What are the recommended topical treatments for psoriatic dermatitis?

Topical Treatment of Psoriatic Dermatitis

Topical corticosteroids combined with vitamin D analogs are the first-line treatment for psoriatic dermatitis, with selection based on body location and disease severity. 1, 2

First-Line Treatment Options

Combination Therapy

• Topical corticosteroids + vitamin D analogs: Most effective first-line approach
  • Can be applied as separate products or as commercially available combinations
  • Application: Either each once daily or mixed 1:1 on finger and applied together twice daily for first 2 weeks 1
  • Maintenance: Reduce to weekends for corticosteroids and weekdays for vitamin D analogs 1

Corticosteroid Selection by Body Region

1. Body/Extremities: Mid to high-potency corticosteroids

   • Class 1-2 (Ultra-high/high potency): For thick plaques, palmoplantar areas
   • Class 3-5 (Medium potency): For moderate thickness plaques
   • Application: Thin film 2-3 times daily depending on severity 3
   • Duration: Up to 3 weeks for super-high potency; up to 12 weeks for high/medium potency 4

2. Face/Intertriginous/Genital Areas: Low-potency corticosteroids or calcineurin inhibitors

   • Tacrolimus 0.1% ointment: Recommended for face and genital regions 1
   • Complete clearance typically achieved within 2 weeks 1
   • Avoids risk of skin atrophy associated with corticosteroids 2, 5

3. Scalp Psoriasis: Corticosteroid solutions, foams, or shampoos 5

Second-Line and Adjunctive Treatments

Tazarotene

• Can be used for mild to moderate psoriasis (Strength of recommendation: B) 1
• More effective when combined with mid/high-potency corticosteroids (Strength of recommendation: A) 1
• Combination decreases treatment duration and increases remission length 1

Emollients/Moisturizers

• Use in conjunction with topical corticosteroids for 4-8 weeks
• Helps reduce itching, desquamation, and total body surface area involvement
• Prevents quick relapse when corticosteroids are discontinued (Strength of recommendation: B) 1

Other Options

• Salicylic acid: Useful as keratolytic agent for thick plaques, enhances penetration of other topicals 5
• Anthralin: Effective but can cause staining; avoid on face and flexures 1
• Coal tar: Traditional treatment with anti-inflammatory properties 1

Application Technique and Dosing

• Fingertip Unit Method: One fingertip unit (medication from fingertip to first crease) covers approximately 2% body surface area 4
• Occlusive Dressings: May be used for recalcitrant psoriasis but should be discontinued if infection develops 3
• Calcipotriene (Vitamin D analog): Maximum 100g weekly to avoid hypercalcemia 2, 6

Treatment Monitoring and Considerations

• Evaluate response after 4 weeks for topical therapy 2
• Monitor for adverse effects:
  • Corticosteroids: Skin atrophy, telangiectasia, striae
  • Calcineurin inhibitors: Initial burning sensation
  • Tazarotene: Skin irritation

Special Populations

Pediatric Patients

• Use lower potency corticosteroids
• Tacrolimus 0.1% recommended for facial and genital psoriasis in children 1
• Young children (0-6 years) are vulnerable to HPA suppression; use high-potency corticosteroids with caution 1

Treatment Algorithm

1. Mild localized disease:

   • Start with topical corticosteroid + vitamin D analog combination
   • Select potency based on location (low for face/intertriginous areas, medium-high for body)

2. For sensitive areas (face, genitals, intertriginous):

   • First choice: Tacrolimus 0.1% ointment
   • Alternative: Low-potency corticosteroids

3. For thick plaques:

   • Add salicylic acid to enhance penetration
   • Consider higher potency corticosteroids

4. For maintenance:

   • Weekend corticosteroid use
   • Weekday vitamin D analog use
   • Regular emollient application

5. For inadequate response to topicals:

   • Consider phototherapy or systemic agents for more extensive disease (>5% BSA) 2