What is a suitable topical cream treatment for plaque psoriasis?

Topical Treatment Options for Plaque Psoriasis

For plaque psoriasis, a combination of potent corticosteroids with vitamin D analogs (such as calcipotriene) is the most effective first-line topical treatment option, providing superior efficacy compared to either agent alone. 1, 2

First-Line Treatment Algorithm

Mild to Moderate Plaque Psoriasis (Less than 10% BSA)

1. Initial Treatment:

   • Combination therapy: Potent corticosteroid + vitamin D analog (calcipotriene)
     • Two-compound products allow once-daily application 1, 3
     • Provides rapid improvement within 2 weeks, maximal improvement after 4 weeks 3
   • Alternative: Medium to high-potency (class III-IV) topical corticosteroid monotherapy 2

2. Application Instructions:

   • Apply once daily for combination products
   • For separate products: morning application of corticosteroid and evening application of vitamin D analog 1
   • Avoid using salicylic acid simultaneously with calcipotriene as it inactivates the vitamin D analog 1

3. Treatment Duration:

   • Limit potent corticosteroid use to 4 weeks to minimize risk of skin atrophy 2
   • After initial control, transition to maintenance therapy

4. Maintenance Strategy:

   • Weekend-only application of corticosteroid
   • Vitamin D analog 5 days per week 1, 4

Special Considerations for Different Body Areas

1. Body Plaques:

   • Start with moderate potency (class III-IV) corticosteroid + calcipotriene 2
   • Calcipotriene ointment 0.005% is FDA-approved for plaque psoriasis in adults 5

2. Sensitive/Intertriginous Areas (face, genitals, skin folds):

   • Use low-potency corticosteroids (class VI-VII) or calcineurin inhibitors 2
   • Avoid potent corticosteroids in these areas due to increased risk of atrophy

3. Scalp Psoriasis:

   • Medicated shampoos containing corticosteroids or vitamin D analogs 2
   • Solutions or foams may provide better penetration

Second-Line Topical Options

If inadequate response to first-line therapy:

1. Tazarotene (topical retinoid):

   • Efficacy comparable to fluocinonide cream 1
   • Best used in combination with corticosteroids to reduce irritation
   • Contraindicated during pregnancy 1

2. Corticosteroids under occlusion:

   • Significantly increases potency and penetration 1, 6
   • Hydrocolloid dressings can enhance efficacy for resistant plaques 6
   • Caution: occlusion can increase systemic absorption and side effects

3. Coal tar preparations:

   • Start with 0.5-1.0% concentration, increase gradually to maximum 10% 2
   • May be combined with corticosteroids or UV therapy

When to Consider Beyond Topical Therapy

Consider phototherapy or systemic therapy if:

• Psoriasis covers >10% of body surface area
• Inadequate response to topical therapy after 4 weeks
• Significant impact on quality of life 1, 2

Monitoring and Adverse Effects

1. Corticosteroids:

   • Monitor for skin atrophy, telangiectasia, and striae
   • Risk increases with potency, duration, and occlusion 2, 7

2. Vitamin D Analogs:

   • Watch for irritation and burning sensation
   • Approximately 6% of calcipotriene is absorbed systemically when applied to psoriasis plaques 5

3. Combination Therapy:

   • Evaluate response after 4 weeks
   • Combination therapy reduces corticosteroid-related side effects while maintaining efficacy 3

Common Pitfalls to Avoid

1. Overuse of potent corticosteroids - Limit to 4 weeks to prevent atrophy and tachyphylaxis
2. Undertreatment - Insufficient potency or inadequate application frequency
3. Inappropriate vehicle selection - Match vehicle to body location (ointments for thick plaques, solutions/foams for scalp)
4. Abrupt discontinuation - Can lead to rebound; taper or transition to maintenance regimen
5. Using salicylic acid with calcipotriene - Inactivates the vitamin D analog 1

The evidence strongly supports combination therapy with potent corticosteroids and vitamin D analogs as the most effective topical approach for plaque psoriasis, with better maintenance of therapeutic effect after discontinuation compared to monotherapy 1, 3.