Integrating Nonsteroidal Topical Therapies in Plaque Psoriasis Care

“The conversation really focused on adding either roflumilast or tapinarof cream, and the most important thing that was highlighted multiple times during the evening was access,” said Benjamin Lockshin, MD, FAAD, during a recent Dermatology Times Case-Based Peer Perspectives custom video series, “Navigating Plaque Psoriasis Treatment: Topical Innovations Beyond Steroids.”

Lockshin is a board-certified dermatologist, assistant professor at Georgetown University’s Division of Dermatology in the Department of Medicine, and director of the Clinical Trials Center at U.S. Dermatology Partners in Rockville, Maryland. He hosted a live Case-Based Roundtable® discussion with local dermatology clinicians to discuss 3 patients with plaque psoriasis who were not responding well to topical corticosteroids.

Case 1: Moderate to Severe Plaque Psoriasis

The first case involved a man aged 55 years with moderate to severe plaque psoriasis, characterized by a Psoriasis Area and Severity Index score over 16 and an Investigator Global Assessment score of 4. The patient presented with extensive plaques on his trunk, arms, and legs, along with common comorbidities such as diabetes, obesity, and gout. Although systemic therapy seemed an appropriate choice given the disease severity, Lockshin and the attendees discussed the complementary role of topical agents in such cases, particularly when systemics are delayed due to insurance or access hurdles.

Lockshin and attendees compared 2 nonsteroidal topical cream options: tapinarof (Vtama; Dermavant Sciences, Inc) and roflumilast (Zoryve; Arcutis Biotherapeutics). Although both were considered effective, many participants favored tapinarof due to its aryl hydrocarbon receptor agonist mechanism, which they found easier to explain to patients. Additionally, tapinarof’s perceived ability to offer a more durable response was seen as a potential advantage over roflumilast, a phosphodiesterase 4 inhibitor. However, clinical experience showed that both agents performed comparably in efficacy.

The patient was previously treated with topical corticosteroids and vitamin D analogues, with limited success. According to Lockshin, vitamin D analogues are rarely used as monotherapy, but they are still necessary in gaining insurance approval for other treatments. The patient was eventually prescribed risankizumab (Skyrizi; AbbVie) 150 mg subcutaneously every 12 weeks, but to address residual lesions, the panel recommended adding tapinarof as “touch-up paint.” All attendees strongly agreed with this approach of combining systemic agents with topical therapies, especially in patients who strive for complete clearance.

Case 2: Psoriasis in a Postpartum Woman With Skin of Color

The second case featured a woman aged 34 years with Fitzpatrick type V skin who developed psoriasis post partum. The plaques initially presented on her elbow but spread to her ankles, thighs, and intertriginous areas after her second pregnancy. This led to significant emotional distress and negatively impacted her quality of life, particularly in her role as a social worker.

Despite the attendees’ consensus that she was a strong candidate for systemic therapy, the patient was adamant about avoiding systemics, citing concerns about adverse effects. She had previously used topical corticosteroids, which resulted in striae and atrophy in her intertriginous areas. Given these concerns, Lockshin and the attendees discussed the potential of nonsteroidal agents such as tapinarof, which was eventually prescribed despite low expectations for success. However, the patient responded remarkably well to tapinarof and showed significant improvement.

According to Lockshin, this case demonstrated the importance of tailoring treatments to patient preferences, even when systemic therapy might be more clinically logical. Additionally, it highlighted the potential of newer nonsteroidal topicals to benefit challenging anatomical areas such as the intertriginous regions.

Case 3: Psoriasis With Genital and Facial Involvement

The final case discussed a White male aged 32 years with moderate to severe plaque psoriasis, primarily affecting areas such as the scalp, forehead, gluteal cleft, and genital area, with a body surface area (BSA) of 4%. Despite the limited BSA, the involvement of sensitive areas led to significant discomfort and itching, particularly around the hairline and genital region. The patient had been on topical corticosteroids and tacrolimus with mixed results. Notably, he found tacrolimus difficult to tolerate due to its ointment formulation, burning sensation, and limited efficacy in thicker, nonfacial plaques.

Given the patient’s dissatisfaction with existing treatments, the discussion shifted to the benefits of newer nonsteroidal topicals such as tapinarof and roflumilast. Lockshin and attendees highlighted how these agents, due to their more elegant cream formulations, offer greater ease of use in sensitive areas such as the face and genital regions.

“One of the participants in the roundtable discussion talked about using roflumilast cream with a hair dye nozzle to help get the cream into hair-bearing areas. And they’ve seen a lot of success with that,” said Lockshin.

The patient was switched to ixekizumab for systemic treatment, given the availability of dedicated studies on its efficacy in treating genital psoriasis. However, the patient continued to use roflumilast for residual plaques on the forehead and other areas, highlighting the value of combining biologics with nonsteroidal topical agents to achieve better patient outcomes.