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- Presentation
New Topical Therapies for Psoriasis and the Definition of Topical Failure
Description
The talk reviewed psoriasis topical therapy, emphasizing that topicals remain a cornerstone of care but are often limited by regimen complexity and poor adherence. Traditional treatments like topical steroids, vitamin D analogs, calcineurin inhibitors, and keratolytics remain useful, though steroids require caution because of side effects with prolonged use. The speaker then highlighted two newer FDA-approved nonsteroidal agents: roflumilast, a PDE4 inhibitor available as cream and foam, and tapinarof, an AhR modulator available as cream. Both are once-daily and showed similar efficacy in trials, but roflumilast offers more vehicle flexibility and strong data for scalp and intertriginous disease with good tolerability, while tapinarof has the advantage of a durable remittive effect after discontinuation but can cause more irritation and folliculitis. The speaker shared practical preferences, such as using roflumilast for hair-bearing areas and tapinarof when treatment durability is a priority. The second half addressed undertreatment and defined topical failure: patients who cannot achieve clear or nearly clear skin after two consecutive four-week topical courses, especially those with extensive disease, high-impact sites, or meaningful quality-of-life impairment, should be considered candidates for systemic therapy. The overall message was to use topicals thoughtfully, recognize when they are insufficient, and avoid prolonged undertreatment.
View moreConclusions
- Topical therapy remains a cornerstone of psoriasis care, but it is often too complex and burdensome for patients to use consistently.
- Poor adherence is common with topical regimens, and treatment complexity and dosing frequency are major contributors.
- Roflumilast and tapinarof are effective newer non-steroidal topical options that expand treatment choices beyond older agents.
- Roflumilast is especially useful for scalp, hair-bearing, and intertriginous areas because it comes in both cream and foam formulations and is generally well tolerated.
- Tapinarof offers similar short-term efficacy to roflumilast, but its key advantage is a durable remittive effect after treatment is stopped.
- Tapinarof may be less practical for some body sites because it is only available as a cream and can cause more irritation and folliculitis.
- Choice between the new topicals should be driven by body site, vehicle preference, tolerability, need for scalp delivery, and whether off-treatment durability is a priority.
- Many patients remain undertreated with topicals alone even when disease burden suggests they should be receiving systemic therapy.
- Topical failure should be recognized as a formal reason to escalate psoriasis treatment rather than waiting for obvious widespread disease.
- A practical definition of topical failure is inability to reach clear or nearly clear skin after two consecutive four-week topical courses.
- Patients with high-impact sites or major quality-of-life impairment may warrant systemic therapy even when overall body surface area is low.
- Greater attention to topical failure and undertreatment should improve treatment selection and patient outcomes in psoriasis.
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