What are the treatment options for inverse psoriasis?

Treatment Options for Inverse Psoriasis

For inverse psoriasis, topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) are recommended as first-line therapy due to their efficacy and lack of skin atrophy in sensitive intertriginous areas. 1

Understanding Inverse Psoriasis

Inverse psoriasis affects intertriginous areas including:

• Axillae (armpits)
• Inframammary areas
• Abdominal, inguinal, and gluteal folds
• Groin and genitalia
• Perineum and perirectal areas

These lesions typically appear erythematous, less indurated, and well-demarcated with minimal scale compared to plaque psoriasis. The warm, moist environment in these areas creates unique treatment challenges but also facilitates medication penetration. 1

First-Line Treatment Options

1. Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment: Recommended for facial and inverse psoriasis for up to 8 weeks (Strength of recommendation: B) 1

  • In clinical trials, 65% of patients using tacrolimus 0.1% were clear or almost clear after 8 weeks compared to 31% with placebo 1

• Pimecrolimus 1% cream: Recommended for inverse psoriasis for 4-8 weeks (Strength of recommendation: B) 1

  • Clinical trials showed 71% of patients using pimecrolimus achieved clear or almost clear status after 8 weeks versus 21% with placebo 1

• Benefits: No skin atrophy, safe for prolonged use in sensitive areas 1

• Side effects: May cause burning and pruritus initially, which typically improves with continued use 1

2. Low-Potency Topical Corticosteroids

• Use lower potencies in intertriginous areas to minimize risk of atrophy 1
• Short-term use only (1-2 weeks) to avoid adverse effects 1
• Caution: Higher risk of atrophy, striae, and systemic absorption in intertriginous areas due to increased penetration 1

3. Vitamin D Analogs

• Calcitriol: Less irritating than other vitamin D analogs, better tolerated on sensitive skin areas 1
• Calcipotriene: May be diluted with moisturizer to reduce irritation in sensitive areas 1
• Can be used in combination with topical corticosteroids for enhanced efficacy 1

Treatment Algorithm

1. Initial Treatment:

   • Start with topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) twice daily for 4-8 weeks 1
   • Apply thin layer to affected areas only

2. For inadequate response after 4-8 weeks:

   • Consider short-term (1-2 weeks) low-potency topical corticosteroids
   • Then return to calcineurin inhibitors for maintenance 1

3. For maintenance therapy:

   • Long-term use of calcineurin inhibitors can be considered (Strength of recommendation: C) 1
   • Apply emollients like petrolatum after bathing to reduce friction and irritation 1

4. For resistant cases:

   • Consider 308-nm excimer laser for targeted treatment of resistant areas 1, 2
   • For widespread or severe disease, systemic therapies may be needed 3, 4

Important Considerations

• Secondary infections: Rule out candidiasis in intertriginous areas (look for satellite pustules) 1
• Friction reduction: Educate patients about avoiding tight clothing and reducing friction in affected areas 1
• Psychological impact: Genital and intertriginous psoriasis can have significant psychological effects regardless of overall disease severity 1
• Pregnancy concerns: For women of childbearing potential, consider pregnancy category of medications 1

Treatment Pitfalls to Avoid

1. Using high-potency corticosteroids in intertriginous areas, which can rapidly lead to atrophy and striae 1
2. Prolonged continuous corticosteroid use in sensitive areas 1
3. Ignoring secondary candidal infections which can complicate treatment 1
4. Failing to address the psychological impact of inverse psoriasis, particularly genital involvement 1
5. Applying medications to moist skin, which can increase irritation with calcineurin inhibitors 1

Despite the FDA boxed warning for calcineurin inhibitors regarding theoretical malignancy risk, there is no evidence showing increased risk with topical use, and these agents remain the cornerstone of treatment for inverse psoriasis due to their efficacy and safety profile in sensitive areas. 1, 5