What is the next step in managing a patient with persistent localized psoriatic lesions despite using betamethasone (corticosteroid) 0.05% cream and an emollient?

From the Guidelines

For persistent localized psoriatic lesions that haven't responded to betamethasone 0.05% cream and emollients, the next step would be to add a vitamin D analog such as calcipotriene (Dovonex) 0.005% ointment or cream, as this combination approach has been shown to be more effective than either agent alone in achieving clear or almost clear status, with 69% to 74% of patients achieving this outcome in a 52-week study 1.

This approach is supported by the most recent and highest quality study, which demonstrated the efficacy and safety of combining calcipotriene with betamethasone dipropionate for the treatment of psoriasis 1. The use of combination treatments with vitamin D analogues and potent topical corticosteroids has been recommended for the treatment of psoriasis, with a strength of recommendation of A 1.

The patient should apply the calcipotriene twice daily to affected areas, alternating with the betamethasone or using them together as a combination product like Taclonex (calcipotriene/betamethasone). If lesions are on the scalp, consider a solution formulation. It is essential to ensure the patient is applying enough medication (fingertip unit concept) and using proper occlusion techniques for thick plaques to enhance penetration.

Some key points to consider when using this combination approach include:

• The potential for increased efficacy with combination therapy 1
• The importance of proper application and occlusion techniques to enhance penetration 1
• The need to monitor for potential side effects, such as skin atrophy and systemic absorption, especially with the use of higher potency corticosteroids over larger body surface areas 1
• The consideration of alternative treatments, such as phototherapy (narrowband UVB) or referral to dermatology for stronger topical agents like tazarotene or systemic therapies, if the disease is significantly impacting quality of life 1

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: Apply a thin film of Betamethasone Valerate Cream or Ointment to the affected skin areas one to three times a day. Dosage once or twice a day is often effective. The most appropriate next step is to increase betamethasone use as the drug label suggests that dosage may be increased in stubborn cases, and the patient's lesions persist with only modest improvement 2.

• The patient is currently using betamethasone 0.05% cream twice daily and then reduced to every other day, which is within the recommended dosage.
• Increasing the frequency of application to three times daily may help improve the patient's condition.
• Adding calcipotriene twice daily may also be considered as it is often used in combination with corticosteroids for the treatment of psoriasis.

From the Research

Next Steps in Managing Psoriatic Lesions

The patient has been using betamethasone 0.05% cream and an emollient for 2 weeks, with modest improvement. Considering the persistence of localized psoriatic lesions, the following options are available:

• Increase betamethasone use to three times daily and add calcipotriene twice daily: This option is supported by studies that demonstrate the effectiveness of combining calcipotriene and betamethasone in treating psoriasis 3, 4.
• Discontinue therapy: There is no evidence to support discontinuing therapy, as the patient has shown modest improvement.
• Refer the patient to a dermatologist for consideration of systemic therapy: This option may be considered if the patient's condition does not improve with topical treatments.
• Reduce betamethasone use to once per week and add calcipotriene twice daily: This option is supported by studies that demonstrate the effectiveness of combining calcipotriene and betamethasone, and reducing the frequency of betamethasone use to minimize side effects 5, 6, 7.

Rationale for Combination Therapy

The combination of calcipotriene and betamethasone has been shown to be effective in treating psoriasis, with a faster onset of action and greater efficacy than using either ingredient alone 3, 4. This combination also reduces the side-effect profile of topical corticosteroids, such as skin atrophy 5. The use of calcipotriene and betamethasone in a two-compound topical formulation has been shown to be effective in once-daily application, which may improve patient adherence 7.