What are the treatment recommendations for topical therapy in long-term management of chronic psoriasis?

From the Guidelines

For long-term chronic psoriasis management, topical corticosteroids remain the first-line treatment, with mid-potency options like triamcinolone 0.1% for body lesions and low-potency hydrocortisone 1-2.5% for sensitive areas, applied twice daily for 2-4 weeks followed by maintenance therapy 2-3 times weekly. According to the most recent guidelines 1, vitamin D analogs such as calcipotriene 0.005% ointment or calcitriol 3mcg/g ointment are effective steroid-sparing agents, often used in combination with steroids (morning steroid, evening vitamin D analog) to enhance efficacy while reducing side effects.

Key Considerations

• For maintenance, calcipotriene/betamethasone dipropionate combination products offer convenience, as supported by the guidelines 1.
• Calcineurin inhibitors (tacrolimus 0.1% ointment, pimecrolimus 1% cream) are valuable for facial and intertriginous areas where steroid use is concerning, as noted in the guidelines 1.
• Coal tar preparations (1-5%) can be used for resistant cases, while salicylic acid (2-10%) helps with thick, scaly plaques by promoting desquamation.
• Moisturizers should be used liberally throughout treatment to maintain skin barrier function and enhance medication penetration, as recommended in the guidelines 1.
• Rotation between different medication classes helps prevent tachyphylaxis and minimizes side effects during long-term management.

Application and Dosage

• The choice of vehicle can significantly alter the use and penetration of the medication and therefore alter the efficacy, as discussed in the guidelines 1.
• Occlusion of topical medications can also alter the penetration, thereby varying the effectiveness, as noted in the guidelines 1.
• The fingertip unit can be used to assess the quantity of topical agents needed to cover a given body surface area, as outlined in the guidelines 1.

Combination Therapy

• Combination products with calcipotriene and topical nicotinamide are effective for the treatment of mild to moderate psoriasis, as supported by the guidelines 1.
• The application of morning high-potency topical corticosteroids and evening topical vitamin D analogues is an effective treatment regimen that can be considered for the treatment of psoriasis, as recommended in the guidelines 1.

From the FDA Drug Label

For the patient with psoriasis, apply tazarotene cream only to psoriasis skin lesions, avoiding uninvolved skin. If undue irritation (redness, peeling, or discomfort) occurs, reduce frequency of application or temporarily interrupt treatment. Moisturizers may be used as frequently as desired. Patients with psoriasis may use a cream or lotion to soften or moisten skin at least 1 hour before applying tazarotene cream.

The treatment recommendations for topical therapy in long-term management of chronic psoriasis using tazarotene cream include:

• Applying the cream only to psoriasis skin lesions, avoiding uninvolved skin
• Reducing frequency of application or temporarily interrupting treatment if undue irritation occurs
• Using moisturizers as frequently as desired
• Softening or moistening skin with a cream or lotion at least 1 hour before applying tazarotene cream 2, 2, 2

From the Research

Treatment Recommendations for Topical Therapy

The treatment recommendations for topical therapy in the long-term management of chronic psoriasis include:

• Topical corticosteroids, which are effective as monotherapy or in combination for sequential or rotational treatment 3
• Vitamin D analogs, such as calcipotriene, which are effective in combination with corticosteroids 3, 4
• Topical immunomodulators, such as pimecrolimus and tacrolimus, which are effective on the face and intertriginous psoriatic lesions 3
• Retinoids, such as tazarotene, which are effective in combination with corticosteroids 3, 5
• Tar preparations, anthralin, and keratolytics, which may be used with ultraviolet light and corticosteroids 3, 6, 5

Long-term Continuous Treatment

For long-term continuous treatment, the following topicals are used:

• Topical corticosteroids, which are the most commonly used topical treatment for psoriasis 4
• Vitamin D analogs, which are used in combination with corticosteroids 4
• Potent topical corticosteroids in combination with vitamin D analogs, which are used for more severe disease 4

Treatment of Specific Body Sites

For specific body sites, the following topicals are used:

• Lower potency topical corticosteroids for flexural and genital psoriasis 4
• Superpotent topical corticosteroids and combination vitamin D analogs/corticosteroids for palmoplantar psoriasis 4

Emerging Paradigm Shift

There is an emerging paradigm shift toward proactive topical treatment of psoriasis, which involves:

• Continuous long-term therapy, chronic intermittent use, step-down therapy, sequential or pulse therapy regimens, and proactive maintenance therapy 7
• Transitioning from acute to maintenance therapy, monitoring long-term treatment, and prescribing a topical preparation suitable for patients' preferences and skin type 7