What is the best treatment for inverse psoriasis?

Treatment of Inverse Psoriasis

Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) 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 folds, inguinal folds, gluteal folds, groin, genitalia, perineum, and perirectal areas. It appears as erythematous, less indurated, and well-demarcated lesions with minimal scale.

Treatment Algorithm

First-Line Treatment

• Topical calcineurin inhibitors (TCIs):
  • Tacrolimus 0.1% or pimecrolimus 1% ointment
  • Apply twice daily for 4-8 weeks
  • Efficacy: 65-71% of patients achieve clear or almost clear status after 8 weeks 1
  • Advantages: No skin atrophy, safe for long-term use in sensitive areas
  • Note: Despite FDA boxed warning regarding theoretical malignancy risk, there is no evidence showing increased risk with topical use 1

Second-Line Treatment (for inadequate response after 4-8 weeks)

• Low-potency topical corticosteroids:
  • Short-term use only (1-2 weeks)
  • Then return to calcineurin inhibitors for maintenance 1
  • Caution: Avoid high-potency corticosteroids in intertriginous areas due to increased risk of atrophy, striae, and systemic absorption 1

Alternative Topical Options

• Vitamin D analogs:

  • Calcitriol is less irritating than other vitamin D analogs and better tolerated on sensitive skin areas 1
  • Diluted calcipotriene with moisturizer can reduce irritation in sensitive areas 1

• Emollients:

  • Use in conjunction with other topical therapies
  • Helps reduce itching, desquamation, and prevents quick relapse when topical corticosteroids are discontinued 2
  • Apply petrolatum after bathing to reduce friction and irritation 1

For Widespread or Severe Disease Unresponsive to Topical Therapies

• Targeted phototherapy:

  • 308-nm excimer laser for resistant areas 1

• Systemic therapies:

  • Consider for widespread or severe disease unresponsive to topical therapies 1
  • Biologics may be effective in cases of inverse psoriasis unresponsive to standard treatments 3

Important Considerations and Precautions

Avoid in Inverse Psoriasis

• Anthralin: Application to face and flexures should be avoided due to staining and irritation 2
• Coal tar: Can cause local irritation, folliculitis, and contact dermatitis 2
• High-potency corticosteroids: Increased risk of atrophy, striae, and systemic absorption in intertriginous areas 1

Additional Management Tips

• Rule out secondary infections, especially candidiasis, in intertriginous areas 1
• Advise patients to avoid tight clothing and reduce friction in affected areas 1
• Apply medications to dry skin to minimize irritation with calcineurin inhibitors 1
• Consider the psychological impact of genital and intertriginous psoriasis, which can significantly affect quality of life regardless of overall disease severity 1

Monitoring

• Assess treatment response after 4-8 weeks
• For patients using topical corticosteroids, monitor for signs of skin atrophy
• For patients with inadequate response to topical therapy, consider referral to dermatology for consideration of systemic therapy

By following this treatment algorithm, most patients with inverse psoriasis can achieve significant improvement in their condition while minimizing adverse effects associated with treatment.