What is the first-line treatment for plaque psoriasis?

First-Line Treatment for Plaque Psoriasis

Topical corticosteroids are strongly recommended as the first-line treatment for plaque psoriasis with limited body surface area involvement. 1

Treatment Algorithm Based on Disease Severity

Mild to Moderate Plaque Psoriasis (Limited Body Surface Area)

1. First-line therapy:

   • Class 1-5 topical corticosteroids for up to 4 weeks 1
   • For thick, chronic plaques: Class 1 (ultrahigh-potency) corticosteroids 1
   • For facial/intertriginous areas: Lower potency corticosteroids to minimize side effects

2. Alternative or adjunctive first-line options:

   • Topical vitamin D analogs (calcipotriene/calcitriol) 1, 2
   • Combination therapy (corticosteroid + vitamin D analog) for enhanced efficacy

Moderate to Severe Plaque Psoriasis (Extensive Body Surface Area)

1. First-line options after topical therapy failure:
   • Phototherapy (particularly narrowband UVB) 1
   • Oral therapies (methotrexate, cyclosporine) 1
   • Biologic agents for severe cases 1

Efficacy of Topical Corticosteroids

Topical corticosteroids have demonstrated high efficacy rates in randomized controlled trials:

• Class 1 (ultrahigh-potency) corticosteroids show efficacy rates of 58% to 92% 1
• In one study, halobetasol propionate ointment (class 1) improved Physician's Global Assessment scores by 92% compared to 39% with vehicle after 2 weeks 1

Duration and Administration

• Initial treatment with topical corticosteroids should be limited to 4 weeks 1
• For maintenance therapy, consider:
  1. Tapering frequency of application
  2. Switching to lower potency corticosteroids
  3. Rotating with non-steroidal agents (vitamin D analogs)

Potential Side Effects and Monitoring

Common adverse effects of topical corticosteroids include:

• Skin atrophy
• Striae
• Telangiectasia
• Folliculitis
• Purpura

Areas at highest risk for side effects include:

• Face
• Intertriginous areas
• Chronically treated areas, especially forearms

Important Clinical Considerations

1. Steroid-sparing strategies:

   • Consider combination therapy with vitamin D analogs to reduce corticosteroid exposure
   • Weekend/weekday regimens (corticosteroids on weekends, vitamin D analogs on weekdays) 3
   • Sequential therapy (initial corticosteroid followed by maintenance with vitamin D analog) 4

2. Monitoring:

   • Regular clinical review is essential 1
   • No unsupervised repeat prescriptions
   • Monitor for signs of skin atrophy and other adverse effects

3. Treatment modifications:

   • For thick, resistant plaques: Consider intralesional corticosteroid injections 1
   • For scalp involvement: Class 1-7 topical corticosteroids for up to 4 weeks 1

4. Caution with abrupt discontinuation:

   • Rebound phenomenon can occur with sudden cessation of topical corticosteroids
   • Gradual reduction in frequency is recommended 1

While other treatment options like phototherapy, systemic agents, and biologics are available for more severe or resistant disease, topical corticosteroids remain the cornerstone of initial therapy for plaque psoriasis with limited body surface area involvement due to their proven efficacy, rapid onset of action, and favorable risk-benefit profile when used appropriately.