What is the best initial topical treatment for severe psoriasis?

From the Guidelines

For severe psoriasis, ultrahigh-potency topical corticosteroids, such as clobetasol propionate 0.05% (Temovate), betamethasone dipropionate 0.05% (Diprolene), or halobetasol propionate 0.05% (Ultravate), are typically the best initial topical treatment, applied thinly to affected areas twice daily for 2-4 weeks, as supported by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy 1.

Key Considerations

• These medications work by reducing inflammation, suppressing immune responses, and decreasing cell proliferation.
• For maintenance after improvement, transition to a medium-potency steroid or use the potent steroid less frequently (weekends only).
• Vitamin D analogs like calcipotriene (Dovonex) can be used in combination with steroids for enhanced efficacy and steroid-sparing effects, as shown in a 52-week study where 69% to 74% of patients achieved clear or almost clear status 1.
• For psoriasis affecting sensitive areas like the face or skin folds, lower potency steroids or steroid-free alternatives like tacrolimus or pimecrolimus are recommended to avoid skin thinning.
• If topical treatments alone don't provide adequate control, consider adding phototherapy or systemic medications under dermatological supervision.

Application Technique

• Proper application technique is crucial - use enough to cover affected areas with a thin film.
• Avoid occlusive dressings unless specifically directed by your physician.

Combination Therapy

• 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.
• The use of combination treatments with vitamin D analogues and potent topical corticosteroids from 3 to 52 weeks is more effective than either agent alone for the treatment of psoriasis 1.

From the FDA Drug Label

The safety and effectiveness of topical calcipotriene in dermatoses other than psoriasis have not been established. Apply a thin layer of calcipotriene cream to the affected skin twice daily and rub in gently and completely. CLINICAL STUDIES Adequate and well-controlled trials of patients treated with calcipotriene cream have demonstrated improvement usually beginning after 2 weeks of therapy.

The best initial topical treatment for severe psoriasis is not explicitly stated in the provided drug labels. However, calcipotriene cream is indicated for the treatment of plaque psoriasis 2. According to the clinical studies, calcipotriene cream has demonstrated improvement in patients with psoriasis, with approximately 50% of patients showing at least marked improvement after 8 weeks of therapy 2. The recommended dosage is to apply a thin layer of calcipotriene cream to the affected skin twice daily 2.

• Key points:
  • Calcipotriene cream is indicated for plaque psoriasis.
  • Apply a thin layer of calcipotriene cream to the affected skin twice daily.
  • Approximately 50% of patients show at least marked improvement after 8 weeks of therapy.

From the Research

Topical Treatment for Severe Psoriasis

The best initial topical treatment for severe psoriasis is a subject of ongoing research, with various studies suggesting different approaches.

• Topical corticosteroids have been a first-line treatment for psoriasis since 1952, offering rapid relief from symptoms 3.
• A study from 1998 found that clobetasol propionate followed by calcipotriol was superior to calcipotriol alone in treating moderate to severe plaque psoriasis 4.
• Clobetasol propionate 0.05% spray has been shown to improve signs and symptoms of plaque psoriasis after just 1 week of treatment 5.
• Adding clobetasol propionate spray 0.05% to a stable regimen of biologic treatment has been found to be effective in patients with moderate to very severe plaque psoriasis 6.
• The combination of vitamin D analogs and corticosteroids has a strong biological rationale, as they act through distinct and complementary mechanisms of action, and may reduce side effects 7.

Key Findings

• Topical corticosteroids are effective in reducing symptoms of psoriasis, but their long-term use is limited due to the risk of side effects 3, 4.
• Combination therapy, such as clobetasol propionate followed by calcipotriol, may offer improved efficacy and tolerability 4, 7.
• Clobetasol propionate 0.05% spray is a effective treatment option for moderate to severe plaque psoriasis, with improvements seen after just 1 week of treatment 5.
• Adding topical corticosteroids to biologic treatment may be a useful strategy for patients with moderate to very severe plaque psoriasis 6.