What is the most appropriate first-line therapy for a patient with approximately 7% of their Body Surface Area (BSA) affected by plaque psoriasis?

From the Guidelines

The most appropriate first-line therapy for a patient with approximately 7% body surface area (BSA) affected by plaque psoriasis is topical therapy, specifically a mid-to-high potency topical corticosteroid, such as triamcinolone acetonide 0.1% or halobetasol propionate 0.05% cream. This recommendation is based on the guidelines of care for the management of psoriasis with topical therapies 1. For a patient with 7% BSA affected, the use of topical corticosteroids is the cornerstone of treatment, particularly for those with limited disease, as they are available in many strengths and formulations, allowing for versatility of use 1. Some key points to consider when using topical corticosteroids include:

• Using the least potent agent that allows for disease control to minimize side effects
• Using more potent agents on a short-term basis to allow for response, then transitioning to less potent agents for long-term management
• Applying a thin layer to affected areas and washing hands thoroughly after application
• Considering combination therapy with other topical agents, such as vitamin D analogs, for better efficacy and to minimize side effects The patient's 7% BSA involvement falls within the mild-to-moderate category of psoriasis severity, making topical therapy the appropriate first choice before considering systemic treatments or phototherapy, which are typically reserved for more extensive disease or when topical treatments fail 1. It is essential to note that the use of topical agents can be both intermittent and long-term, and patients should receive regular examinations to monitor disease control and potential side effects 1. In terms of specific treatment regimens, a common approach would be to apply the topical corticosteroid once or twice daily to affected areas for 4-8 weeks, followed by maintenance therapy 2-3 times weekly as needed. For scalp involvement, solutions or foams may be preferred for better penetration through hair. Ultimately, the goal of treatment is to achieve adequate disease control while minimizing side effects and improving the patient's quality of life.

From the FDA Drug Label

DOSAGE & ADMINISTRATION Topical corticosteroids are generally applied to the affected area as a thin film from two to three times daily depending on the severity of the condition.Occlusive dressing may be used for the management of psoriasis or recalcitrant conditions.If an infection develops, the use of occlusive dressing should be discontinued and appropriate antimicrobial therapy instituted. The most appropriate first-line therapy for a patient with approximately 7% of their Body Surface Area (BSA) affected by plaque psoriasis is topical corticosteroids, such as Triamcinolone acetonide 0.025% cream.

• The patient's BSA affected is relatively mild to moderate, making topical therapy a suitable option.
• Triamcinolone acetonide 0.025% cream is a low to medium potency topical corticosteroid, which is often used as a first-line treatment for mild to moderate plaque psoriasis 2.

From the Research

First-Line Therapy for Plaque Psoriasis

The patient presents with approximately 7% of their Body Surface Area (BSA) affected by plaque psoriasis. Considering the severity of the condition, the most appropriate first-line therapy should be effective, safe, and well-tolerated.

Treatment Options

• Topical Corticosteroids: Triamcinolone acetonide 0.025% cream (option a) is a mild topical corticosteroid, which may not be sufficient for a patient with 7% BSA affected 3.
• Halobetasol Propionate: Halobetasol propionate 0.05% cream (option c) is a potent topical corticosteroid, which has been shown to be effective in treating moderate to severe plaque psoriasis 4.
• Referral to a Dermatologist: Immediate referral to a dermatologist (option b) may not be necessary for a patient with mild to moderate plaque psoriasis, as first-line topical treatments can be initiated by a primary care provider 5.
• Methotrexate: Methotrexate (option d) is a systemic medication typically reserved for patients with severe psoriasis or those who have failed topical therapies 6.

Recommended First-Line Therapy

Based on the evidence, halobetasol propionate 0.05% cream (option c) is a suitable first-line therapy for a patient with approximately 7% BSA affected by plaque psoriasis, due to its efficacy and safety profile 4, 5.