What is the initial treatment for a psoriasis flare?

Initial Treatment for Psoriasis Flare

For a psoriasis flare, the initial treatment should be topical corticosteroids, preferably starting with a moderate potency (Class III) formulation for most body areas, with adjustments based on location and severity. 1

Topical Corticosteroid Therapy

Selection and Application

• Start with moderate potency (Class III) corticosteroids for most body areas
• For thicker plaques or resistant areas: Consider high-potency (Class I-II) corticosteroids like clobetasol propionate 0.05%
• For sensitive areas (face, intertriginous regions, genitals): Use lower potency corticosteroids (Class VI-VII)
• Application frequency: Once daily application is more effective than alternate day application for complete remission 2

Combination Approaches

• Consider combining with topical vitamin D analogs (calcipotriene/calcipotriol) for enhanced efficacy
  • Can be applied simultaneously (mixed 1:1) or serially
  • After initial control (typically 2 weeks), transition to weekend corticosteroid use and weekday vitamin D analog use 3
• For scalp psoriasis: Use medicated shampoos containing coal tar, salicylic acid, or solutions/foams of corticosteroids 1

Special Considerations

Anatomical Location

• Face and genital regions: Tacrolimus 0.1% ointment is recommended as monotherapy 3
• Scalp: Solutions or foams of corticosteroids are preferred for better penetration

Duration and Monitoring

• Short-term use (2-4 weeks) is recommended for initial control
• Regular clinical review is essential to monitor for adverse effects
• Watch for signs of skin atrophy, telangiectasia, and striae with prolonged use 1
• Avoid unsupervised repeat prescriptions

Potential Adverse Effects

• Local: Burning sensation (most common), itching, irritation, dryness, folliculitis 4
• With prolonged use: Skin atrophy, striae, telangiectasia, hypopigmentation 4
• Systemic (rare with appropriate use): HPA axis suppression, Cushing's syndrome 4

Important Cautions

• Avoid systemic corticosteroids for psoriasis treatment as they may precipitate erythrodermic psoriasis, generalized pustular psoriasis, or unstable psoriasis upon withdrawal 3, 5
• Systemic corticosteroids should only be used in specific circumstances:
  • Persistent uncontrollable erythroderma causing metabolic complications
  • Generalized pustular psoriasis (von Zumbusch type) if other drugs are contraindicated
  • Hyperacute psoriatic polyarthritis threatening irreversible joint damage 3

For Moderate to Severe Disease

If the psoriasis flare is moderate to severe (>3% body surface area) and doesn't respond adequately to topical therapy:

1. Consider phototherapy (narrowband UVB) as first-line treatment 1
2. For more extensive disease, consider systemic agents:
   • Methotrexate (7.5-25 mg weekly)
   • Cyclosporine (3-5 mg/kg/day for short courses of 3-4 months)
   • Biologics for severe, recalcitrant disease 1

Adjunctive Measures

• Moisturizers to reduce itching and desquamation
• Coal tar preparations (0.5-1.0% crude coal tar in petroleum jelly)
• Dithranol (Anthralin) starting at 0.1-0.25% concentration with short contact therapy (15-45 minutes daily) 1

Remember that proper patient education on application techniques and potential side effects is essential to improve adherence and treatment outcomes.