What are the treatment options for plaque psoriasis?

Treatment Options for Plaque Psoriasis

Topical corticosteroids are the first-line treatment for mild to moderate plaque psoriasis, with class 1-3 (high to ultra-high potency) preparations recommended for up to 4 weeks for non-intertriginous areas. 1

First-Line Topical Treatments

Topical Corticosteroids

• Potency selection:

  • Class 1 (ultra-high potency): For thick, chronic plaques
  • Class 2-5 (high to moderate potency): Initial therapy for most body areas
  • Class 6-7 (low potency): For face, intertriginous areas, and steroid-sensitive regions 1

• Application guidelines:

  • Treatment duration: Up to 4 weeks initially
  • Monitor for adverse effects: skin atrophy, striae, telangiectasia
  • Taper frequency after improvement
  • No unsupervised repeat prescriptions 1
  • For maintenance: Consider weekend-only application 1

• Cautions:

  • Avoid prolonged use on face, intertriginous areas, and forearms
  • Regular clinical review required
  • No more than 100g of moderately potent preparation monthly 1
  • Very potent preparations should be under dermatological supervision

Vitamin D Analogues

• Options: Calcipotriene (calcipotriol), calcitriol
• Efficacy: 4-8 weeks treatment is effective for mild to moderate psoriasis 1
• Benefits: Less skin atrophy than corticosteroids, may prolong remission
• Application: Once or twice daily for 8 weeks
• Caution: Avoid using with salicylic acid (inactivates calcipotriene) 1

Combination Therapy

• Corticosteroid + Vitamin D analogue:
  • Most studied and effective combination
  • Higher efficacy than either agent alone
  • Two-compound products allow once-daily application
  • Recommended regimen: Morning high-potency corticosteroid and evening vitamin D analogue 1, 2

Calcineurin Inhibitors

• Options: Tacrolimus, pimecrolimus
• Best for: Inverse psoriasis (intertriginous areas)
• Application: Apply twice daily for 4-8 weeks 1
• Benefit: No skin atrophy, suitable for sensitive areas

Tazarotene (Topical Retinoid)

• Application: Once daily for 8-12 weeks
• Efficacy: Comparable to medium-potency corticosteroids
• Best used: In combination with corticosteroids to reduce irritation
• Contraindication: Pregnancy 1

Treatment Algorithm Based on Disease Severity and Location

Mild-Moderate Plaque Psoriasis (Non-Sensitive Areas)

1. First choice: Class 2-5 topical corticosteroid for up to 4 weeks
2. Alternative: Vitamin D analogue (calcipotriene/calcitriol)
3. Optimal approach: Combination of corticosteroid and vitamin D analogue
4. Maintenance: Weekend-only corticosteroid application or vitamin D analogue

Thick, Chronic Plaques

1. First choice: Class 1 (ultra-high potency) corticosteroid
2. Alternative: Tazarotene plus corticosteroid
3. For resistant lesions: Consider intralesional corticosteroids (triamcinolone up to 20mg/mL every 3-4 weeks) 1

Face, Intertriginous Areas, Genitalia

1. First choice: Class 6-7 (low potency) corticosteroid for short duration
2. Alternative/maintenance: Calcineurin inhibitors (tacrolimus, pimecrolimus)
3. For facial psoriasis: Calcipotriene or tacalcitol combined with hydrocortisone 1

Scalp Psoriasis

1. First choice: Topical corticosteroids (any class) for minimum 4 weeks
2. Alternative: Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1

Common Pitfalls and How to Avoid Them

• Tachyphylaxis misconception: Poor response over time is often due to poor adherence rather than true tachyphylaxis 1
• Rebound phenomenon: Avoid abrupt discontinuation; taper frequency gradually
• Steroid-induced skin atrophy: Rotate treatments, use steroid-sparing agents, avoid prolonged use on sensitive areas
• Treatment failure: If one topical fails, try an alternative before considering systemic therapy 1
• Candidiasis in intertriginous areas: Consider antifungal treatment if satellite pustules are present 1
• Vitamin D analogue irritation: Start with lower concentrations or use combination products

Special Considerations

• Pregnancy: Avoid tazarotene; low-potency corticosteroids are generally considered safer
• Children: Use lower potency corticosteroids for shorter durations
• Diabetes/immunosuppression: Monitor closely for infections, especially in intertriginous areas
• Maintenance therapy: Intermittent application of topical steroids (weekends only) can prolong remission 3

For patients with moderate-to-severe psoriasis not responding to topical therapy, consider referral to dermatology for phototherapy (UV-B, PUVA) or systemic agents such as methotrexate, acitretin, cyclosporine, or biologics like adalimumab 4, 5.