What are the treatment options for facial psoriasis?

Treatment Options for Facial Psoriasis

For facial psoriasis, topical calcineurin inhibitors (tacrolimus 0.1%) are recommended as first-line treatment due to their efficacy and safety profile in sensitive areas. 1, 2

First-Line Treatment Options

Topical Calcineurin Inhibitors

• Tacrolimus 0.1% ointment is the preferred first-line therapy for facial psoriasis 1, 2
  • Achieves clearance or excellent improvement within 30 days in most patients
  • Complete clearance can occur as quickly as 72 hours in some cases 1
  • Avoids the adverse effects associated with corticosteroids in sensitive facial skin
  • Apply twice daily until improvement, then reduce to maintenance therapy

Low-Potency Topical Corticosteroids

• Can be used as an alternative first-line option for short-term control 2, 3
  • Should be limited to 1-2 weeks of continuous use on the face
  • Class 6-7 (low potency) corticosteroids like hydrocortisone are preferred for facial areas
  • Risk of skin atrophy, telangiectasia, and striae with prolonged use

Second-Line and Combination Approaches

Vitamin D Analogs

• Calcipotriene (calcipotriol) can be used alone or in combination with low-potency corticosteroids 2, 4
  • FDA-approved for plaque psoriasis in adults 4
  • Can be alternated with corticosteroids for maintenance therapy
  • Apply once daily, typically on weekdays when alternating with corticosteroids on weekends

Combination Therapy

• Alternating or sequential therapy is often more effective than monotherapy 2, 5
  • Week 1-2: Daily application of low-potency corticosteroid
  • Maintenance: Corticosteroid (weekends) + calcipotriene (weekdays)
  • This approach minimizes side effects while maintaining efficacy

Special Considerations for Facial Psoriasis

Advantages of Calcineurin Inhibitors for Facial Use

• No risk of skin atrophy, which is particularly important for thin facial skin 1, 3
• Effective for long-term maintenance therapy
• May cause temporary burning/stinging upon application but this typically resolves with continued use

Treatment Monitoring

• Evaluate response after 4 weeks of initial therapy 2
• For patients with inadequate response, consider:
  1. Confirming diagnosis (rule out seborrheic dermatitis or other facial dermatoses)
  2. Assessing treatment adherence
  3. Switching to an alternative agent or combination approach

Treatment Algorithm for Facial Psoriasis

1. Initial Treatment:

   • Tacrolimus 0.1% ointment twice daily for 2-4 weeks 1, 2

2. If inadequate response after 4 weeks:

   • Add short course (1 week) of low-potency corticosteroid
   • Then return to tacrolimus maintenance

3. Maintenance Therapy:

   • Tacrolimus 0.1% applied 2-3 times weekly
   • For flares: temporarily increase to twice daily application

4. For resistant cases:

   • Consider alternating tacrolimus with vitamin D analogs
   • For severe cases, evaluate need for systemic therapy if facial psoriasis is part of more widespread disease

Common Pitfalls to Avoid

• Avoid medium to high-potency corticosteroids on the face due to high risk of skin atrophy and other adverse effects 2, 6
• Don't use occlusive dressings on facial psoriasis as this increases steroid absorption and side effects
• Don't ignore burning sensation with calcineurin inhibitors - inform patients this is common initially and typically resolves with continued use
• Don't forget to address psychological impact of facial psoriasis, which can significantly affect quality of life 2

Facial psoriasis requires special attention due to the visibility and sensitivity of the area. While tacrolimus has shown excellent efficacy in this location, treatment should be adjusted based on response, with careful monitoring for adverse effects.