What is the best treatment for psoriasis on the elbows?

Treatment of Psoriasis on the Elbows

For psoriasis on the elbows, the best treatment is a combination of high-potency topical corticosteroids with or without a vitamin D analogue, applied as directed to the affected areas. 1

Understanding Elbow Psoriasis

Psoriasis commonly affects extensor surfaces such as the elbows, which are classic sites for plaque psoriasis. The elbows present unique challenges for treatment due to:

• Thicker skin requiring more potent treatments
• Frequent movement and friction that can worsen plaques
• Tendency for more resistant plaques to develop in this location

Treatment Algorithm

First-Line Treatment:

1. Topical Corticosteroids:

   • Use high-potency (Class I-II) topical corticosteroids for elbow psoriasis
   • Apply a thin film 1-2 times daily to affected areas
   • One fingertip unit (approximately 0.5g) covers one elbow (large plaque) 1
   • Examples include:
     • Triamcinolone acetonide 0.1% ointment 2
     • Mometasone furoate 0.1% ointment 3

2. Combination Therapy:

   • Preferred approach: High-potency corticosteroid with vitamin D analogue (Level A evidence) 1
   • Apply corticosteroid in the morning and vitamin D analogue (calcipotriene 0.005%) in the evening, or use a combination product
   • Calcipotriene is specifically indicated for plaque psoriasis in adults 4

For Thick Plaques:

• Add keratolytic agent (salicylic acid 2-5%) to enhance penetration of other medications 5
• Consider occlusive dressing for recalcitrant plaques to increase efficacy 2

Maintenance Strategy:

• After initial improvement (typically 2-4 weeks), transition to:
  • Weekend-only application of corticosteroid
  • Daily vitamin D analogue
  • This approach minimizes steroid-related side effects while maintaining efficacy 6

Special Considerations

1. Monitoring for Side Effects:

   • Watch for skin atrophy, striae, and telangiectasia with prolonged use of high-potency steroids
   • Perform regular clinical examinations when using potent topical medications long-term 1

2. For Resistant Cases:

   • Consider adding tar preparations or tazarotene to the regimen 5
   • For severe, resistant elbow plaques unresponsive to topical therapy, consider:
     • Phototherapy (narrowband UVB)
     • Systemic therapy (methotrexate, biologics) if multiple areas are affected 1

3. Application Technique:

   • Apply after bathing when skin is hydrated
   • Use ointment formulations for thicker plaques (more effective than creams for elbow psoriasis) 6
   • Apply with gentle pressure in the direction of hair growth

Practical Tips

• Moisturize regularly with emollients between medication applications
• Avoid scratching and trauma to the area
• Wear loose-fitting clothing to reduce friction on elbows
• Once-daily application of high-potency steroids may be as effective as multiple daily applications, improving adherence 3

The evidence strongly supports that combination therapy with high-potency topical corticosteroids and vitamin D analogues provides superior efficacy compared to monotherapy for elbow psoriasis, with a strong recommendation (Level A evidence) from the American Academy of Dermatology guidelines 1.