What are the recommended topical treatments for psoriasis?

Recommended Topical Treatments for Psoriasis

Topical corticosteroids are the first-line treatment for mild to moderate psoriasis, with coal tar preparations also strongly recommended (strength of recommendation: A) for mild to moderate disease. 1

First-Line Topical Therapies

Topical Corticosteroids

• Potency selection based on location:

  • Class 1 (Ultrahigh-potency): Clobetasol propionate 0.05%, halobetasol propionate for resistant plaques 2
  • Class 2-5 (High to moderate potency): Betamethasone dipropionate, triamcinolone acetonide for trunk and extremities 2
  • Class 6-7 (Low potency): Hydrocortisone, desonide for face, intertriginous areas, and children 2

• Application frequency:

  • Once daily application is effective and reduces risk of side effects 3
  • For severe cases, twice daily application may provide better initial control 4
  • Treatment duration: Limited to 2-4 weeks for high-potency steroids to avoid side effects 5

• Special formulations:

  • Spray, foam, lotion, and shampoo formulations available for different body areas and to improve adherence 5
  • Scalp psoriasis: Clobetasol propionate 0.05% solution is highly effective 4

Vitamin D Analogs

• Calcipotriene 0.005% ointment is FDA-approved for plaque psoriasis in adults 6
• Can be used as monotherapy or in combination with corticosteroids
• Less rapid in onset than corticosteroids but safer for long-term use

Combination Therapy Approach

Recommended sequential therapy: Clobetasol propionate for 2 weeks followed by calcipotriene is superior to calcipotriene alone 7

Combination therapy benefits:

• Vitamin D analogs with mid/high-potency corticosteroids (Strength of recommendation: A) 2
• Decreases treatment duration
• Increases remission length
• Reduces itching and desquamation
• Reduces total body surface area involvement

Other Recommended Topical Agents

Coal Tar Preparations

• Strongly recommended for mild to moderate psoriasis (Strength of recommendation: A) 1
• Can be used alone or in combination with phototherapy (Goeckerman therapy) 1
• Caution: May cause irritation, folliculitis, and has an unpleasant odor that reduces adherence 1

Salicylic Acid

• Can be used for 8-16 weeks for mild to moderate psoriasis (Strength of recommendation: B) 1
• Particularly useful for thick, scaly plaques
• Combination with topical corticosteroids recommended for moderate to severe psoriasis (BSA ≤20%) 1

Anthralin (Dithranol)

• Recommended for 8-12 weeks for mild to moderate psoriasis (Strength of recommendation: B) 1
• Start at 0.1% concentration and increase as tolerated
• Short contact therapy (up to 2 hours per day) recommended to limit side effects 1

Topical Calcineurin Inhibitors

• First-line for intertriginous areas 2
• Alternative to corticosteroids for facial and genital psoriasis

Special Considerations

Anatomical Location

• Scalp: High-potency corticosteroid solutions or foams 4
• Intertriginous areas: Topical calcineurin inhibitors or low-potency corticosteroids 2
• Genital psoriasis: Requires special attention due to psychological impact 2

Pediatric Patients

• Use lower potency corticosteroids 2
• Young children (0-6 years) are vulnerable to HPA axis suppression 2
• Avoid high-potency corticosteroids in children when possible

Monitoring and Assessment

• Evaluate response after 4 weeks of topical therapy 2
• Monitor for adverse effects:
  • Corticosteroids: skin atrophy, telangiectasia, striae, HPA axis suppression 8
  • Coal tar: irritation, folliculitis, contact dermatitis, phototoxicity 1

Common Pitfalls to Avoid

1. Overuse of high-potency corticosteroids:

   • Limit use to 2-4 weeks to prevent skin atrophy and systemic absorption 5
   • Avoid occlusive dressings which substantially increase absorption 8

2. Inappropriate vehicle selection:

   • Choose ointments for thick plaques and dry skin
   • Use solutions, foams, or shampoos for scalp psoriasis 5

3. Poor adherence:

   • Consider patient preference for vehicle (ointment vs. cream vs. foam)
   • Newer formulations may improve adherence compared to traditional ointments 5

4. Pregnancy considerations:

   • Avoid coal tar preparations during pregnancy and lactation 1
   • Use lowest effective potency of corticosteroids when needed