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Competing Interests: Conflicts of interest Dr Bhutani is a principal investigator for trials sponsored by AbbVie, Castle, CorEvitas, Dermavant, Galderma, Mindera, and Pfizer. She has served as an adviser for AbbVie, Arcutis, Boehringer Ingelheim, Bristol Myers Squibb, Janssen, Leo, Lilly, Novartis, Pfizer, Sun, and UCB. Authors Spencer, Jin, and Elhage as well as Drs Davis, Hakimi, and Liao have no conflicts of interest to declare.

Introduction: Halobetasol propionate foam has been established as an efficacious and easy-to-use topical treatment for adults with plaque psoriasis. Its recent approval in the United States expanded its use for adolescents from ages 12 to 17 years old., Areas Covered: We briefly summarize the chemistry of halobetasol and review clinical trials involving halobetasol propionate 0.05% foam to evaluate its efficacy and safety profile with a specific focus on adolescents with plaque psoriasis., Expert Opinion: Halobetasol propionate 0.05% foam is an effective and cosmetically elegant superpotent topical corticosteroid, with a tolerable safety profile in adolescents. The use of this foam offers another option to address patient-specific needs and preferences, adding to the toolbox of currently available treatments for adolescent psoriasis.

Purpose: Interleukin (IL)-17 and IL-23 inhibitors are the newest biologic agents used in the management of moderate-to-severe psoriasis. Active comparator studies allow for direct comparison of different biologic agents. We sought to systematically investigate the efficacy of newer biologic agents compared to earlier biologics., Materials and Methods: We conducted a literature search for randomized control trials that compared the efficacy of a biologic agent with an active comparator. Articles from January 1 2010 to June 26 2017 were searched. Reference lists were also reviewed for studies for inclusion., Results: Twelve studies were included, a majority being phase III trials. All of the studies compared the efficacy of IL-17 and IL-23 inhibitors with adalimumab, etanercept, or ustekinumab with the exception of one study that compared the efficacy of ustekinumab with etanercept. IL-17 and IL-23 inhibitors consistently demonstrate superior efficacy over TNF inhibitors and ustekinumab as assessed by 75%, 90%, and 100% improvement in baseline Psoriasis Area and Severity Index (PASI) scores at week 12., Conclusions: Overall, IL-17 and IL-23 inhibitors appear to demonstrate superior efficacy and more rapid clinical improvement when compared to older biologic agents. This review may help predict patient outcomes, manage patient expectations, and biologic agent utilization.

Background: The development of biologic agents directed against distinct cytokines and receptors has advanced the therapeutic options available for psoriasis patients. Evidence from preclinical studies suggests that IL-17 may contribute to the pathogenesis of psoriasis. Objective: The objective was to review the safety and efficacy profile for each IL-17 inhibitor by evaluating phase III clinical trial data. Methods: We reviewed the results of phase III clinical trials for the IL-17 inhibitors secukinumab, ixekizumab, and brodalumab. Results: At week 12, the proportion of patients reaching Psoriasis Area and Severity Index (PASI 75) was above 60% for the most efficacious dose of each agent with favorable and comparable safety profiles. The most commonly reported adverse events were nasopharyngitis, headache, and upper respiratory tract infection. Conclusions: The clinical improvement among psoriasis patients on IL-17 inhibitors is similar or superior to the improvement seen with commercially produced biologic agents available accompanied by a favorable short-term safety profile. The results of the phase III trials indicate that IL-17 inhibitors are effective therapeutic options for psoriasis patients.

Introduction: Guselkumab is a human monoclonal antibody targeting the p19 subunit of IL-23 that has been approved for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. This medication blocks the IL-23/IL-17 axis, which has been implicated in playing a key role in the pathogenesis of psoriasis. Areas covered: This review outlines the pharmacologic properties, safety, and efficacy of guselkumab for the treatment of plaque psoriasis. Expert commentary: Guselkumab is the first IL-23 specific inhibitor to be approved for the treatment of plaque psoriasis. Phase II and III clinical trial results have demonstrated excellent safety and efficacy of guselkumab. IL-23 inhibitors may offer potential benefits over existing therapies for moderate-to-severe plaque psoriasis in terms of safety, frequency of administration, and efficacy. Long-term safety data will be critical in evaluating the role of guselkumab in the treatment of psoriasis.

The largest proportion of psoriasis patients are candidates for topical treatment rather than treatment paradigms encompassing systemic, biologic and apremilast, and phototherapy, making skillfulness with topical therapy of paramount importance. As such, numerous studies have been conducted to demonstrate the benefits of using topical therapy in combination with other therapies. In addition, innovative uses of otherwise conventional methods, such as proactive use to minimize flare, have been developed. This article reviews five types of strategies for improved efficacy from topical agents beyond monotherapy. These strategies include proactive use, rotational therapy, sequential therapy, using topical agents to shorten the onset of therapeutic action for slower internal agents or phototherapy, and combination use for added efficacy. Each of these is reviewed in detail.

Atopic dermatitis (AD) is a common inflammatory dermatosis characterized by pruritus, erythema, induration, and lichenification. Current treatment options for generalized atopic dermatitis are limited and have potentially serious adverse effects, especially in patients with severe, chronic AD who frequently require systemic anti-inflammatory agents. Apremilast, an oral phosphodiesterase-4 inhibitor, was FDA approved in September 2014 for the treatment of moderate-to-severe plaque psoriasis. However, its upstream anti-inflammatory effects, ease of use as an oral agent, and mild side-effect profile make it an interesting treatment option for AD as well. Herein, we present a patient with a life-long history of AD recalcitrant to topical steroids and cyclosporine who attained subjective and objective improvement in pruritus and erythema after 10-week treatment with apremilast.

Background: Alefacept (Amevive®) was the first biologic agent to be approved by the FDA for use in moderate to severe chronic plaque psoriasis and remains one of the safest systemic agents. However, alefacept is the least utilized of all the biologic agents due to the finding that it is only effective in a small proportion of patients and its maximal efficacy is not seen until approximately 6 weeks after treatment completion., Objective: To determine whether intralesional injections with a biologic agent can predict who will be a responder or a non-responder to the medication., Methods: This was a single-center 22-week study consisting of three phases: i) intralesional injection to a target plaque, ii) intramuscular alefacept injections for 12 weeks (standard dose) and iii) post-treatment follow-up., Results: There appears to be a perfect correlation between patients who show a response to an intralesional injection of alefacept to a small, target plaque and those who eventually respond to a full 12-week systemic course of the medication (achieve at least 70% improvement in their PASI scores from baseline) (p = 0.0003)., Limitations: This study had a small sample size and was limited by the fact that it was open-label without a control arm., Conclusion: The results from this pilot study demonstrated that alefacept appears to work intralesionally and this may be usable to predict systemic response. More importantly, these results strongly suggest that a biologic agent can work locally - a novel concept that contradicts the common notion that biologic agents must work "systemically".

The availability of new biologic agents for the treatment of psoriasis provides hope for improved quality of life outcomes. However, the way patients come to use biologics, the potential barriers they encounter, and their attitudes towards using these medications are still not well studied. Here, we conducted a survey of 106 psoriasis patients at an academic medical center to discern patient attitudes towards biologics. We found that most patients learn of biologics through their physician and perform follow-up research using the Internet. Most patients did not find it difficult to make the decision to start a biologic. Difficulty in obtaining biologics was associated with age less than 55 (p = 0.01), lower income level (p = 0.007), and lack of insurance (p = 0.04). Patients were found to have high satisfaction and compliance rates on biologics. Of patients who missed a dose of their biologic, this was mainly due to logistical reasons such as not having the medication or forgetting to take it, rather than being depressed or overwhelmed. Patients with lower income levels had increased cut backs in personal expenses due to co-payments (p = 0.001). Among respondents, the mean annual out-of-pocket expense for a biologic was $557.12 per year, with a range of $0-7000.

Progressive multifocal leukoencephalopathy (PML) is a frequently fatal demyelinating disease of the brain caused by activation of the John Cunningham virus. It typically occurs in immunocompromised patients, including transplant recipients on immunosuppressant medications, patients receiving chemotherapy for hematologic malignancies, and patients with human immunodeficiency virus. Unfortunately, there is no effective treatment for PML. By contrast, reversible progressive leukoencephalopathy syndrome (RPLS) is a generally treatable disorder that is diagnosed based on clinical symptoms (eg, altered mental status, visual abnormalities, headache, and seizures) and neuroradiographic changes (eg, cerebral edema). It is classically associated with malignant hypertension and immunosuppressive medications. Symptoms usually resolve over time, or with treatment of the underlying cause. Amid the relatively recent withdrawal of efalizumab from the US market because of its association with PML, and the added warning found on ustekinumab describing RPLS as a possible adverse effect, there has been an increasing level of concern in dermatology that biologics and other systemic medications used in the treatment of psoriasis may be related to an increased risk of specific leukoencephalopathies. In this review, we evaluate the association of prebiologics (eg, cyclosporine, methotrexate, acitretin) and biologics (eg, adalimumab, alefacept, efalizumab, etanercept, infliximab, rituximab, and ustekinumab) with the potential risk of developing PML and RPLS.

Background: Alefacept is a remittive treatment for generalized psoriasis but is rarely used due to its erratic efficacy., Objective: To determine if psoriasis plaques will respond to intralesional alefacept and if this predicts a systemic response to intramuscular (IM) alefacept., Methods: We describe a 25-week, single-center, open-label study. Patients received weekly intralesional alefacept of increasing concentrations into target plaques for 3 weeks followed by IM injections for 12 weeks and concluded with an observation period of 9 weeks. The psoriasis area and severity index (PASI) was used to assess the efficacy of IM alefacept., Results: Interim results are reported for the first seven patients enrolled. Two patients responded intralesionally to the most dilute 1:100 concentration of alefacept to sterile water and achieved a 59% and 100% improvement in PASI. Five patients did not respond intralesionally to the most dilute form of alefacept and none achieved PASI 75. Two of these five patients did not respond to any concentration and achieved a 26% and 38% improvement in PASI. Limitations to this study include a small sample size and being non-placebo-controlled., Conclusion: Alefacept is effective intralesionally and may predict a systemic response - challenging the concept that biologics must work systemically.

Occlusive therapy with or without topical agents is effective in the treatment of psoriasis. This study assessed the efficacy and safety of an occlusive hydrogel dressing. Participants were treated with calcipotriene 0.005%-betamethasone dipropionate 0.064% ointment with and without a hydrogel patch. Thirty participants completed the 6-week, bilaterally controlled, investigator-blinded, single-center study. Substantial reductions in total modified psoriasis area and severity index (PASI) scores of occluded lesions versus nonoccluded lesions were seen as early as the first week of treatment and sustained through 4 weeks of the study. No adverse effects related to the study, including skin irritation, were observed or reported. Hydrogel dressings provide an effective and safe occlusive option to enhance topical therapy for psoriasis.

Psoriasis is a chronic disease that exists in two phases: (1) the acute, flaring phase when psoriasis is highly inflamed, erythematous and pruritic and (2) the chronic, indolent phase after the acute manifestations are brought under control. Ideal therapies for psoriasis must focus on both of these phases. Therefore, a rapid and effective agent must be utilized to treat the acute phase, followed by safe long-term therapy for maintenance. This article proposes a new, effective sequential topical therapy for psoriasis using ongoing treatment with clobetasol (Clobex®) spray for one month followed by calcitriol (Vectical®) ointment for the next month. This strategy provides a highly effective, reliable and safe treatment option with minimal local and systemic adverse risks.