"Although there is no question that systemic retinoid therapy is the most effective treatment for acne, and biologicals are the most effective treatment for psoriasis, these aggressive interventions are not indicated for all patients. Topical treatments are appropriate for individuals with less severe disease and can be highly effective.

"Unfortunately, we do not always achieve successful outcomes because of compliance issues," said Dr. Fleischer, professor and chairman of dermatology, Wake Forest University School of Medicine, Winston-Salem, NC.

Offering a few tips for optimizing efficacy of topical therapy, Dr. Fleischer recommended that rather than switching gears immediately in the management of an apparent nonresponder, clinicians should first review, in a nonjudgmental way, how the individual has been using the medication(s).

A second strategy for increasing success is to decrease the frequency of application. There are numerous publications of studies evaluating various topical treatments for rosacea, atopic dermatitis, psoriasis and acne showing that once-daily therapy can be just as effective as twice-daily application.

For patients who are on multimodal therapy, selecting agents that can be applied together versus at different times of day is also feasible for most combination approaches.

"Almost all topical dermatologics are compatible, although there are a few notable exceptions," Dr. Fleischer said.

Dr. Fleischer also reminded dermatologists to "go back to basics." In the treatment of acne, that means remembering that a topical retinoid should be considered a primary agent for all patients. Patients must also be counseled on proper application, and particularly about using the correct amount of medication.

"A recent publication estimating the quantity of topical product being used estimated that 95 percent of patients underdose," said Dr. Fleischer.

He also advocated using occlusion and cited a few published studies showing its benefits for enhancing the efficacy of topical treatments.

"Occlusion really does work, and although occluding topical corticosteroids is off-label, I still find it is often appropriate," Dr. Fleischer said. DT