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Arcutis Zoryve July 2023

What are your thoughts on topical roflumilast as becoming standard of care and gradual shifting away from topical corticosteroids?

Psoriasis

You. So this is a controversial question, and I think that to some degree, topical corticosteroids are going to be the anchor. They're a keystone of dermatology, and it's going to be very hard to push them out of that position for a long time. And there are a few reasons why. The first reason is that we have an unparalleled amount of experience with them. We have really more than 60 years of experience with them in the real world world. So we know a lot about them. The devil that you know versus the devil that you don't know. The second is that they are incredibly accessible. Almost everybody can afford a topical steroid. Almost every insurance plan, be it government sponsored or private insurer, is going to cover that. Or even if they can, a cash pay patient can often spend what usually amounts to less than $10 or $20 to get a fairly large quantity of topical steroid, at least ideally. Sometimes there are shenanigans that happen, but they're very accessible. And then the third piece is that I do think they can be used very, very broadly. Almost every single patient you put a topical steroid on, they are going to see some improvements. So just the fact that they are broadly applicable means that they're hard to beat. That being said, essentially 100% of my patients have been on at least one, sometimes multiple, topical corticosteroids over the months or years leading up to the time when they've seen me. And many times they're very frustrated. They've been given the same prescription over and over. Maybe they've had a side effect. Maybe they're concerned about side effects. And so I really think that if not, if, we can't bump them from the first line, and again, that may not even be appropriate. I really would like to get people thinking about the next step. So for the mildest patient who does use just a little bit of topical steroid intermittently, leave it be. I don't think I have a beef with that. That's fine, but it's for the patient that either is overusing the steroids, constantly needing them, and maybe isn't even getting to where they need to be in terms of safety. It's like if I put it on every day for two months, yes, those plaques improve, but then as soon as I stop, it's right back. So I'm basically putting on high potency topical storage continuously to an area of skin, which I think is a bad idea. So I'd like to avoid those. Or for people that have maybe had an issue and don't want to use them. And I have to respect that. I think obviously if costs were the only consideration, then the answer would be no. But I think that we're a little bit more sophisticated than that. It's not just a cost basis for how we make decisions for healthcare. It's a shared decision making process. And I have a lot of patients who are concerned about steroids. Now sometimes the answer really is a steroid. If they're using a lot of other non steroidal things and are still struggling, I say, listen, I think we need to think about incorporating those. But for a patient who's maybe mild or moderate and is responding to a non steroidal agent, I think it would be really nice for a patient who says, listen, I've had some issues or I have some concerns about steroids, I'd like to go non steroidal. And I really do think that for those patients, they potentially could use monotherapy with non steroidals. And increasingly so as we get newer and better ones. So it might not even just be one non steroidal agent. Perhaps we're going to pair it with other things, or again, this rotational therapy, maybe they'll do phototherapy for a while and then use one of these non steroidals. So we have some options for that.

What are your thoughts on topical roflumilast as becoming standard of care and gradual shifting away from topical corticosteroids?

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