Journal of Clinical and Aesthetic Dermatology

Updates on Psoriasis & Cutaneou Oncology

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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S15 P r o c e e D i n G s JCAD jOUrnAl Of ClInICAl And AEsthEtIC dErMAtOlOgy september 2017 • volume 10 • number 9 • supplement variable domain (DvD) drug that inhibits tnf and il-17 (aBt-122), and guselkumab. a novel selective t-cell costimulator (abatacept) used to treat rheumatoid arthritis and juvenile idiopathic arthritis was recently evaluated in the astraea trial (eecacy and safety of subcutaneous abatacept in adults With active Psoriatic arthritis [astraea] nct01860976) and was shown to be edective against Psa and well tolerated, even in patients previously exposed to tnf inhibitors. 31 new agents that help to inhibit JaK pathways are being explored for their potential role in treating psoriasis and rheumatic diseases. 32 the two best known JaK inhibitors are tofacitinib and ruxolitinib. in a randomized placebo- and active- controlled, double-blind, Phase 3 study, Psa patients were randomized to one of fve groups: oral tofacitinib 5mg twice daily (n=107), tofacitinib 10mg daily (n=104), subcutaneous adalimumab 40mg once every two weeks (n=106), placebo patients who were migrated to tofacitinib 5mg twice daily at the end of three months (n=52), and placebo patients who were migrated at three months to 10mg of tofacitinib twice daily (n=53). 33 tofacitinib was signifcantly superior to placebo on the american college of rheumatology and 20-percent improvement (acr20) response rates and improved scores on the Health assessment Questionnaire Disability index at three months. safety was similar in all groups. the oPal BeyonD trial (tofacitinib in Psoriatic arthritis subjects with inadequate response to tnf inhibitors nct01882439) examined tofacitinib's edectiveness in 395 patients with Psa who did not respond to tnf inhibition therapy. 34 edectiveness with tofacitinib was superior to placebo in acr20 response and improved scores on the Health assessment Questionnaire Disability index with superiority becoming evident as early as the frst assessment (Week 2). no new safety risks emerged in this study. tOPICAl thErAPIEs fOr PsOrIAsIs the vehicle for topical products plays a large role in edectiveness, safety, and patient satisfaction. for example, topical calcipotriene produced marked improvement in more patients (70%) as an ointment compared to solution (31%), foam (41%), or cream (50%). However, skin irritation is markedly lower in the solution and foam formulations; calcipotriene ointment and cream have rates of skin irritation around 10 to 15 percent. this gives rise to the question as to whether "designer vehicles" can be created to help optimize drug penetration into the skin, skin permeation rates, and how well the active ingredients are absorbed into the receptor guid. to this end, a novel betamethasone dipropionate (BD) emollient spray was formulated, aimed at gaining better epidermal penetration in skin adected by psoriasis while minimizing systemic absorption. this new formulation was compared with super-potent augmented BD 0.05% lotion in adults with moderate plaque psoriasis. 35 Patients in this study (n=351) were randomized to receive augmented BD or the new emollient spray or vehicle alone to be applied twice a day to adected areas for two weeks. the primary endpoint was an iGa score of 0 or 1 and at least two-grade improvement over baseline. at baseline, the mean Bsa adected by psoriasis in patients was about 13 percent. the primary endpoint was achieved at two weeks in 19.0 percent of the emollient spray patients, 18.9 percent of the superpotent augmented BD lotion patients, and 2.3 percent in the vehicle patients (spray was signifcantly better than placebo, p<0.001). response was rapid, with 10 percent of patients responding to the emollient spray at eight days versus 6.7 percent of augmented BD patients and 1.2 percent of vehicle patients. all products were well tolerated but signifcantly more patients reported burning or stinging with augmented BD compared to the emollient spray (13.6% vs. 4.1%, p=0.006). 35 combination therapy may be an important consideration in topical therapy of psoriasis. the rationale behind combination therapy is to enhance eecacy by using multiple products with complementary mechanisms of action while, when possible, reducing side edects by using lower doses of each medication. 3 6 for example, topical combination therapies have been proposed with the aim of reducing steroid use while still providing safe, edective treatment. in a three-arm study of calcipotriene ointment 0.005% applied mornings and halobetasol propionate 0.05% ointment applied evenings, this combination therapy was compared to the twice-daily use of either product alone (n=127). 37 at two weeks, the calcipotriene/halobetasol combination group had signifcantly improved results in the treatment of psoriasis and fewer cutaneous adverse edects than either of the two components applied in monotherapy. lesional or perilesional irritation, a side edect sometimes reported with calcipotriene ointment monotherapy, did not occur in the combination group. 37 this study terminated at two weeks. to assess the durability of therapies, a double-blind, placebo-controlled study of the 40 patients in the prior study who achieved 50-percent or greater improvement were then randomized to receive either halobetasol ointment twice daily on weekends and calcipotriene ointment twice daily on week days (n=20) or halobetasol ointment twice daily on weekends and placebo ointment twice daily on weekdays (n=20). at six months, 66 percent of the combination patients were able to maintain remission compared to 40 percent of the control patients. 38 the drawback with combination therapy that relies on two diderent products is that it may be too complex, inconvenient, or burdensome for patients to manage self-

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