Rethinking the Routine: Moving from Topicals to Systemics in Psoriasis

Announcer:
This is DermConsult on ReachMD. Today, we’ll hear from Dr. Christopher Bunick, who will be sharing his insights on sequencing psoriasis therapies. Dr. Bunick is an Associate Professor of Dermatology at the Yale School of Medicine in New Haven, Connecticut.

Let’s hear from him now.

Dr. Bunick: 
So, when it comes to sequencing, it’s challenging. You talk to 20 different dermatologists, and you’re going to get probably 20 different answers in how they sequence their psoriasis therapies. So I can speak about what I do, but I don’t necessarily think there’s always a right or wrong. I do think there’s an evidence-based approach and there’s a standard of care approach, which is what I try to do. So, for example, I’m generally trying to get patients onto a systemic therapy, not because I think, with systemic therapies, that, “Oh, we need to only push systemic therapies,” but it’s because most patients with topicals are inadequately treating their skin; they’re hard to stay compliant; they’re complaining about their topical therapies; and they’ve been cycling a lot of different topical therapies, both steroidal and nonsteroidal. But also, we now have definitions from the International Psoriasis Council of what a topical failure is. If I’m treating someone or if someone comes to me and they have used two consecutive four-week trials of a topical therapy and they’re not clear or almost clear, then our own guidelines now, our own recommendations from the International Psoriasis Council, tell us we should be moving to systemics and that these are systemic-eligible patients. I also, in my sequencing, made a big point of emphasizing that psoriasis is a systemic inflammatory disease. There are consequences elsewhere inside the body, whether it’s the joints or whether it’s the heart and the blood vessels. When we think about the cardiovascular risks that occur in psoriasis patients, we cannot simply just sit on topicals for very long if there’s active systemic inflammation. So I’m a big believer in getting from those topicals to those systemic therapies.

That being said, I think that when you have a patient on a systemic therapy, whether it’s oral or biologic, and they have a little bit of active disease, that is an amazing opportunity to use the advanced nonsteroidal therapies that we have in psoriasis. I’m a big fan of roflumilast. I think its potency is something to celebrate. I think it works very well. You also have tapinarof. You have other therapies you can use if you to go to the old therapies, such as tacrolimus, but I think your new ones, especially roflumilast and tapinarof, are really good options.

Announcer:
That was Dr. Christopher Bunick discussing how to effectively sequence psoriasis therapies. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!