What are the recommended treatments for plaque psoriasis, specifically topical creams?

Topical Treatment Options for Plaque Psoriasis

For mild to moderate plaque psoriasis, combination therapy with vitamin D analogues and topical corticosteroids is the recommended first-line treatment, with vitamin D analogues (like calcipotriene) recommended for long-term use up to 52 weeks. 1

First-Line Topical Treatments

Vitamin D Analogues

• Calcipotriene (calcipotriol) is FDA-approved for plaque psoriasis in adults 2
• Can be used for long-term therapy (up to 52 weeks) for mild to moderate psoriasis 1
• Maximum weekly dose should not exceed 100g to avoid hypercalcemia 3
• Available in various formulations including ointment, cream, foam, and solution

Topical Corticosteroids

• Selected based on plaque location and thickness:
  • Low potency (Class 6-7): For face and intertriginous areas
  • Medium potency (Class 4-5): For body
  • High/ultrahigh potency (Class 1-2): For thick plaques 3
• Clobetasol propionate 0.05% (Class 1) shows significant improvement in plaque psoriasis within 1 week of treatment 4
• Duration should be limited to 4 weeks for most areas to avoid adverse effects 5
• Maximum weekly use of ultrahigh potency agents should not exceed 50g 3

Combination Approaches

Vitamin D + Corticosteroid Combinations

• Most effective approach: Combination of vitamin D analogues with potent class II and III topical corticosteroids 1
• Several effective regimens:
  1. Morning corticosteroid + evening vitamin D analogue 1
  2. Vitamin D analogues twice daily on weekdays + corticosteroids twice daily on weekends for maintenance 1
  3. Calcitriol ointment on weekdays + clobetasol spray on weekends (shows effectiveness and good tolerance) 6

Important Precautions

• Avoid simultaneous use of salicylic acid with calcipotriene as the acidic pH inactivates calcipotriene 1
• If using with phototherapy, apply vitamin D analogues after the phototherapy session to prevent inactivation by UVA or blocking of UVB 1
• Monitor for signs of skin atrophy, telangiectasia, and striae with prolonged corticosteroid use 5

Alternative Topical Options

Tazarotene

• Topical retinoid recommended for 8-12 weeks for mild to moderate psoriasis 1
• Acts by normalizing keratinocyte differentiation and proliferation
• Comparable efficacy to fluocinonide cream in clinical trials 1

Calcineurin Inhibitors

• Tacrolimus and pimecrolimus are particularly useful for facial and intertriginous areas 3
• Calcipotriene combined with tacrolimus shows greater efficacy than tacrolimus alone 1

Special Considerations

Scalp Psoriasis

• Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel recommended for 4-12 weeks 1
• Medicated shampoos containing coal tar, salicylic acid, or solutions/foams of corticosteroids can be used 3

Facial Psoriasis

• Topical tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks 1
• Low-potency corticosteroids preferred to minimize risk of skin atrophy 3

Nail Psoriasis

• Topical vitamin D analogues combined with betamethasone dipropionate can reduce nail thickness, hyperkeratosis, and onycholysis 1
• Limited efficacy for severe nail disease due to poor penetration 1

Treatment Assessment

• Evaluate treatment response after 4 weeks 3
• If inadequate response to topical therapy alone, consider adding phototherapy:
  • Narrowband UVB is first-line phototherapy for moderate-to-severe psoriasis 3
  • PUVA should only be considered if NB-UVB has not been adequately effective 1

Common Pitfalls to Avoid

1. Using vitamin D analogues simultaneously with salicylic acid (reduces effectiveness)
2. Applying vitamin D analogues before phototherapy (causes inactivation)
3. Prolonged use of high-potency corticosteroids beyond 4 weeks without supervision
4. Exceeding maximum weekly doses (50g for ultrahigh potency corticosteroids, 100g for vitamin D analogues)
5. Using high-potency corticosteroids on face, groin, or axillae (increased risk of atrophy) 5

By following these evidence-based recommendations, most patients with plaque psoriasis can achieve significant improvement in symptoms and quality of life.