Increasing use of non-traditional vehicles for psoriasis and other inflammatory skin conditions.

BACKGROUND: Although topical corticosteroid ointments were once viewed as the best vehicle for treating inflammatory skin diseases, the recognition of the problem of poor compliance and patients' preferences for other vehicles has led to the development of corticosteroid products in alternative formulations. OBJECTIVE: To describe patterns of use of newer vehicle formulations including foams, shampoos, sprays, and lotions for the treatment of psoriasis and other dermatoses. METHODS: The use of non-traditional vehicles was identified using visit with diagnoses for psoriasis and other dermatoses from the National Ambulatory Medical Care Survey 2000-2010 data. Trends in corticosteroid vehicles mentions were evaluated over the study period to determine how the use of non-traditional vehicles has changed. The odds ratios of being prescribed a nontraditional vehicle were reported for patient and office-based characteristics of visits. RESULTS: Approximately 2.3% and 1.9% of visits mentioned foam and other non-traditional vehicles (shampoo, lotion, spray), respectively. The use of corticosteroids in shampoo, lotion, or spray preparations increased by 0.5% annually (p=0.008) but did not significantly change for corticosteroids in a foam preparation (p=0.10). Psoriasis and seborrheic dermatitis were the leading diagnoses at visits prescribed corticosteroids in nontraditional vehicles. Dermatologists were more likely than non-dermatologists to prescribe foam products [OR: 8.4 (3.6, 19.9)] or clobetasol in another non-traditional vehicle [OR: 49.7 (10.3, 240.5)]. LIMITATIONS: Product vehicle was not specified for all corticosteroids. CONCLUSION: Although there was increasing use of non-traditional vehicles, the rate of use has remained low. Dermatologists appear to have greater familiarity with the use of these newer vehicle formulations than do physicians in other specialties.

Are topical keratolytic agents needed in the treatment of scalp psoriasis?

BACKGROUND: Topical corticosteroids are the primary treatment for scalp psoriasis. Keratolytic agents are promoted as adjunctive treatments. However, complex treatment regimens may result in poor adherence and outcomes. OBJECTIVE: To evaluate the evidence for the need for use of topical keratolytic agents as opposed to topical corticosteroid monotherapy in the treatment of scalp psoriasis. METHODS: A review of the literature was performed seeking clinical trials using topical keratolytics, topical corticosteroids or the combination for treatment of scalp psoriasis. RESULTS: Complete clearance of scalp psoriasis can be achieved in 10-78% of patients using topical corticosteroids alone, in 3% of patients using topical keratolytics alone, and in up to 84% using a combination of topical keratolytics and topical steroids. Clinical trials comparing the combination of keratolytics and topical corticosteroids versus topical corticosteroids alone found marginally more efficacy using combination regimens. LIMITATIONS: We could not find any long term study evaluating the efficacy of combination therapy in scalp psoriasis and its effect on the patients' adherence. CONCLUSION: High potency topical corticosteroids are usually effective in treating scalp psoriasis in clinical trials. Poor efficacy in clinical practice may be owing to poor adherence to the treatment regimen. Using a keratolytic agent in conjunction with a topical corticosteroid may provide marginal additional benefit in clinical trials, but that benefit is likely outweighed by the downside of complicating treatment and reducing adherence in the clinical setting, unless a single product containing both medications were used.