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It's Been A Long Time Coming For Long-term Topical Psoriasis Treatments
Psoriasis is a tricky disease to manage, as drawbacks and side effects loom with each and every type of treatment. Anyone who watches television has heard the list of potential adverse reactions, considering that commercials for psoriasis treatments are seemingly only outnumbered by goofy ads for auto insurance.
Topicals — creams, ointments, foams, and lotions applied directly to the affected areas of the skin — don't get nearly as much TV time as their systemic biologic counterparts, the self-injectables with catchy theme songs, where the smiley and sleeveless walk confidently down the street and/or swim. But two new non-steroidal topicals were introduced this year — Dermavant Science's Vtama and Arcutis Biotherapeutics' Zoryve — and each one solves a long-time problem plaguing millions of psoriasis patients. There are no limitations on the duration of use.
How to quantify severity
Patients afflicted with psoriasis have a malfunctioning immune system that mistakenly attacks the body by overproducing skin cells, which leads to a build-up of scaly plaques. Those who develop psoriatic arthritis are saddled with joint pain and inflammation.
When categorizing the severity of psoriasis, it's generally defined by the total amount of skin surface area covered by plaques. Less than 3% is considered mild, 3-10% moderate, and anything greater than 10% is severe. In other cases, the location of the affected areas can influence the level of severity. When sensitive areas like the face, the palm of a hand, or the sole of a foot are inflamed, a diagnosis of severe is possible due to the pain or discomfort experienced from even the most basic of movements.
First in class
In May, the U.S. Food and Drug Administration approved Vtama (tapinarof) cream, an aryl hydrocarbon receptor agonist and the first FDA-approved steroid-free topical medication in its class. Two months later, Arcutis won approval for its Zoryve (roflumilast) cream. Both are once-a-day treatments.
For moderate to severe cases, systemic biologics work to suppress the immune system and bring relief to the skin and joints. For milder cases, doctors have traditionally prescribed topical corticosteroids, vitamin D analogues, and retinoids.
Vtama and Zoryve have different mechanisms of action, but are lumped together into the newer novel agents class that are indicated for all levels of severity in psoriasis. Unlike traditional topical steroids, Vtama and Zoryve are safe for long-term use. The approvals add two more options for psoriasis patients hoping to stay away from biologics as long as they can. If symptoms remain mild to moderate, patients can stay on these drugs indefinitely.
Vtama and Zoryve work in different pathways, but there is no clear superior option and there have been no head-to-head trials. And they can still be used in combination with a potent corticosteroid to treat flare-ups on a temporary basis.
Side effects, front and centre
Systemic biologics are better for cases of psoriasis that do not resolve with lower-potency topicals, so the patient can avoid applying high-potency drugs over large areas of the body. To counteract the high level of steroidal absorption into the skin, these treatments can be combined with vitamin D analogues.
Topical corticosteroids block the immune system on the surface where applied, while biologics flow through the bloodstream. When used in moderation, this contributes to better side-effect profiles for the topicals because they aren't compromising the entire immune system.
While topical corticosteroids work well and are much cheaper, they do come with limitations. Lower to moderate potency topical corticosteroids are safer, but they don't work as well. When patients ultimately need to take more aggressive action in their treatment, high-potency options take precedent.
That comes with side effects, some of which are known to cause thinning of the skin. This may lead to cuts and bruises or suppression of the hypothalamic-pituitary-adrenal axis, which is a systemic condition that results in a decrease in cortisol, a natural stress hormone found in humans. When this hormone is suppressed, response to stressors (e.G. Trauma, surgery, inflammation) may be impaired, which results in an inadequate defense against infections.
Manage it early
Psoriasis isn't like a rash or chickenpox, where it pops up all of a sudden, spreads quickly, and becomes instantly noticeable. It may start off as a tiny patch on an elbow. The best course of action is to manage it early when the surface area affected is minimal. These first-in-class treatments give patients more options to find something that works early and stick with it.
Systemic biologics are quite expensive, with some costing close to $100K or more annually. Vtama, at about $1,300 for a one-month supply, and Zoryve, at about $825 per month, are much more affordable. At a cheaper cost for health plans and patients alike, and with the ability to be used long term, nonsteroidal topicals like Vtama and Zoryve are a welcome addition to dermatologists' arsenal. All that's missing is a catchy theme song.
About the author
Rob Louie RPh is EVP, Clinical Services at RemedyOne, a formulary and rebate optimization company and part of Goodroot, a community of companies reinventing healthcare, one system at a time. He has more than 30 years of experience as a pharmacist.
Topical Steroid Addiction: Patients Call For More Support
Elin Wade had a bad reaction to the creams she was using for eczema
A woman who lost three stone (19kg) and had hallucinations while using topical steroids has called for more support for people reacting to skin treatments.
Teacher Elin Wade, from Swansea, had bad reactions after using creams prescribed for an eczema flare-up.
The 29-year-old said she was made to feel like a "fraud" as topical steroid addiction is not recognised as an official condition by the NHS.
The Welsh government said serious reactions were "uncommon".
About 10% of adults and 20% of children in the UK have eczema, with topical steroids considered a safe and effective way in most cases to manage it.
The creams and ointments come in various strengths, and are usually meant to be used in short courses.
But some people react badly to the creams, either while using them or when they stop - a condition which has become known as topical steroid addiction.
Symptoms include hot red rashes, oozing, excessive skin shedding, cracked skin, severe itches, extremes of body temperature, swelling, swollen lymph nodes, fatigue, mental health issues and insomnia.
In January the British Association of Dermatologists and the National Eczema Society published guidance acknowledging topical steroid withdrawal for the first time.
Elin Wade has had mild eczema since childhood, but had a bad flare up in her twenties
In February 2019, Ms Wade stopped using her steroid creams after she lost weight, had hallucinations and her hair fell out.
"I went from being a perfectly healthy 25-year-old woman to being a 29-year-old injecting incredibly potent drugs into my system just to get some sort of relief," she said.
She said it was "exhausting" and "frustrating" trying to tell doctors she believed the creams were driving her symptoms, and that she was made to feel like a "fraud".
Elin Wade believes it was topical steroid addiction that led to her losing weight
"It's always been made very clear to me that I should be using topical steroids, that they don't cause addiction, they don't cause withdrawal and it's impossible to get addicted to them," she said.
"It's been so traumatic, the suffering is so intense, there's no way I'd put myself through this if I didn't see other people get better."
Ms Wade said she had been tested for HIV, lymphoma and leukaemia but she still did not have a diagnosis as the condition is not recognised.
"It'd just be a lot less stressful because you're suffering so much anyway, just to have somebody acknowledge that this is a condition that actually is happening," she added.
Emily Banks described the reaction of doctors as "disheartening"
Lecturer Emily Banks, 30, from Cardiff, also decided to stop using topical steroids after the ointments she was prescribed stopped working.
Desperate to find answers about why her skin was so bad, she made a "cry for help" on social media, sharing photos of her skin.
She said being disbelieved by doctors was "really disheartening when you're in pain and you just want help".
George Moncrieff, a GP in Oxfordshire, said he "couldn't imagine practicing medicine" without topical steroids.
The former chairman of the Dermatology Council of England believes they are so integral to the treatment of skin conditions, sometimes the medical community "don't want to hear bad news" about adverse reactions to them.
Emily Banks turned to social media to try and find out what was wrong
Dr Moncrieff said because some patients were reluctant to use topical steroids in the first place - so-called "steroid-phobia" - doctors can sometimes assume people with genuine concerns about bad reactions to steroid creams could be ignored.
"If doctors think something's uncommon they don't recognise it and they don't discuss it. It's therefore never diagnosed and it continues to be assumed to be uncommon," he added.
Research suggests the average medical school offers about two weeks of dermatology training during six years of study, while nine out of 10 patients with skin issues were not seen by a skin specialist.
Julie Keeley from the Welsh council of the Royal College of GPs said patients should not be afraid to consult their doctor if they were worried they had signs of the condition, and to ask for the second opinion of a dermatology specialist if necessary.
Specialist training
But she also said GPs needed more specialist training on skin so they could distinguish the signs between normal skin conditions that will respond to steroid creams, and topical steroid addiction.
"I think it's a good way forward to have more education for dermatology based in Wales and more readily available to healthcare professionals," she added.
"And also integrating it more into the medical school curriculum so people have a better awareness of these conditions."
Advice on Acne and masks
The author of the new guidance, Celia Moss, said labels like "topical steroid addiction" and "red skin syndrome" were not helpful for doctors because they are not recognised medical terms.
Her work breaks down topical steroid withdrawal into recognisable and treatable diagnoses for doctors.
She said she hoped it would go some way to ending the "friction" and "open up channels of communication" between doctors and patients.
Dr Moss also wants to see better labelling of steroid creams so doctors and patients understand how strong they are and how they should be used.
The Welsh government said topical steroids played an important role in the treatment of some conditions, but longer-term use should be monitored carefully.
"More significant reactions following withdrawal of topical steroids are relatively uncommon, however anyone concerned about side effects should discuss this with their doctor," a spokeswoman said.
'Skin problems aren't only skin deep'
'Some days I wanted to rip my skin off'
New approach to eczema treatment closer
Best Hair Loss Treatments Of 2024
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What are Topical Hair Loss Treatments?Topical treatments are among the most popular options for those facing hair loss. These treatments are applied directly to the scalp to help stimulate hair growth, reduce hair thinning and potentially prevent further hair loss.
Two of the most well-known topical treatments for men and women are minoxidil and corticosteroids. Both have undergone research studies and have shown promising results to help combat certain types of hair loss.
Minoxidil, also known as Rogaine, can help improve blood flow to hair follicles to promote healthier and stronger hair growth, while corticosteroids can help reduce inflammation that might be contributing to hair loss.
Other treatments, such as finasteride, can be prescribed to address specific hair loss issues, scalp conditions and male or female pattern hair loss.
Consult a doctor as some treatment types suited for men may not be suitable for women and vice versa.
Topical Solutions for Different Types of Hair LossDifferent types of hair loss require tailored treatments to address the underlying causes and promote healthy regrowth. Understanding the specific condition you're dealing with can help you and your doctor determine the best topical solution for you.
Here are the most common treatments for various hair loss issues in men and women:
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Best Hair Treatment for Men
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How to Choose the Best Hair Loss Treatment for YouFinding the right hair loss treatment depends on the type and severity of your hair loss. With so many options available, it's important to consult your doctor to understand how each treatment works and to determine the best options to treat your condition.
Topical vs. Oral TreatmentsTopical treatments, like minoxidil and corticosteroid creams, are applied directly to the scalp to potentially help treat the affected area.
Oral treatments are taken as pills. Please be aware that they may cause side effects like sexual dysfunction or unwanted hair growth on the face and body.
Topical treatments generally have fewer side effects compared to oral medications.
Prescription TreatmentsPrescription treatments may be necessary in more severe cases or when over-the-counter options are ineffective.
Over-the-Counter OptionsFor those starting their hair loss treatment journey or looking for maintenance options, these OTC treatments and supplements are available:
Hair growth vitamins, supplements and more intensive treatments like laser therapy have also become popular options to support overall hair health and strength, though results may vary.
Factors to Consider when Choosing a Hair Loss TreatmentWhen choosing a hair loss treatment, consider the following factors:
Hair loss can be distressing, but not all hair loss requires a doctor's visit. You may want to consider seeing a doctor if you experience:
Consulting a healthcare professional can help determine the underlying cause of your hair loss and guide you toward the most effective treatment plan.
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