What are alternative treatments for psoriasis if topical corticosteroid (steroid) cream is ineffective?

From the Guidelines

If steroid creams aren't working for your psoriasis, the most effective alternative is to use a combination of calcipotriene and a potent topical corticosteroid, such as betamethasone dipropionate, for up to 52 weeks, as recommended by the joint AAD-NPF guidelines of care 1. This approach has been shown to be more effective than using either agent alone, with 69% to 74% of patients achieving clear or almost clear status compared to 27% with vehicle control 1.

Key Considerations

• The use of calcipotriene or tacalcitol ointment combined with hydrocortisone is also efficacious for the treatment of facial psoriasis 1.
• Topical vitamin D analogues combined with betamethasone dipropionate can be used for the treatment of nail psoriasis to reduce nail thickness, hyperkeratosis, onycholysis, and pain 1.
• It's essential to avoid simultaneous use of salicylic acid with calcipotriene, as the acid pH of salicylic acid can inactivate calcipotriene and reduce its effectiveness 1.

Treatment Options

• Calcipotriene (Dovonex) is a vitamin D analog that slows skin cell growth and can be used as a monotherapy or in combination with other treatments 1.
• Tazarotene (Tazorac) is a retinoid that normalizes cell differentiation and can be used as an alternative to calcipotriene 1.
• Phototherapy using UVB light three times weekly for 2-3 months may provide significant improvement for moderate to severe cases 1.
• Systemic medications, such as methotrexate, cyclosporine, or biologics like adalimumab, etanercept, or ustekinumab, may be necessary when topical treatments fail 1.

Important Notes

• It's crucial to consult with a dermatologist to determine the most appropriate next treatment based on your psoriasis severity, affected areas, and medical history, as each option has different side effect profiles and monitoring requirements 1.
• Combining separate vitamin D and corticosteroid preparations into specific easy-to-follow regimens can be used to reduce both the adverse effects of topical corticosteroids and the cost for some patients 1.

From the FDA Drug Label

The initial dose of cyclosporine [MODIFIED] should be 2.5 mg/kg/day. Cyclosporine [MODIFIED] should be taken twice daily, as a divided (1.25 mg/kg b.i.d.) oral dose. Patients should be kept at that dose for at least 4 weeks, barring adverse events. If significant clinical improvement has not occurred in patients by that time, the patient's dosage should be increased at 2 week intervals. Patients generally show some improvement in the clinical manifestations of psoriasis in 2-weeks. Satisfactory control and stabilization of the disease may take 12 to 16 weeks to achieve Treatment should be discontinued if satisfactory response cannot be achieved after 6 weeks at 4 mg/kg/day or the patient's maximum tolerated dose

Cyclosporine can be considered as a treatment option for psoriasis if steroidal cream is not working. The initial dose is 2.5 mg/kg/day, taken twice daily, and can be increased if significant clinical improvement is not seen after 4 weeks.

• Key points:
  • Initial dose: 2.5 mg/kg/day
  • Dose increase: at 2-week intervals if no improvement
  • Treatment duration: 12 to 16 weeks for satisfactory control
  • Discontinuation: if no response after 6 weeks at maximum tolerated dose 2

From the Research

Alternative Treatment Options

If steroidal cream is not working for psoriasis treatment, there are several alternative options to consider:

• Topical vitamin D analogs, such as calcipotriene, which have been shown to be effective in treating psoriasis 3, 4
• Combination therapy, which involves using multiple topical agents or combining topical agents with systemic therapies, such as biologics or phototherapy 5, 6
• Non-steroidal topical therapies, such as tacrolimus or pimecrolimus, which may be safer for long-term use than topical corticosteroids 7
• Systemic therapies, such as conventional or biologic agents, which may be necessary for patients with moderate-to-severe psoriasis who are not responding to topical treatments 6

Considerations for Treatment

When considering alternative treatment options, it's essential to take into account the patient's individual needs and circumstances:

• The severity of the psoriasis and the impact on the patient's quality of life 6
• The patient's medical history and any potential contraindications for certain treatments 7
• The potential benefits and risks of each treatment option, including the risk of systemic side effects with long-term use of topical corticosteroids 7
• The importance of patient adherence to treatment regimens and the potential need for education and support to ensure optimal outcomes 7

Additional Therapies

Additional therapies that may be considered for patients with psoriasis who are not responding to steroidal cream include:

• Phototherapy, which involves exposure to specific wavelengths of light to reduce inflammation and slow down skin cell growth 5, 7
• Biologics, which are systemic therapies that target specific molecules involved in the inflammatory process 5, 6