For skin diseases, what are the first-line treatments?

First-Line Treatments for Skin Diseases

For skin diseases, first-line treatments typically include topical corticosteroids, which remain the cornerstone therapy for most inflammatory skin conditions. 1, 2

Psoriasis

First-Line Treatments

• For localized plaque psoriasis not affecting intertriginous areas, moderate to high potency topical corticosteroids (classes 2 to 5) are recommended for a maximum of 4 weeks 1
• Vitamin D analogs (calcipotriene/calcipotriol) combined with topical corticosteroids provide a synergistic effect and are considered first-line therapy 1
• For scalp psoriasis, topical corticosteroids of class 1 to 7 are recommended for at least 4 weeks 1
• For face, intertriginous areas, and sensitive areas, lower potency corticosteroids should be used to avoid skin atrophy 1

Treatment Algorithm

• Start with topical corticosteroids for localized disease 1
• Add vitamin D analogs for enhanced efficacy (can be used as combination products) 1
• For maintenance, consider weekend-only application of corticosteroids while using vitamin D analogs on weekdays 1
• For moderate to severe disease (>5% body surface area), consider phototherapy, methotrexate, or systemic agents 3, 1

Special Considerations

• Coal tar can be used as an alternative treatment, starting with concentrations of 0.5-1.0% and gradually increasing up to 10% 1, 4
• Tazarotene (topical retinoid) is effective when combined with moderate to high potency topical corticosteroids 1
• Avoid systemic corticosteroids as they can precipitate or worsen psoriasis flare-ups 1

Atopic Dermatitis (Eczema)

First-Line Treatments

• Topical corticosteroids are the first-line treatment for eczema flare-ups 5, 6
• Emollients should be used as adjunctive therapy to reduce itching, scaling, and help maintain skin barrier function 4, 5
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) can be used in conjunction with topical corticosteroids as first-line treatment, especially for sensitive areas 5, 6

Treatment Algorithm

• For mild to moderate eczema: topical corticosteroids of appropriate potency based on location and severity 5, 6
• For face and intertriginous areas: low potency corticosteroids or topical calcineurin inhibitors 5, 6
• For moderate to severe cases: consider stepping up to more potent corticosteroids or adding topical calcineurin inhibitors 5
• For cases unresponsive to first-line therapy: consider phototherapy (narrowband UVB) 5, 6

Vitiligo

First-Line Treatments

• Topical corticosteroids are the usual first-line treatment for vitiligo 3
• Highly potent (clobetasol) or potent (betamethasone) topical steroids can repigment vitiligo, though only in a small proportion of cases 3
• Sunscreens and cosmetic camouflage including fake tanning products are recommended for all patients 3

Treatment Algorithm

• Start with topical steroids for localized vitiligo 3
• For widespread vitiligo, narrowband UVB phototherapy is recommended before considering PUVA 3
• PUVA should only be considered if narrowband UVB has not been adequately effective 3

Bacterial Skin Infections

First-Line Treatments

• For localized external skin layer infections, topical antibiotics are adequate 7
• Most commonly used topical antibiotics include erythromycin, clindamycin, mupirocin, and fusidic acid 7
• For widespread and deeper infections, systemic antibiotics are needed, primarily beta-lactams, macrolides, and tetracyclines 7

Common Pitfalls and Caveats

• Avoid using high-potency corticosteroids on the face, intertriginous areas, and sensitive areas due to increased risk of skin atrophy 1, 5
• Do not exceed 100g of a moderate potency corticosteroid preparation per month 1
• Regular clinical follow-up is essential when using topical corticosteroids 1, 4
• Plan annual periods where an alternative treatment is used to avoid tachyphylaxis and side effects 1
• Avoid simultaneous use of salicylic acid with calcipotriol, as the acidic pH will inactivate calcipotriol 1
• Perceived "tachyphylaxis" to topical corticosteroids is often due to poor patient adherence rather than receptor down-regulation 1
• For psoriatic arthritis, NSAIDs are first-line for mild disease, while DMARDs (sulfasalazine, leflunomide, methotrexate) are first-line for moderate to severe disease 3, 8

Emerging Therapies

• For atopic dermatitis, newer topical agents include phosphodiesterase-4 inhibitors (crisaborole, roflumilast), JAK inhibitors (ruxolitinib, delgocitinib), and aryl hydrocarbon receptor modulators (tapinarof) 5, 9
• In network meta-analyses, potent corticosteroids, JAK inhibitors, and tacrolimus 0.1% were consistently ranked as the most effective topical treatments for eczema 5