severe psoriasis, 75 percent of the patients assigned to clobetasol lotion remained clear four weeks after
stopping their medicine, compared with 50 percent of the patients assigned to clobetasol cream.
Scalp psoriasis
Scalp psoriasis is uniquely difficult to treat, says Mark Lebwohl, M.D., professor and chair of dermatology, Mount Sinai School
of Medicine, New York City.
Creams, lotions and ointments are less than ideal for use on the scalp, and ultraviolet therapy cannot penetrate the hair.
Ketoconazole shampoo (Nizoral, Janssen Pharmaceutica), ciclopirox 1 percent (Loprox, Medicis) and fluocinolone acetonide topical
shampoo, 0.01 percent (Capex, Galderma) are useful for patients with scalp psoriasis with minimal or moderate scale. Options
for patients with moderate to thick scale are 2 percent salicylic acid (P & S Liquid/Shampoo) and clobetasol shampoo (Clobex
Shampoo).
Instructions for applying clobetasol shampoo are a bit different than those for traditional shampoos, Dr. Bikowski says. Clobetasol
shampoo is applied to a dry scalp, left in place for 15 minutes, lathered up with water and then rinsed. Clinical data show
that the once daily application is as effective as once daily application of clobetasol solution.
What is appropriate?
Systemic or biologic therapy is appropriate for the 10 to 15 percent of patients with extensive disease. The biologic agents
have received a lot of attention for this patient population but phototherapy remains a mainstay of treatment, experts say.
"My most common treatment for severe psoriasis is phototherapy," Dr. Lebwohl says. "Unfortunately, phototherapy requires visits
three times a week for months and some patients simply can't make it in that often."
Methotrexate and cyclosporine have been used for more severe or refractory forms of psoriasis, but the toxicity associated
with these agents make biologics all the more attractive, agree Drs. Lebwohl and Bikowski.
"Cyclosporine can cause kidney damage when used over the long term and bone marrow gets wiped out with methotrexate," Dr.
Lebwohl says. "There are all kinds of ways you can make mistakes with methotrexate."
Makes 'no sense'
The benefit/risk ratio is much greater with the biologics vs. the systemic medications, Dr. Bikowski says. The difficulty
is that managed care often requires a trial of a systemic agent before approving the use of a biologic.
"This makes no sense," he says. "If you subject a patient to a drug like methotrexate, with all of the possible risks, and
if the patient does well, you have to keep him on that drug. If you were able to use a biologic, with much less risk, and
the patient did well, you'd have a safer prolonged therapy."
Still, long-term safety data with the biologics are lacking, Dr. Feldman says.
"We know methotrexate well because it has been around a long time," he says. "We don't know what will happen 10 years from
now with some of the biologics."
Heed psychosocial needs
Beyond treatment, dermatologists need to address the psychosocial needs of their patients with psoriasis, Dr. Feldman says.
(See related story) Techniques to treat the psychosocial needs of patients include making the patient feel touchable.
"I establish a close relationship with patients," he says. "I put my hands on their lesions, assuring them that there is nothing
contagious."
Major needs can be addressed using the National Psoriasis Foundation (www.psoriasis.org). Resources there can reduce patients' feelings of isolation and provide empowerment, Dr. Feldman says.
Emotional effects
Psoriasis has a physical impact on the skin, but it also affects people's feelings, behaviors and experiences, says Gail Zimmerman,
president and chief executive officer of the National Psoriasis Foundation.
In a survey conducted by the National Psoriasis Foundation in 2004, 44 percent of patients reported psoriasis to be a large
problem in everyday life, and 38 percent said it was a moderate problem. A quality of life component of this same survey revealed
that more than half of patients with psoriasis feel angry/frustrated and helpless, and nearly half say that their psoriasis
affects their choice of clothing. Almost half of the patients surveyed also felt embarrassed or self-conscious because of
their psoriasis.
According to Dr. Feldman, suicidal ideation is evident in one fourth of patients with psoriasis. A SAD (stress, anxiety, depression)
evaluation that measures these levels on a scale of 1 to 10 can sometimes pick up underlying depression, Dr. Bikowski adds.
The SAD evaluation "is a nice simple way to keep an objective measurement of how much they're being affected by their disease,
and how well the therapies are working on the emotional aspect," he says.
According to Dr. Lebwohl, "even a moderate improvement in psoriasis will have an impact on quality of life."
