David N. Adam, MD, FRCPC1-3; Sonya J. Abdulla, MD, FRCPC4; Patrick Fleming, MD, FRCPC1; Melinda J. Gooderham, MD, FRCPC5; John Ashkenas, PhD6; Clinton B. McCracken, PhD7
1Division of Dermatology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
2Baywood Dermatology and CCA Medical Research, Ajax, ON, Canada
3Probity Medical Research, Waterloo, ON, Canada
4Dermatology on Bloor, Toronto ON, Canada
5Skin Centre for Dermatology, Peterborough, ON, Canada
6imc North America, Toronto, ON, Canada
7LEO Pharma Inc. Canada, Thornhill, ON, Canada
Conflict of interest:
D. Adam has been an investigator, speaker, or advisory board member for LEO Pharma, AbbVie, Amgen, Arcutis, Bausch Health, Boehringer Ingelheim, BMS, Celgene, Coherus, Dermira, Dermavant, Eli Lilly, Galderma, Incyte, Janssen, Merck, Novatrtis, Pfizer, Regeneron, Sanofi Genzyme, Sun Pharma, and UCB. S. Abdulla has been a speaker or advisory board member for LEO Pharma, AbbVie, Celgene, Eli Lilly, Galderma, Janssen, Novartis, Pfizer, Sanofi Genzyme, UCB, and Bausch/Valeant. P. Fleming has received honorarium and/or consulting and/or advisory boards and/or speaking fees for AbbVie, Altius, Aralez, Bausch Health, Cipher, Galderma, Eli Lilly, UCB, Janssen, Novartis, Pfizer, and Sanofi-Genzyme. M. Gooderham has been an investigator, speaker, or advisory board member for LEO Pharma, AbbVie, Amgen, Akros, Arcutis, Boehringer Ingelheim, BMS, Celgene, Dermira, Dermavant, Eli Lilly, Galderma, GSK, Janssen, Kyowa Kirin, Medimmune, Merck, Novartis, Pfizer, Regeneron, Sanofi Genzyme, Sun Pharma, UCB, and Bausch/Valeant. J. Ashkenas received support via imc North America (Toronto, ON) from LEO Pharma Inc. Canada for participating in the development of the practice reflective and for analyzing the findings. He has no other financial interest to declare. C. McCracken is employed by LEO Pharma Inc. Canada.
Patient preferences for psoriasis treatment may affect treatment adherence and disease control; changing topical formulation may improve adherence and patient acceptance of treatment. This study explored dermatologists’ reasons for transitioning psoriasis patients from an ointment or gel (Dovobet®) formulation to an aerosol foam (Enstilar®) formulation of calcipotriol and betamethasone dipropionate (Cal/BD), and to assess the success of this transition. Medical records of 81 Canadian patients from 9 dermatologists were retrospectively reviewed for symptoms affecting quality of life, reasons for transitioning treatment, and whether transition was successful. Reasons for transition included efficacy, quality of life, and patient adherence. At follow-up, median psoriasis severity and body surface area affected had decreased from baseline, and patients experienced improved quality of life. Itch and itch-related sleep loss, which were identified as burdensome in 63% of patients at baseline, had resolved in 33% and improved in 54% of patients at follow-up. Dermatologists deemed the transition successful in 85% of patients, with the most common reasons being patient-reported success, clearance of signs/symptoms, and continued prescription refills. Transition from Cal/BD ointment or gel to aerosol foam was generally deemed successful by patients and dermatologists, and was associated with improved quality of life and improved itch control.
psoriasis; topical treatment; foam; formulation; fixed combination
Psoriasis is a chronic condition that commonly requires topical treatment, either as monotherapy or in combination with phototherapy or systemic treatment. Given the challenge of consistent long-term adherence to treatment for psoriasis,1-3 patient acceptance of topical treatment is an important consideration.4,5 Formulations with more appealing cosmetic features could affect patient acceptance, and therefore adherence and ultimately disease control.6-9
Calcipotriol and betamethasone dipropionate (Cal/BD) are the active ingredients in Dovobet® ointment or gel (Cal/BD ointment or gel) and Enstilar® aerosol foam (Cal/BD foam). Cal/BD aerosol foam has improved skin penetration and is reported to be better accepted by patients, relative to Cal/BD ointment or gel.10 Switching to Cal/BD foam can improve disease control. Significantly more patients using Cal/BD foam achieved a 2-grade improvement according to the physician’s global assessment of disease severity, with their psoriasis being clear or almost clear, by week 4 compared with patients using Cal/BD gel by week 8 (38.3% vs. 22.5%, respectively; P < 0.001).11,12 Given that the active ingredients are the same, comparisons between the products relate purely to formulation.
In this study, medical records of Canadian psoriasis patients who transitioned from Cal/BD ointment or gel to Cal/BD foam were examined retrospectively. The objective was to explore Canadian dermatologists’ reasons for changing topical treatment formulation in these patients and to assess reasons the transition was judged successful or unsuccessful. As patients on topical monotherapy may have different motivations for and success with treatment transition, compared with those receiving concomitant topical and non-topical therapies (i.e., systemic treatment or phototherapy), the study included patients from both populations.
Patients and Methods
In this retrospective chart review, 9 Canadian dermatologists reviewed the medical records of their patients with plaque psoriasis who were previously treated with Cal/BD ointment or gel and were switched to treatment with Cal/BD foam. The study protocol was approved by RRB (Research Review Board Inc., Waterloo, ON, Canada; approval # 2019.538). The need for informed consent was waived due to the retrospective design of the study.
The dermatologists reviewed the medical records from their 10 most recent patients meeting all inclusion criteria: ≥18 years of age, with active psoriasis, and transitioned from Cal/BD ointment or gel to Cal/BD foam at the baseline visit (defined as the visit where the change in treatment occurred). Patients could not have made any change in prescribed systemic treatment or phototherapy from 3 months before to 1 month after the switch to Cal/BD foam. Baseline findings were from the visit during which the dermatologist first prescribed Cal/BD aerosol foam. Follow-up data were from the first subsequent visit, no less than 4 weeks and no more than 32 weeks after the baseline visit.
Using the data collected from the medical records, the dermatologists completed an online questionnaire developed from a pilot study carried out by 3 authors of the current study. The pilot study sought to identify classes of data that could be reliably found in medical records for psoriasis patients seen in normal Canadian dermatology practice. Pilot study data were not included in the current report.
Demographic and clinical characteristics extracted from the baseline visit records included age, gender, symptoms affecting quality of life, the dermatologist’s reasons for transitioning the patient to Cal/BD foam, the number of clinic visits in the 12 months prior to baseline, and history of psoriasis therapies in the 24 months prior to baseline. Patients were considered to be on topical monotherapy if they were using Cal/BD ointment or gel with or without other prescription or non-prescription topical agents, but without systemic treatment or phototherapy. Conversely, patients were considered as on combination therapy if they were using Cal/BD ointment or gel concomitant with phototherapy or systemic therapy. Physicians submitted their findings for each patient electronically until they had completed 10 reports. After the seventh report of patients in one class of treatment (topical monotherapy or combination therapy), the physician received an automatic reminder that both classes should be represented among their 10 reports.
The dermatologist’s assessments of psoriasis severity, as noted in the medical records, for the patient’s lifetime worst severity, severity at baseline, and severity at follow-up, were reported in the questionnaire using a 5-point scale (0 = absent; 1 = mild; 2 = moderate; 3 = severe; 4 = very severe). Estimated percent body surface area (BSA) affected by psoriasis was extracted from the baseline and follow-up visits. The dermatologist’s assessments of improvement in quality of life, the impact of Cal/BD foam on overall psoriasis disease and itch or itch-related sleep loss, and whether the transition to Cal/BD was successful, were extracted from the records of the follow-up visit. Improvement in quality of life was rated on a 4-point scale (0 = no improvement; 4 = significant improvement). The level of impact on overall psoriasis disease and itch or itch-related sleep loss was rated as ‘Worsened’, ‘Same’, ‘Improved’, or ‘Resolved’. Dermatologists were asked to identify one or more specific signs or symptoms with the greatest impact on quality of life. If the patient’s record did not include the relevant information, dermatologists indicated ‘Unknown/Not documented’.
Descriptive statistics were analyzed using Microsoft® Excel for Mac version 16.40 and reported as mean ± standard deviation (SD), median (range), and proportions. Missing data were not imputed, and the results for each variable were reported based on the number of patients for whom data were available.
Nine dermatologists completed questionnaires for 10 patients each. Of those 90 questionnaires, 9 were excluded, leaving 81 patient records for analysis. Reasons for exclusion were that insufficient data were included (n = 1), Cal/BD foam was not used between baseline and follow-up (n = 4), and the follow-up visit was not within the 4 to 32-week timeframe (n = 4).
Baseline demographic and clinical characteristics are shown in Table 1. More patients were on monotherapy than on combination therapy. Psoriasis at lifetime worst was less severe in patients on topical monotherapy vs. combination therapy. The most commonly affected body areas were the legs, arms, trunk, and scalp.
|Baseline characteristic||All patients|
(N = 81)
|Patients on monotherapy|
(n = 48)
|Patients on combination therapy|
(n = 33)
|Na||Mean ± SD or n (%)||Na||Mean ± SD or n (%)||Na||Mean ± SD or n (%)|
|Male||45 (55.6)||26 (54.2)||19 (57.6)|
|Age, years||51.2 ± 17.5||51.8 ± 17.7||50.5 ± 17.6|
|Duration of psoriasis, years||46||11.1 ± 8.6||25||11.2 ± 9.1||21||11.0 ± 8.1|
|Psoriasis severity at worst||75||2.5 ± 0.9||44||2.3 ± 0.9||31||2.9 ± 0.8|
|Affected body areas||73||41||32|
|Scalp||31 (42.5)||14 (34.2)||17 (53.1)|
|Face||12 (16.4)||7 (17.1)||5 (15.6)|
|Body||65 (89.0)||34 (82.9)||31 (96.9)|
|Arms||65 (89.0)||34 (82.9)||31 (96.9)|
|Trunk||39 (53.4)||14 (34.2)||25 (78.1)|
|Legs||50 (68.5)||25 (61.0)||25 (78.1)|
|Hands||13 (17.8)||5 (12.2)||8 (25.0)|
|Skin folds||1 (1.4)||0 (0.0)||1 (3.1)|
|Other||9 (12.3)||4 (9.8)||5 (15.6)|
|Table 1: Patient demographics and baseline characteristics|
aNumber of patient records from which the relevant data were available if less than the total.
Complete data for psoriasis severity (at worst, at baseline, and at follow-up) were available for 72 patients (Figure 1); with the remainder missing data from at least one of those time points. In those patients with complete data, severity at worst was mild or moderate in 36 (50%) patients. At baseline and at follow-up, 53 (74%) patients and 62 (86%) patients, respectively, experienced mild or moderate disease.
Patients who had experienced severe, or very severe psoriasis at its worst, were more likely to be on combination therapy and had greater baseline psoriasis severity and BSA affected, relative to those with mild or moderate psoriasis at worst (Table 2). For patients with severe or very severe disease, scaling, itch or itch-related sleep loss, and redness were identified as the signs and symptoms with the greatest impact on the quality of life. Among patients with mild or moderate psoriasis at worst, itch or itch-related sleep loss had the greatest impact on the quality of life. Similarly, redness had the greatest impact on quality of life for 8 of 14 (57%) patients on combination therapy but 3 of 14 (21%) patients on monotherapy, whereas itch or itch-related sleep loss had the greatest impact in 10 of 14 (71%) patients on monotherapy but 7 of 14 (50%) patients on combination therapy.
|Baseline characteristic||Severity score for psoriasis at worst||Patients on monotherapy||Patients on combination therapy|
|1 or 2|
(N = 37)
|3 or 4|
(N = 38)
|(N = 48)||(N = 33)|
|Na||mean ± SD or n (%)||Na||mean ± SD or n (%)||Na||mean ± SD or n (%)||Na||mean ± SD or n (%)|
|Psoriasis severity at baseline||1.9 ± 0.7||37||2.3 ± 0.9||45||2.1 ± 0.8||32||2.1 ± 0.8|
|BSA at baseline||27||4.9 ± 5.5||29||10.9 ± 11.9||36||8.0 ± 9.9||23||7.5 ± 9.2|
|Symptoms with greatest impact on QoL||11||16||14||14|
|Itch/itch-related sleep loss||8 (72.7)||9 (56.3)||10 (71.4)||7 (50.0)|
|Scaling||5 (45.5)||10 (62.5)||8 (57.1)||7 (50.0)|
|Redness||3 (27.3)||8 (50.0)||3 (21.4)||8 (57.1)|
|Stigma||4 (36.4)||5 (31.3)||6 (42.9)||4 (28.6)|
|Dryness||3 (27.3)||5 (31.3)||3 (21.4)||5 (35.7)|
|Poor sleep||0 (0.0)||1 (6.3)||0 (0.0)||1 (7.1)|
|Other||1 (9.1)||2 (12.5)||0 (0.0)||3 (21.4)|
|Type of therapy|
|Monotherapy||27 (73.0)||17 (44.7)||–||–|
|Combination therapy||10 (27.0)||21 (55.3)||–||–|
|Table 2: Correlates of psoriasis severity at its worst|
aNumber of patient records from which the relevant data were available if less than the total. QoL, quality of life.
The most common reasons cited for transitioning to Cal/BD foam were to improve clinical efficacy (74/81; 91%), quality of life (49/81; 61%), and treatment adherence (41/81; 51%). These reasons were ranked similarly for patients on monotherapy and on combination therapy (data not shown).
In patients for whom data were available at both baseline and follow-up, median psoriasis severity score (range) was 2.0 (1.0-4.0) at baseline and 1.0 (0.0-4.0) at follow-up. Median BSA was 4.0 (1.0-45.0) at baseline and 1.5 (0.0-25.0) at follow-up. The median and overall ranges for psoriasis severity and BSA were similar for patients on mono- and combination therapy. These findings were comparable across all 9 dermatologists’ patient sets.
At follow-up, quality of life as assessed by the investigator had improved for 79% and worsened for 4% of the 80 patients for whom quality of life data were reported (Figure 2A). Improvement was also experienced by 5/10 (50%) patients for whom stigma was reported as having a major impact on quality of life. Itch or itch-related sleep loss resolved in 33% and improved in 54% of patients overall (Figure 2B). Of note, very similar improvements were observed for both quality of life and itch/itch-related sleep loss measures in subsets of patients who cited those specific respective factors as the reason for seeking to transition. Overall, disease resolved in 16%, improved in 66%, and stayed the same in 15% but worsened in 3% of patients (n = 79) at the follow-up visit.
In each category of psoriasis severity at baseline, at least half of patients experienced improved quality of life, improved or resolved overall disease, and improved or resolved itch or itch-related sleep loss (Table 3). When grouped by baseline severity, the proportions of patients showing improved quality of life (mild: 15/17, 88%; moderate: 33/40, 83%; severe/very severe: 12/20, 60%) and improved itch or itch-related sleep loss (mild: 11/17, 65%; moderate: 20/40, 50%; severe: 11/20, 60%) were highest for the mild severity patients but roughly similar across groups; the study was not powered to draw any conclusions with respect to improvement according to baseline severity.
|Outcome||Psoriasis severity at baseline|
|Number of patients||17||40||20|
|QoL improved||15 (88.2)||33 (82.5)||12 (60.0)|
|Overall disease improved or resolved||14 (82.4)||65 (87.5)||13 (65.0)|
|Itch or itch-related sleep loss improved or resolved||11 (64.7)||20 (50.0)||11 (55.0)|
|Table 3: Outcomes correlated with baseline psoriasis severity|
Reported for the 77 patients for whom the baseline severity data were available. QoL, quality of life.
Transition was considered successful in 69 of 81 (85%) patients. Of the 12 patients for whom transition was deemed unsuccessful, 7 needed systemic treatment, including biologics (3 and 4 patients on monotherapy and combination therapy, respectively), and no improvement was seen in 2 (1 on monotherapy; 1 on combination therapy). In addition, 1 patient disliked the cosmetic features of the aerosol foam; for 2 patients, no reason was cited. The most common reasons cited for considering transition successful were that the patient reported success (40/69; 58%), signs and symptoms of psoriasis had cleared at follow-up (32/69; 46%), and the patient continued to fill prescriptions (22/69; 32%).
In this retrospective chart review, the transition from a Cal/ BD ointment or gel formulation (Dovobet®) to a Cal/BD foam formulation (Enstilar®) was rated successful in most cases. The most common reason cited was patient-reported success, and most patients experienced improvement in the specific measure (e.g., itch or itch-related sleep loss) cited as a reason for wanting to transition. These findings are supported by results of a previous survey in which Canadian respondents generally rated Cal/BD foam as more pleasant cosmetically, relative to previously used topical products,8,9 consistent with other data that foam products are well accepted relative to other formulations.6
Transition success in the current study did not appear related to whether the patient was on mono- vs. combination therapy, as similar benefits were found in both groups. These benefits included improvements in overall disease, quality of life, and itch and itch-related sleep loss.
Itch is a pervasive challenge for psoriasis management, and itch severity is broadly associated with clinical severity.13 In this population, itch or itch-related sleep loss was reported in all severity groups. Following transition to Cal/BD foam, most patients with mild disease at baseline, as well as approximately half of others, experienced improvement or resolution of itch or itch-related sleep loss. Resolution was reported at a similar rate in the overall population and in patients for whom itch control was identified as a reason for treatment change. Given the clear disease burden associated with itch, dermatologists should ask their patients about their experience of itch and itch-related sleep loss, regardless of overall disease severity, and they should consider a change of topical treatment regimen in those who are dissatisfied with their current level of itch control.
Strengths and Limitations
This was a retrospective chart review of individuals transitioning between topical formulations, namely Cal/BD ointment or gel, to Cal/BD foam. The population may not be fully representative of Canadian psoriasis patients under a dermatologist’s care, since it would be expected to disproportionately include patients who are unsatisfied with Cal/BD gel or ointment. Due to the absence of a control group, no firm conclusions can be drawn regarding changes in symptoms of psoriasis related to the use of Cal/BD foam. For similar reasons, the findings here may not be generalized to other topical formulation transitions, including other transitions to foam formulations.
Conversely, strengths of this study include the real-world setting of treatment and the fact that the questionnaire used was developed through a pilot study that helped ensure that sufficient data could be captured for most variables of interest. It is also reassuring to note that the 9 physicians reported similar levels of treatment success among their individual patient sets, suggesting that the questionnaire was reliable and transparent to the respondents.
The benefits of transitioning from Cal/BD ointment or gel to aerosol foam formulation in this Canadian patient population were similar to those reported in clinical studies and were seen consistently among patients with a range of treatment priorities and with differing history of psoriasis severity and treatment history. Changing the topical treatment formulation, even without a change in active ingredients, should be considered for patients who are dissatisfied with their current topical treatment, independent of their psoriasis severity.
The authors thank the dermatologists who participated in the survey, Alice Kowalczyk, PharmD (LEO Pharma Inc. Canada) and Kristel Bermejo, PhD (imc North America, integrated medhealth communication) for contributing to the study design, and Celeste Lavallee, MSc (imc North America, integrated medhealth communication) for contributing to the data analysis and writing the article.
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- Ali SM, Brodell RT, Balkrishnan R, et al. Poor adherence to treatments: a fundamental principle of dermatology. Arch Dermatol. 2007 Jul;143(7):912-5.
- Nolan BV, Feldman SR. Adherence, the fourth dimension in the geometry of dermatological treatment. Arch Dermatol. 2009 Nov;145(11):1319-21.
- Canadian Psoriasis Guidelines Addendum Committee. 2016 addendum to the Canadian guidelines for the management of plaque psoriasis 2009. J Cutan Med Surg. 2016 Sep;20(5):375-431.
- Canadian Psoriasis Guidelines Committee. Canadian guidelines for the management of plaque psoriasis: overview. J Cutan Med Surg. 2011 Jul-Aug;15(4):210-9.
- Housman TS, Mellen BG, Rapp SR, et al. Patients with psoriasis prefer solution and foam vehicles: a quantitative assessment of vehicle preference. Cutis. 2002 Dec;70(6):327-32.
- Svendsen MT, Feldman SR, Tiedemann SN, et al. Psoriasis patient preferences for topical drugs: a systematic review. J Dermatolog Treat. 2021 Aug;32(5): 478-83.
- Vender R, Gooderham MJ, Guenther LC, et al. Canadian patients’ preferences in topical psoriasis care: insights from the PROPEL surveys. J Cutan Med Surg. 2018 Sep/Oct;22(5):464-71.
- Vender R, Gooderham MJ, Guenther LC, et al. Psoriasis patients’ preference for an aerosol foam topical formulation. J Eur Acad Dermatol Venereol. 2018 Nov;32(11):e400-e1.
- Lind M, Nielsen KT, Schefe LH, et al. Supersaturation of calcipotriene and betamethasone dipropionate in a novel aerosol foam formulation for topical treatment of psoriasis provides enhanced bioavailability of the active ingredients. Dermatol Ther (Heidelb). 2016 Sep;6(3):413-25.
- Paul C, Leonardi C, Menter A, et al. Calcipotriol plus betamethasone dipropionate aerosol foam in patients with moderate-to-severe psoriasis: sub-group analysis of the PSO-ABLE study. Am J Clin Dermatol. 2017 Jun;18(3):405-11.
- Paul C, Stein Gold L, Cambazard F, et al. Calcipotriol plus betamethasone dipropionate aerosol foam provides superior efficacy vs. gel in patients with psoriasis vulgaris: randomized, controlled PSO-ABLE study. J Eur Acad Dermatol Venereol. 2017 Jan;31(1):119-26.
- Pithadia DJ, Reynolds KA, Lee EB, et al. Psoriasis-associated itch: etiology, assessment, impact, and management. J Dermatolog Treat. 2020 Feb;31(1): 18-26.