Advancing Care for Coexisting Psoriasis and Seborrheic Dermatitis

Announcer Introduction
You’re listening to DermConsult on ReachMD. On this episode, we’ll hear from Dr. Raj Chovatiya, who’s a Clinical Associate Professor at the Rosalind Franklin University Chicago Medical School and Founder and Director of the Center for Medical Dermatology and Immunology Research. He’ll be discussing management of coexisting psoriasis and seborrheic dermatitis. Here’s Dr. Chovatiya now.

Dr. Chovatiya:
In the case of seborrheic dermatitis, historically, first-line treatments have usually been antifungals, topical corticosteroids, and topical immunomodulators like tacrolimus or pimecrolimus. And we've actually had a lot of advancement in our understanding of seborrheic dermatitis in the last handful of years as we've realized that this probably is not a primarily yeast-driven disease, but rather, you can think about yeast dysbiosis and overactivity being one of several components driving this disease. There's also some barrier issues at play. There's also some immune dysregulation at play. And so even with corticosteroids, they can chronically sometimes make the barrier worse and thus may not be perfect long-term treatments. And many of these treatments are just not delivered in vehicles that are going to be really helpful for all different types of hair and skin. This, of course, is really highlighting some of the limitations that our antifungal shampoos have as they're very drying, but also greasiness can come with a lot of our corticosteroids.

So one of the biggest advancements we've seen in the last few years is a topical therapy called roflumilast that's delivered as a foam to the scalp and the face region or anywhere else seborrheic dermatitis might be involved. And it has some really compelling phase three clinical data to suggest that correcting the immune dysregulation in this disease can remit a lot of the symptoms. In the case of psoriasis, there's some overlap with what I discussed. Topical steroids, vitamin D analogs, immunomodulators, or even retinoids are historically what was used. And then typically systemic agents when you're not getting to where you want to with topicals.

Knowing the challenge of treating psoriasis, especially in areas that might be hair bearing, like the face and scalp, which are special sites that oftentimes don't respond adequately to topicals, there has always been a big need for either better targeted topical therapies or systemic therapies. And so nowadays, we oftentimes will go down the route of potentially thinking about some of our next generation non-steroidals. So this includes things like roflumilast PDE4 inhibitor in a cream base, or tapinarof, an aryl hydrocarbon receptor modulator that also comes in a cream. And then thinking also about systemic therapies, which could potentially include biologics or oral small molecules as well.

Now, when thinking about overlap cases, treatments might be layered or sequenced in this case. And sometimes you're going to start off with some of the same things with topical corticosteroids, knowing that they oftentimes are not going to be potent or able to used for long enough or have safety concerns, irritancy concerns, or tolerability concerns. Then, you may potentially consider some of those systemic medications that are probably a little more helpful for psoriasis than seborrheic dermatitis.

Advancements in anti-inflammatory therapy, particularly in the topical realm, have actually made it a little easier to treat cases where there might be a couple things going on, or it's very difficult to dissociate between two different conditions. Roflumilast, a phosphodiesterase-4 inhibitor, is one great example as it currently is approved for seborrheic dermatitis and psoriasis, both of which in a foam base as well as a cream base for psoriasis. So that's actually been a big game changer for hair-bearing seborrheic areas where sometimes we believe that there is an overlap in these conditions.

Now, it's important to note that if there is misclassification of conditions and you're really dealing with one or the other, there's always the risk of overtreatment or even mistreatment, especially if you're thinking about a targeted therapy. So in instances where you don't necessarily have a one-target-fits-all treatment like a phosphodiesterase-4 inhibitor, it's really important to tailor your treatment to the dominant pathology.

Announcer Close
That was Dr. Raj Chovatiya talking about treatment approaches for overlapping psoriasis and seborrheic dermatitis. To access this and other episodes in our series, visit DermConsult on ReachMD dot com, where you can Be Part of the Knowledge. Thanks for listening!