What side effect is most expected with prolonged use of topical corticosteroids (CS), but not with calcipotriene, in patients with psoriasis?

Skin Atrophy is the Most Expected Side Effect with Prolonged Topical Corticosteroid Use, Not Seen with Calcipotriene

Skin atrophy is the most common and expected side effect with prolonged topical corticosteroid use in psoriasis patients, while this adverse effect is not seen with calcipotriene. 1

Topical Corticosteroid Side Effects

Topical corticosteroids are effective first-line treatments for plaque psoriasis, but prolonged use comes with significant risks:

• Skin atrophy is the most common local adverse effect of prolonged topical corticosteroid use, along with striae, telangiectasia, and purpura 1
• Face, intertriginous areas, and chronically treated areas (especially forearms) are at greatest risk for developing these atrophic changes 1
• Skin thinning can occur rapidly - studies show approximately 15% skin thinning after just 16 days of continuous application of potent corticosteroids 2
• The atrophogenic effect occurs through direct inhibition of fibroblast proliferation, reduction of mast cell numbers, depletion of mucopolysaccharides and elastin fibers, and inhibition of collagen synthesis 3
• Other adverse effects of topical corticosteroids include folliculitis, contact dermatitis, exacerbation of acne/rosacea/perioral dermatitis, and potential rebound effect upon discontinuation 1

Calcipotriene Side Effects Profile

Calcipotriene (a vitamin D analog) has a distinctly different side effect profile:

• The most common side effect of calcipotriene is irritant dermatitis in lesional and perilesional skin, which is typically transient 1
• Unlike corticosteroids, calcipotriene does not cause skin atrophy - in fact, it has been shown to thicken the skin 4, 5
• Reversible elevation of serum calcium can occur, more likely in patients using more than 100g/week 1
• Calcipotriene can cause photosensitivity 1

Comparative Safety Profile

The distinct difference in side effect profiles makes these agents complementary in psoriasis treatment:

• Topical corticosteroids cause fewer immediate adverse reactions compared to vitamin D analogs, but have more significant long-term risks 6
• Calcipotriene is comparable to mid-potency topical corticosteroids in efficacy but does not cause skin atrophy or lead to tachyphylaxis 5
• Combination regimens of calcipotriene with topical corticosteroids can provide a steroid-sparing effect, reducing the risk of steroid-induced atrophy 4
• Topical corticosteroids can suppress the irritant dermatitis that may occur with calcipotriene treatment 4

Clinical Implications

When managing psoriasis requiring prolonged topical treatment:

• For long-term maintenance, calcipotriene may be preferred over topical corticosteroids to avoid skin atrophy 1
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are also steroid-sparing alternatives that don't cause skin atrophy, especially useful for facial and intertriginous areas 1
• If topical corticosteroids are needed for prolonged periods, they should be used under careful physician supervision with regular monitoring for skin atrophy 1
• Intermittent application schedules (every 10-14 days) may allow skin thickness to return to normal levels between applications 2

Pitfalls and Caveats

• Skin atrophy from topical corticosteroids can persist for up to 3 days after a single application 2
• Gradual reduction in frequency of topical corticosteroid use is recommended after clinical improvement to avoid rebound effects 1
• The American Academy of Dermatology recommends limiting use of class 1 topical corticosteroids to 2-4 weeks, with longer use requiring careful supervision 1
• For patients requiring prolonged treatment, combination therapy or rotational approaches using both agents may optimize efficacy while minimizing side effects 1, 4