Yin-Yang Strategy: Proposing a New, Effective, Repeatable, Sequential Therapy for Psoriasis
August 2011 | Volume 10 | Issue 8 | Original Article | 831 | Copyright © 2011
Tina Bhutani MD, Kristine B. Zitelli MD, John Koo MD
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.
J Drugs Dermatol. 2011;10(8):831-834.
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Psoriasis affects nearly 7.5 million Americans and 125 million people worldwide.1 It exists in two phases: the acute, flaring state and the chronic, indolent state. We designate the acute stage as "Fire" and the chronic phase as "Ember" for the purposes of this review. Fire represents the acute phase when psoriasis is highly inflamed, very erythematous, pruritic and flaring. Ember refers to what happens after the acute manifestations are brought under control—the phase in which maintenance therapy is needed to keep the persistent plaques from returning to a flaming, acute phase.
Dermatology as a specialty has been struggling to attain two goals with regard to topical therapy for psoriasis. The first goal is to provide rapid and highly reliable, very effective treatment for the acute Fire phase of psoriasis. The second goal is to provide a safe, long-term maintenance therapy for the more chronic Ember phase with virtually no deterioration from the state of improvement attained in the first phase.
This has been a long and difficult struggle since even the strongest of topical therapies, namely the super potent class I topical steroids, are not always able to attain the first goal of rapid clearing. Moreover, the less potent steroids and non-steroidal topicals that are safer and more suited for a maintence role often prove inadequate to sustain all of the improvement achieved during the first phase of treatment.
However, recently there are two new agents for the management of Fire and Ember. First is clobetasol (Clobex) spray and the second is calcitriol (Vectical) ointment. These two new additions to our topical therapy armamentarium may make the attainment of both of the above goals a reality. It may now be possible to provide rapid and extremely effective treatment for Fire and offer a way to control Ember with essentially no deterioration. This "rabbit" (clobetasol spray) to "turtle" (calcitriol ointment) approach is the essence of sequential therapy strategy. Moreover, with optimized strategy, this can be accomplished with virtually no risk of cutaneous or systemic serious adverse reactions. The following describes this strategy in detail.