What is a recommended topical steroid for plaque psoriasis?

Recommended Topical Steroids for Plaque Psoriasis

For plaque psoriasis, class 1 (ultrahigh-potency) topical corticosteroids are recommended for thick, chronic plaques, while class 2-5 (high to moderate potency) corticosteroids are recommended as initial therapy for most other presentations. 1

Selection Based on Plaque Characteristics

Plaque Thickness and Location

• Thick, chronic plaques: Class 1 (ultrahigh-potency) corticosteroids such as clobetasol propionate or halobetasol propionate 1
• Moderate plaques: Class 2-5 (high to moderate potency) corticosteroids 1
• Face and intertriginous areas: Lower potency (class 6-7) corticosteroids to minimize adverse effects 1
• Scalp psoriasis: Any class (1-7) of topical corticosteroids can be used 1

Efficacy Rates

• Ultrahigh-potency (class 1) corticosteroids show efficacy rates of 58-92% in clinical trials 1
• In one study, halobetasol propionate ointment (class 1) improved PGA scores by 92% compared to 39% with vehicle after 2 weeks 1
• Another study showed clobetasol foam (class 1) achieved PSGA scores of 0-1 in 68% of patients after 2 weeks 1

Duration of Treatment

• Initial treatment: 2-4 weeks 1
• Extended use: Treatment beyond 12 weeks should only be done under careful physician supervision 1
• Tapering strategy: Gradually reduce frequency of application after clinical improvement to prevent rebound 1

Vehicle Selection

The choice of vehicle significantly affects medication penetration and efficacy:

• Ointments: Most effective for thick plaques, but greasy
• Creams: Less greasy, better for daytime use
• Solutions, foams, sprays: Ideal for scalp and hair-bearing areas
• Occlusion: Can dramatically increase potency (e.g., flurandrenolide tape functions as a class 1 steroid despite being class 5 in cream form) 1

Combination Approaches

To enhance efficacy and reduce steroid-related adverse effects:

• Vitamin D analogues + corticosteroids: More effective than either agent alone 1
  • Can be used as separate products or as combination products
  • Apply vitamin D in morning and corticosteroid in evening
  • Or use corticosteroids on weekends and vitamin D on weekdays
• Coal tar + corticosteroids: Can be effective for maintenance therapy after initial clearance 2

Common Pitfalls and Caveats

1. Adverse effects: Prolonged use of high-potency steroids can cause skin atrophy, striae, folliculitis, telangiectasia, and purpura 1
2. High-risk areas: Face, intertriginous areas, and forearms are at greatest risk for adverse effects 1
3. Rebound phenomenon: Abrupt discontinuation can lead to disease recurrence worse than before treatment 1
4. Tachyphylaxis: Decreasing effectiveness with continued use
5. Incompatible combinations: Avoid using calcipotriene with salicylic acid as the acidic pH inactivates calcipotriene 1

Practical Application Guidelines

• Use the fingertip unit method to ensure appropriate quantity application 1
• For maintenance therapy after initial clearance, consider:
  1. Weekend-only steroid use
  2. Combination with steroid-sparing agents like vitamin D analogues
  3. Switching to lower potency steroids for long-term management

Monitoring

• Regular assessment for signs of skin atrophy and other local adverse effects
• Systemic absorption is generally minimal with short-term use, with studies showing no clinically significant HPA axis suppression even in extensive disease 3

For patients with inadequate response to topical steroids alone, combination therapy with vitamin D analogues or transitioning to systemic therapies should be considered based on disease severity and impact on quality of life.