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.