Maui Derm Hawaii 2026 featured a discussion on the evolving treatment landscape of topical therapies for patients with plaque psoriasis, including the role of newer targeted topical therapies either alone or in combination with systemic therapies.

Following this presentation, featured expert Jason E. Hawkes, MD, MS, FAAD, was interviewed by Conference Reporter Associate Editor-in-Chief Rick Davis, MS, RPh. Clinical perspectives from Dr Hawkes on these findings are presented here.

Topical therapies play an important role in the management of plaque psoriasis for most patients, sometimes in combination with systemic therapies. Historically, the brunt of the work was carried by topical corticosteroids because they are effective, readily accessible, and inexpensive. Providers can easily prescribe these medications in the clinic with few of the administrative burdens that come with prescribing newer nonsteroidal medications. However, topical corticosteroids have drawbacks in that they cannot be used on all body sites, are applied twice daily, cannot be used continuously without the risk of corticosteroid-induced atrophy or striae, and occasionally have rare systemic effects. We can also see corticosteroid treatment withdrawal or tolerance develop with the chronic use of topical corticosteroids.

So, there is clearly a need for improved topical therapies for plaque psoriasis. Over the past decade, we have seen the development of novel nonsteroidal treatments. These agents get around some of the drawbacks of topical corticosteroids by having advantages that include simplified (ie, once-daily) treatment regimens and the ability to use them across all body sites, including the face and genitals. Additionally, they do not have limitations related to long-term use.

At the recent Maui Derm Hawaii 2026 meeting, Linda Stein Gold, MD, provided information on plaque psoriasis during her presentation titled “What’s New in Topical Therapy?” The 2 unique therapies in plaque psoriasis that she highlighted were tapinarof, an aryl hydrocarbon receptor (AhR) agonist, and roflumilast, a PDE4 inhibitor. These medications add to our understanding of the immunopathogenesis of plaque psoriasis, as the clinical efficacy of these agents underscores the ability of the AhR and PDE4 pathways to regulate key cytokines involved in psoriatic disease.

What is striking about tapinarof as an AhR agonist is that it promotes skin barrier function and the inhibition of the immune response, which is different from the usual mechanism-of-action story. Tapinarof activates AhR to help calm down the immune system, downregulating IL-23 and IL-17 signaling, which we know plays a significant role in the pathogenesis of plaque psoriasis. AhR is widely expressed on the skin and on a number of immune cells involved in regulating skin inflammation.

This medication was well tolerated in the phase 3 PSOARING 1 and PSOARING 2 studies, as discussed by Dr Stein Gold, showing up to 40% of patients achieving clear or almost clear skin at 3 months. Additionally, she talked about the interim results from the PSOARING long-term extension study (ie, PSOARING 3), which showed that tapinarof may also have a prolonged treatment response (or a remittive effect) even after topical treatment has been discontinued. We think of it more like a disease-free interval, where patients remain well controlled before having to reuse the medication. This is an important characteristic for patients who very quickly grow tired of having to constantly reapply any topical medication for their chronic disease.

Similarly, roflumilast, which was approved by the US Food and Drug Administration (FDA) in 2022 for plaque psoriasis, showed dramatic improvement relative to placebo with very good efficacy and tolerability in the phase 3 DERMIS-1 and DERMIS-2 trials. This medication works by blocking the PDE4 pathway, which is an intracellular signaling pathway that is critical for a number of inflammatory cells and subsets of T cells, such as differentiated Th1, Th2, and Th17 lymphocytes. Importantly, roflumilast also downregulates the NF-κB pathway, which is a central proinflammatory pathway with broad implications involving tissue inflammation. This helps explain why this unique mechanism of action works for the treatment of multiple conditions, including plaque psoriasis, atopic dermatitis, and seborrheic dermatitis, which can mimic one another due to shared clinical features.

We also occasionally see patients on systemic therapies who have had an inadequate treatment response, with a few difficult-to-treat areas (eg, persistent plaques on the extremities, severe disease of the palms and soles, or scalp disease). For these patients, we may want to consider topical treatments as adjunct therapy to help promote clearance in these stubborn body sites when systemic agents are not enough. Through our conversations with patients, we assess their lifestyle and therapy preferences to choose the best combination of treatment properties that will help promote skin clearance while not simultaneously complicating their lives to the point where they are not going to follow through with a prescribed treatment plan. Providers, therefore, need to have a good understanding of how to use topical therapies, as well as the pros and cons of the various steroid and nonsteroidal medications.

Newer topicals such as tapinarof and roflumilast are beginning to push us into an era of simplified topical regimens that are less complicated and more versatile, and they are starting to move our discussion away from chronic topical corticosteroids and the concerns that clinicians and patients have about their long-term use. There may also be periods when patients with plaque psoriasis do not have to use these topical therapies every day but still have sustained skin clearance in between application periods. This is a key concept that is driving patient interest in advanced topical medications, and we have just started to scratch the surface on a prolonged disease-free interval (or remittive effect) off therapy and the underlying biological mechanisms that characterize this clinical observation.