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[LIVE BLOG] Managing Your Plaque Psoriasis Patient with Sequential Therapy (Product Theater)

In this Live Blog from the 10th Annual Fall SDPA Conference in Las Vegas, Dr. Del Rosso presents on a Product Theater for Galderma: Clobex spray and Vectical ointment.  
Dr. Del Rosso reminds us that plaque psoriasis tends to take a longer time to control and can be resistant to many treatments.  Putting patients on high potency medicine long-term is not a realistic option, and this is where you have to be creative in your therapies.  With sequential therapy, a stronger, high potency topical steroid can initially reduce or clear the plaque and the management of the remaining underlying abnormalities can be managed through a Vitamin D ointment.  This is where the combination of Clobex Spray and Vectical Ointment can be implemented.  
Plaque Psoriasis: Pathophysiology
Clinical hallmarks:
+ scaling
+ erythema
+ plaque elevation
Histological Hallmarks of Psoriasis
+ Inflammation
-T-cell infiltrate
-Cytokines and Chemokines
-AMPs secreted by keratinocytes, neutrophils
+ Hyper-proliferation
+ Abnormal cellular differentiation
-Immature keratinocytes in stratum corneum lead to breakdown of barrier
+Proliferation of the skin
-This is where Vitamin D Topicals come in!
Topical Steroids
Topical steroids are highly effective for resolving plague psoriasis lesions because of their anti-inflammatory and anti-proliferative properties.  They are not selective; they are like the electrician that goes straight to the fuse box in the house and shuts the whole thing down.
However, it should be noted that the structural abnormalities persist in lower layers after visual lesion resolution.  Lower layers of the epidermis remain deregulated in quiescent lesion sites.  This is one reason why re-flaring tends to occur in the same place.  
When you clear up the plaque with Clobex spray and get a great response, you are not done.  It may appear to be an inactive area but, genetically, the tendency of psoriasis is still there.  This is why in sequential therapy, Clobex can be used initially when you need to get thick plaques under control.  
Keep in mind that a lot of Topical Steroid have on the label “2 weeks of use”. For Clobex, usage is fine for up to 4 weeks
Vitamin D Regulates Cellular Differentiation 
Restoration of normal epidermal structure
Effects of treatment with topical Calcitriol
+ restoration of granular layer
+ reduced acanthosis and parakeratosis
+ marked reduction in hyperproliferation and normalization of keratinization
+ reduction in inflammatory cells penetrating the epidermal layer
Having Vitamin D analogue helps some of the non-visible changes
Topical Vitamin D is important for longterm management (not maintenance: this implies that the disease is totally clear, but there is always underlying disease.) You need something to continue the improvement process.  Calcipotriene has demonstrated ability to normalize cell differentiation and delay plaque recurrence.
Step 1: Get the disease under control.
Step 2: Sustain the benefit.
Summary of Tolerability
Itching will not be as severe, but some patients will have Pruritus as a side effect
When plaques go away, you may see telangiectasia. 
Adverse Events
Majority are mild
Stinging or burning is related to the steroid
Summary Sequential Treatment Regimen
Clobex Spray for up to 4 weeks, with 8 weeks of Vectical
Many patients had improvement without any safety signals of concern.
What is going on underneath the disease?  Just because the disease gets better, you need to know that maganging the underlying issues that will only bring it back. This can’t be treated long term with steroids.

[Image by Brian Talbot]

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