Nonsteroidal Topicals in Psoriasis: From Reactive to Proactive Management

The approval of nonsteroidal topical agents like roflumilast has fundamentally shifted the paradigm for managing patients with psoriasis, enabling a transition from reactive to proactive disease control, Benjamin Lockshin, MD, FAAD, of US Dermatology Associates, explains. Unlike traditional corticosteroids—which were largely used intermittently in response to flares—nonsteroidal options allow patients to continue treatment even during periods of skin clearance, helping to maintain remission and reduce the cycles of disease recurrence that many patients experience. This shift in approach is both clinically meaningful and psychologically reassuring for patients who previously felt their treatment was always a step behind their disease.

Beyond efficacy, the safety advantages of nonsteroidal topicals are compelling. Long-term corticosteroid use, even topically, has been associated with local adverse effects such as skin atrophy, striae, and telangiectasia, as well as systemic risks including osteoporosis and bone fractures with prolonged exposure. Nonsteroidal agents like roflumilast do not carry these same concerns, making them more suitable for sustained use and allowing clinicians to prescribe them with greater confidence.

In clinical practice, roflumilast fits into 3 key patient groups: those with mild-to-moderate disease seeking to reduce or replace steroid use; patients with moderate disease who might otherwise require systemic therapy but can be successfully managed topically; and individuals on biologics or systemic agents who need an adjunctive option for residual or breakthrough lesions. The simplicity of a single formulation applicable to all body areas—including sensitive skin sites—offers a practical advantage over the tiered potency approach required with corticosteroids. These characteristics, combined with encouraging persistence data, position nonsteroidal topicals as a cornerstone of modern psoriasis management.