What is the first line topical treatment for psoriasis?

First-Line Topical Treatment for Psoriasis

The first-line topical treatment for psoriasis is combination therapy with a topical corticosteroid and vitamin D analogue (such as calcipotriene), with initial dual therapy followed by maintenance with the vitamin D analogue for long-term use. 1

Treatment Algorithm

Initial Treatment (First 2-4 weeks)

1. Topical Corticosteroid Selection

   • For body/extremities: Medium to high-potency corticosteroid (Class 2-5)
   • For face/intertriginous areas: Low-potency corticosteroid (Class 6-7)
   • For thick plaques: Ultra-high potency corticosteroid (Class 1)
   • Apply once or twice daily 2, 1

2. Vitamin D Analogue

   • Calcipotriene/calcipotriol 0.005% ointment or cream
   • Apply once or twice daily 2, 1

3. Application Method Options:

   • Apply separately (corticosteroid in morning, vitamin D analogue in evening)
   • Mix 1:1 on finger and apply together 2

Maintenance Phase (After 2-4 weeks)

• Weekdays: Vitamin D analogue only
• Weekends: Topical corticosteroid 2, 1
• This regimen minimizes corticosteroid side effects while maintaining efficacy

Special Considerations

Anatomical Locations

• Scalp: Clobetasol propionate 0.05% solution/foam or calcipotriene foam 1
• Face/Genitals/Intertriginous areas: Tacrolimus 0.1% ointment (off-label) or low-potency corticosteroids 2
• Thick plaques: Consider adding salicylic acid to increase penetration 3

Safety Considerations

• Maximum usage:
  • Ultra-high potency corticosteroids: ≤50g/week, limit to 4 weeks of continuous use 1
  • Vitamin D analogues: ≤100g/week to avoid hypercalcemia 2, 1
• Monitoring: Evaluate treatment response after 4 weeks 1
• Caution: Avoid using vitamin D analogues with salicylic acid as the acidic pH inactivates calcipotriene 1

Evidence Quality and Efficacy

• Combination therapy shows superior efficacy compared to monotherapy with either agent 4, 5
• Topical corticosteroids provide rapid relief with efficacy rates of 41-92% depending on potency 2
• Vitamin D analogues normalize keratinocyte differentiation and proliferation, complementing the anti-inflammatory effects of corticosteroids 2
• Newer formulations (sprays, foams) may improve adherence with similar efficacy to traditional ointments and creams 6

Common Pitfalls to Avoid

• Using only topical corticosteroids long-term (risk of skin atrophy, telangiectasia, and tachyphylaxis)
• Applying excessive amounts of ultra-high potency corticosteroids (risk of systemic absorption)
• Abrupt discontinuation of corticosteroids (risk of rebound)
• Using vitamin D analogues alone for initial treatment of moderate-to-severe plaques (less effective than combination therapy)
• Neglecting to rotate to maintenance therapy after initial control is achieved

The combination approach balances efficacy and safety, providing rapid improvement with corticosteroids while allowing for long-term disease control with vitamin D analogues that have a better safety profile for extended use.