What are the treatment options for inverse psoriasis?

Treatment of Inverse Psoriasis

Topical calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus 1% cream) are the first-line therapy for inverse psoriasis due to their efficacy and lack of skin atrophy in sensitive intertriginous areas. 1

Understanding Inverse Psoriasis

Inverse psoriasis affects intertriginous areas including:

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

Unlike typical plaque psoriasis, inverse psoriasis appears erythematous, less indurated, and well-demarcated with minimal scale. The warm, moist environment in these areas creates unique treatment challenges.

First-Line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment: Apply twice daily for up to 8 weeks
  • Clinical trials show 65% of patients achieve clear or almost clear status after 8 weeks (vs 31% with placebo) 1
• Pimecrolimus 1% cream: Apply twice daily for 4-8 weeks
  • Clinical trials show 71% of patients achieve clear or almost clear status after 8 weeks (vs 21% with placebo) 1

Benefits:

• No skin atrophy
• Safe for prolonged use in sensitive areas
• Can be used for maintenance therapy

Side effects:

• Initial burning and pruritus (typically improves with continued use)

Alternative First-Line Options

• Calcitriol: Less irritating than other vitamin D analogs and better tolerated on sensitive skin areas 2, 1
• Low-potency topical corticosteroids: Short-term use only (1-2 weeks) to minimize risk of atrophy 1

Second-Line Treatment Options

For Inadequate Response After 4-8 Weeks

1. Consider short-term (1-2 weeks) low-potency topical corticosteroids
2. Return to calcineurin inhibitors for maintenance therapy 1
3. Consider diluted calcipotriene with moisturizer to reduce irritation in sensitive areas 2, 1
4. 308-nm excimer laser for targeted treatment of resistant areas 2, 1

Treatment for Moderate-to-Severe or Resistant Cases

For widespread or severe disease unresponsive to topical therapies:

• Systemic therapies may be needed, including biologics 3
• Case reports have shown success with TNF-α inhibitors like adalimumab 4
• IL-17 inhibitors and PDE-4 inhibitors have shown efficacy 5

Important Considerations and Precautions

Do's:

• Rule out secondary infections, especially candidiasis, in intertriginous areas
• Apply emollients like petrolatum after bathing to reduce friction and irritation
• Consider the psychological impact of genital and intertriginous psoriasis

Don'ts:

• Avoid high-potency corticosteroids in intertriginous areas (can rapidly lead to atrophy and striae)
• Avoid prolonged continuous corticosteroid use in sensitive areas
• Don't ignore secondary candidal infections, which can complicate treatment
• Don't apply medications to moist skin (can increase irritation with calcineurin inhibitors)

Treatment Algorithm

1. Initial therapy: Tacrolimus 0.1% ointment or pimecrolimus 1% cream twice daily for 4-8 weeks
2. If inadequate response: Add short-term (1-2 weeks) low-potency topical corticosteroid
3. Maintenance: Return to calcineurin inhibitors for long-term management
4. For resistant cases: Consider 308-nm excimer laser or referral for systemic therapy evaluation

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.