Psoriasis is a tricky disease to manage, as inconveniences and side effects loom with each type of treatment. Anyone who watches TV has heard the list of potential adverse effects, given that ads for psoriasis treatments apparently outnumber goofy ads for car insurance.
Topicals – creams, ointments, foams and lotions applied directly to affected areas of the skin – don’t get as much TV time as their systemic biological counterparts, self-injectables with catchy theme songs, where the smiley and the sleeveless walk confidently down the street and/or swim. But two new nonsteroidal topicals were introduced this year – Vtama from Dermavant Science and Zoryve from Arcutis Biotherapeutics – and each solves a long-standing problem that plagues millions of psoriasis patients. There is no limitation of duration of use.
How to quantify gravity
Psoriasis patients have a faulty immune system that mistakenly attacks the body by overproducing skin cells, resulting in a buildup of scaly plaques. Those who develop psoriatic arthritis struggle with joint pain and inflammation.
When categorizing the severity of psoriasis, it is usually defined by the total amount of skin surface covered in plaques. Less than 3% is considered mild, 3-10% moderate, and anything above 10% is severe. In other cases, the location of the affected areas can influence the level of severity. When sensitive areas like the face, palm of a hand, or sole of a foot are inflamed, a diagnosis of severity is possible due to pain or discomfort felt during even the most basic movements.
First in class
In May, the United States 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 got approval for its Zoryve cream (roflumilast). Both are once-a-day treatments.
For moderate to severe cases, systemic biologics work to suppress the immune system and relieve skin and joints. For less severe cases, doctors traditionally prescribe topical corticosteroids, vitamin D analogues, and retinoids.
Vtama and Zoryve have different mechanisms of action, but are grouped into the newer class of new agents that are indicated for all levels of psoriasis severity. 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 for as long as they can. If symptoms remain mild to moderate, patients can continue taking these medications indefinitely.
Vtama and Zoryve work in different ways, but there is no clear superior option and there were no head-to-head trials. And they can still be used in combination with a strong corticosteroid to temporarily treat flare-ups.
Side effects, front and center
Systemic biologics are better for cases of psoriasis that do not resolve with low-potency topicals, so the patient can avoid applying high-potency drugs to large areas of the body. To counteract the high level of steroid absorption into the skin, these treatments can be combined with vitamin D analogues.
Topical corticosteroids block the immune system at the surface where they are applied, while biologics circulate through the bloodstream. When used in moderation, this contributes to better side effect profiles for topicals because they don’t compromise the entire immune system.
Although topical corticosteroids work well and are much cheaper, they have limitations. Low to moderate potency topical corticosteroids are safer, but they don’t work as well. When patients ultimately need to take more aggressive steps in their treatment, high potency options take precedence.
This comes with side effects, some of which are known to cause thinning of the skin. This can lead to cuts and bruises or suppression of the hypothalamic-pituitary-adrenal axis, which is a systemic condition that leads to a decrease in cortisol, a natural stress hormone found in humans. When this hormone is suppressed, the response to stressors (eg, trauma, surgery, inflammation) may be impaired, resulting in an inadequate defense against infections.
Handle it early
Psoriasis is not like a rash or chicken pox, where it appears suddenly, spreads quickly and becomes instantly noticeable. It can start as a small spot on an elbow. It is best to manage it early when the surface area affected is minimal. These first-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 $100,000 or more per year. Vtama, at around $1,300 for a one-month supply, and Zoryve, at around $825 per month, are much more affordable. At a lower cost to health plans and patients, and with the potential for long-term use, nonsteroidal topicals like Vtama and Zoryve are a welcome addition to dermatologists’ arsenals. 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 is part of Goodroot, a business community reinventing healthcare, one system at a time. He has over 30 years of experience as a pharmacist.