What is the first line of treatment for psoriasis?

First-Line Treatment for Psoriasis

Topical corticosteroids of moderate to high potency (classes 2-5) are the first-line treatment for localized psoriasis, typically used for a maximum of 4 weeks for plaques not affecting intertriginous areas. 1

Topical Corticosteroid Therapy

• Topical corticosteroids are the mainstay of treatment for mild to moderate psoriasis, with efficacy demonstrated within the first 2-4 weeks of treatment 2
• For psoriasis plaques not affecting intertriginous areas, moderate to high potency corticosteroids (classes 2-5) should be used 1
• Lower potency corticosteroids should be used on the face, intertriginous areas, and sensitive areas to avoid skin atrophy 1
• Very potent (class 1) corticosteroids should only be used under dermatological supervision 1

Combination and Alternative Topical Therapies

• Vitamin D analogs (calcipotriene/calcipotriol) combined with topical corticosteroids provide a synergistic effect and are more effective than either agent alone 3
• A popular regimen is dual therapy with high/ultra-high potency topical steroid and topical vitamin D analogue, either as separate products or as a fixed combination product 3
• Tazarotene (topical retinoid) is effective when combined with moderate to high potency topical corticosteroids, which helps reduce irritation while enhancing efficacy 3, 1
• Topical calcineurin inhibitors (tacrolimus 0.1%) are recommended for psoriasis of the face, genitalia, and body folds as they don't cause skin atrophy 3

Treatment Algorithm for Localized Psoriasis

1. Start with moderate to high potency topical corticosteroids for non-intertriginous areas for up to 4 weeks 1
2. For maintenance, consider weekend-only application of corticosteroids while using vitamin D analogs on weekdays 3
3. For face and intertriginous areas, use low potency corticosteroids or topical calcineurin inhibitors 3, 1
4. For scalp psoriasis, use topical corticosteroids of appropriate potency for at least 4 weeks 1

Important Precautions

• Do not exceed 100g of moderate potency corticosteroid preparation per month 1
• Avoid simultaneous use of salicylic acid with calcipotriene/calcipotriol as the acidic pH will inactivate the vitamin D analog 1
• Plan annual periods where alternative treatments are used to minimize corticosteroid side effects 1
• Avoid systemic corticosteroids as they can precipitate or worsen psoriasis flare-ups, especially when discontinued 1

When to Consider Systemic Therapy

• If topical treatments are unsuccessful, consider phototherapy (UVB or PUVA) as the next step 4
• For moderate to severe psoriasis (>5% body surface area) or inadequate response to topical therapy, systemic therapies including methotrexate, acitretin, or cyclosporine should be considered 3, 4
• Patients with severe psoriasis requiring systemic agents should be referred to a dermatologist due to potential toxicity 1

Special Considerations

• Perceived "tachyphylaxis" to topical corticosteroids is often due to poor patient adherence rather than receptor down-regulation 3
• Innovative formulations like sprays, foams, and nail lacquers can improve patient adherence by tailoring treatment to individual needs 5
• For pustular psoriasis, acitretin is particularly effective as a systemic option 6

Remember that psoriasis is a chronic condition requiring long-term management strategies. The goal is to achieve rapid control of the disease, prolonged remission, and minimal adverse effects 2.