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Opinion

Video

Exploring the Safety of Newer Nonsteroidal Topicals in Psoriasis

Panelists discuss how safety and tolerability are key advantages of newer topical psoriasis treatments such as tapinarof and roflumilast, which avoid many steroid-related risks such as hypothalamic-pituitary-adrenal (HPA) axis suppression and skin thinning, cause minimal irritation, and have favorable real-world profiles that support their use as effective, long-term, steroid-sparing therapies.

Safety is a crucial factor in choosing therapies for psoriasis, especially when considering topicals vs systemics. With traditional topical corticosteroids, concerns such as HPA axis suppression, especially in children or when treating large body surface areas, have limited their long-term use. The newer agents, such as topical tapinarof and roflumilast, avoid many of these risks. Both are generally well tolerated, with low incidence of serious adverse events. Notably, these newer topicals have not shown issues such as tachyphylaxis (loss of effect over time), HPA axis suppression, bone fractures, or skin thinning, which are important safety concerns for steroid-based treatments.

Tolerability is another key concern for topical medications. Both tapinarof and roflumilast have been shown to cause minimal burning, stinging, or itching—adverse effects often associated with first-generation PDE4 inhibitors and topical calcineurin inhibitors. A unique adverse effect of tapinarof is a mild to moderate acneiform or keratosis pilarislike eruption thought to be related to follicular plugging, occurring in about 10% to 20% of patients but rarely causing treatment discontinuation. Some patients also develop localized contact dermatitis, though it’s unclear whether this is allergic or irritant. Headaches were reported but generally at low rates. Overall, the tolerability profiles are favorable compared with older treatments.

In real-world use, gastrointestinal adverse effects such as diarrhea or nausea related to PDE4 inhibitors are rare and mild. Clinicians also noted that some label warnings, such as avoiding roflumilast in patients with advanced liver disease, stem from oral formulations and are not yet supported by data on the topical versions used in dermatology. It’s important for providers to be aware of these distinctions to better counsel patients who may raise concerns after reading medication labels. Overall, the safety and tolerability of these newer topicals support their role as steroid-sparing options for chronic psoriasis management.

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