Yin-Yang Strategy: Proposing a New, Effective, Repeatable, Sequential Therapy for Psoriasis

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.

Clobetasol Spray: Class "Zero" Topical Steroid

The authors of this manuscript are aware that there is no such category as class zero in the topical steroid classification system. However, an evidence-based stance argues that perhaps there should be with regard to clobetasol spray. As seen in Table 1, which reflects efficacy data of various FDA approved clobetasol agents, clobetasol spray has an efficacy at least twice that of all other clobetasol preparations in terms of percentage of patients who achieved a "clear" or "almost clear" status in two or four weeks of use. It is well accepted that the same steroid molecule, such as betamethasone, can be appropriately placed in several different categories of topical steroid potency. By such criteria, the data in Table 1 indicate that all clobetasol agents are not created equal. Clobetasol spray appears to have demonstrated efficacy above all other clobetasol agents and might be clas-