Topical therapies are often a cornerstone of treatment for plaque psoriasis, with treatment selection tailored to each patient. At the 2024 Fall Clinical Dermatology Conference, a forum was held to discuss and explore the current state of topical therapy for psoriasis.

Following this presentation, featured expert Steven R. Feldman, MD, PhD, was interviewed by Conference Reporter Associate Editor-in-Chief Rick Davis. Dr Feldman’s clinical perspectives on this topic are presented here.

Plaque psoriasis can manifest differently in different areas of the body, and different areas of the body can differ in their sensitivity to drugs and adverse events. There are numerous topical therapies available for plaque psoriasis that is on different areas of the body, which can offer flexibility in management. Unfortunately, patients are less likely to follow complex regimens requiring multiple medications to be used on different areas of the body when adherence to just one treatment can be poor.

Tapinarof and roflumilast are nonsteroid topicals for plaque psoriasis that can potentially be used on skin throughout the body. These drugs may help to minimize the complexity of the treatment regimen and the side effects from steroids, but we still have to get patients to consistently apply them. Even when a topical treatment is very tolerable and nice to use, I think that getting a patient to apply it on a regular basis is much harder than getting them to take a pill—and we know that many patients do not take their pills as they should. New topical agents work great in clinical trials, but patients tend to be more adherent in clinical trials than they are in real life. Patients may use their medication before all the monitoring visits in a clinical trial the way that people are more likely to floss their teeth before seeing a dentist. In clinical practice, seeing a patient 8 to 12 weeks after starting a medication is not the same as what was done in the studies, which may have also brought a patient back at weeks 1, 2, 4, and 6.

The “Topical Therapy Forum” presented by James Q. Del Rosso, DO, Linda F. Stein Gold, MD, and Elizabeth Swanson, MD, at the 2024 Fall Clinical Dermatology Conference included data from the PSOARING 3 study of tapinarof. One-year safety and efficacy data showed that 40.9% of patients achieved complete disease clearance (Physician Global Assessment [PGA] = 0) at least once during the trial. In addition, patients treated with tapinarof experienced an approximately 4-month mean remittive effect off therapy. I do not know that tapinarof is quite as effective as clobetasol, but it does not have steroid side effects. Further, when a topical agent such as clobetasol works so quickly, it makes me wonder if patients who have failed clobetasol due to poor adherence will see treatment success with an even slower–acting drug. In the study, 22.7% of patients developed folliculitis, but, in my experience, folliculitis would not affect our ability to prescribe the drug or a patient’s use of it.

Results from pivotal trials (ie, DERMIS-1 and DERMIS-2) for roflumilast cream showed that approximately 40% of patients with psoriasis had Investigator Global Assessment (IGA) success (ie, clear or almost clear status plus ≥2-grade improvement from baseline [score range, 0-4]) with roflumilast cream at 8 weeks compared with approximately 7% with vehicle cream. Data from the phase 3 ARRECTOR trial in patients with scalp and body psoriasis were presented by Joshua Zeichner, MD, in a session at the 2024 Fall Clinical Dermatology Conference. The data showed that roflumilast 0.3% foam significantly reduced scalp itch, with more than 50% of patients reporting minimal or no itch after 8 weeks, 66% reporting IGA success in scalp psoriasis, and 40% achieving a clear scalp. An effective nonsteroid treatment in a foam vehicle may be valuable for simplifying treatment and thereby improving adherence by allowing one product to be used in multiple different body areas, as the foam can be used on the scalp, face, elbows, and other areas, and the nonsteroidal allows it to be used in sensitive areas (ie, the face and genital area) and nonsensitive areas.

I think the thing that grabs people’s attention from the PSOARING 3 data is the potential remittive effect in patients who achieved skin clearance. The mean duration of remission off of therapy for patients who had achieved a PGA score of 0 was 130.1 days, or more than 4 months. Patients want to have clear skin, but they do not want to have to use drugs. Telling the patient that there is an opportunity for skin clearance and to be able to have their skin stay clear off of therapy for a considerable period of time is probably very appealing to both patients and physicians. We do not have any head-to-head data showing that the remission rate observed with tapinarof is longer than for clobetasol. I think the general impression is that steroids would not have a remittive effect like this, but I would love to see what the remission rates are in a head-to-head trial.